Last night I attended a Clinical Commissioning Group meeting. The genuine interest of these many GPs lags far behind their attendance record. They know the unspoken rules for survival: the human energy in the room is fatigued, desultory and acquiescent.
An executive officer is addressing us with well-worn competence. His messages are clearly sound-amplified and powerpointed onto the screen behind him.
He vaunts yet another rebranded initiative for ‘Integrated Care’, as if an arcane group of scientists had made an exciting discovery. He profiles the many dislocations, replications and retroflections as if we do not know. We do, though not his statistics.
The standing expert speaks: the many sitters mostly look blank. It is hard to distinguish listening from vacuous passivity. The executive winds up with authoritative courtesy: “Any questions?”
There is an inert fugal silence, like waking from a light anaesthetic. I want to galvanise myself, so I raise my hand to speak:
“I think you (and we) have long had good intent about these matters. But we cannot counter the massively divisive and fragmentary influence of the NHS Internal Market that embeds and commands us.
“This – and then its subsidiary procedures of Competition, Commissioning and Commodification – make better kinds of holistic integrated care almost impossible. All experienced, thoughtful older practitioners – who served well before the Internal Market – recognise this fact and hold this view. This toxic burden is spoken of frequently privately, yet not publicly. Can we please do so now?”
The executive looks discomfited, repeatedly shifting his weight from one leg to the other as if testing his most solid posture. He clears his throat softly: "Um … I don’t really think that is an appropriate topic for this meeting…"
He looks toward the chairman who nods support. I have little voice now, so I want to have the last word: “So, we have no forum now where such discussion is deemed ‘appropriate’. That is the size and nature of the problem: the official policy is of straight talk and democracy, but somehow the translated reality becomes oligarchic, and then, as here, our range of discourse is controlled and prescribed.”
There is a rustle of further awakening among the sitters. The chairman parries my democratic heroism with apparently effortless and deft alacrity: “Thank you. Any more questions?”
I need to loosen my tangled mental processes. I leave the hermetic conference room to stroll in the lobby. There, a smartly attired woman looks up at me in friendly recognition. She is another CCG Executive.
I ask her what her prepared entrance is about. “Oh”, she says with diplomatic cheeriness, “in a quarter of an hour I have to talk to all you GPs about how we can cut down inappropriate and excessive Accident and Emergency attendances. It’s costing the CCG an awful lot of money, you know.”
She says this, I think, with a faint tinge of accusation: that if people like me tried harder, this profligacy would be stemmed. My thoughts about the Internal Market have primed me for pre-emption: “Jocelyn, there’s only so much GPs can do. Yes, of course, we must give our best to be accessible, competent, friendly and imaginative. And then give patients timely and correct information about the correct use of services. But to further change the pattern, we must have a very different quality of relationships within our enormous and increasingly divided Health Service. Our current system makes genuinely collaborative and cooperative work almost impossible. We certainly need to retrieve such collegial confederation in what you’re about to talk about…”
Jocelyn looks openly and genuinely puzzled: “In what way?”
I was expecting the question: “Because the Internal Market is divisive, and division is the opposite of integration. Yes, we want to ‘save money’ by keeping patients away from hospital A&E departments, but the hospitals want to ‘make money’ by treating ‘our’ patients there and then charging our Trust for their services. So in this commercialised, competitive healthcare system all the Trusts have to pour in money and professional time, attention and guile to stop the competing Trusts gaining advantage and control.
“In this kind of endless tug-of-war how can we assure our better qualities and energies? How can we perform our subtle, longer-viewed human welfare work? Welfare is not business. Providing people with good urgent care and advice often depends on making good, trusting relationships not only with them, but also between us – the healthcarers. We’re doing increasingly badly with the relationships…” I pause. “The Internal Market is ill-faring our Welfare”, I summarise with, I think, pithy bombast.
“Oh, that!” she says, as if irritated by familiarity. “You can’t change that. We’re much too far down the line to do anything about it. You’re right, but nobody’s going to listen to you. The system is far too entrenched and massive…” Her voice wearies, she looks away and her shoulders sag a little.
“Well, the Soviet Communist system looked pretty formidable for six decades, and then it rapidly crumbled…” I venture, trying to regain her interest or alliance.
Her shoulders rise and her voice sharpens. Her look is direct, strong and warmly ironic: “Six decades might be rather long for me. I have a family, a home, a job, and I want to keep them. With my work I’ll do what I can, but there’s no point my destroying myself trying to change what I cannot.”
My democratic heroism limpens.
Jocelyn enters the brightly lit conference hall. I escape in the opposite direction: a fugitive, alone and into the dark and silent car park.
This time, with Jocelyn, I do not insist on having the last word. She knows what I want to say: it would be clumsy and churlish.