David Zigmond https://www.opendemocracy.net/taxonomy/term/13610/all cached version 17/10/2018 06:57:43 en How and Why Do We Retire? Ill omens for younger doctors https://www.opendemocracy.net/ournhs/david-zigmond/how-and-why-do-we-retire-ill-omens-for-younger-doctors <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p class="MsoNormal"><span style="font-family: Arial, sans-serif; line-height: 1.5;">The nature of our departures from our work often tells us much about what kind of problems are being left behind. The individual may escape, but what about the wider community?</span></p> </div> </div> </div> <p class="MsoNormal"><span class='wysiwyg_imageupload image imgupl_floating_none 0'><a href="//cdn.opendemocracy.net/files/imagecache/wysiwyg_imageupload_lightbox_preset/wysiwyg_imageupload/549093/older doctor placard.jpg" rel="lightbox[wysiwyg_imageupload_inline]" title=""><img src="//cdn.opendemocracy.net/files/imagecache/article_xlarge/wysiwyg_imageupload/549093/older doctor placard.jpg" alt="" title="" width="460" height="307" class="imagecache wysiwyg_imageupload 0 imagecache imagecache-article_xlarge" style="" /></a> <span class='image_meta'></span></span><em>Image: Junior doctors protest, March 2016. Rights: <a href="https://www.flickr.com/photos/garryknight/22069970708">Garry Knight/Flickr</a></em></p><p class="MsoNormal"><span>The continuing troubles and discontents of junior doctors have evident newsworthiness; not so the equivalent problems in later careers. This is easy to understand: younger doctors have (we hope) a long future career ahead – that future is also </span><em>our</em><span> future healthcare, so we want them to be there, and in fine fettle. Older doctors will have retired from that picture: we are less concerned.</span></p> <p class="MsoNormal"><span>So, the morale and welfare of older doctors does not arouse the same kind of public interest or apprehension. Yet older doctors have much to tell us about our direction of travel: they have witnessed and practised many kinds of care and treatment, management and colleagueiality, ethos or its lack. Surely, the story and state of our elders’ retirement conveys much about the trend in our healthcare culture and, therefore, what we may expect.</span></p> <p class="MsoNormal"><span>Throughout my long NHS career I have talked with many doctors about their retirement. In previous decades the better ones (and there were many) left their work often in incremental stages – with much grace, gratitude, dignity, charity and affectionate appreciation. Importantly, this was reciprocal: the sentiments would resonate between their <em>community</em> of colleagues and staff. ‘The demands have often been difficult but our shared human rewards are rich. Thank you everybody’ was a common departing coda.</span></p> <p class="MsoNormal"><span>In the last decade such departures have become very rare. Retirement mindsets now are increasingly of wearied stoicism or sourness: either ‘Well I’ve made it to 60, thank goodness. I just hope there’s enough of me left to restore the rest of my life’, or ‘I’m 56 but my pension is now good enough to go early. I just don’t enjoy my work as I did. Not only can I not care for people like I used to, but I don’t feel cared for when I’m doing the work. Community?! I have become just a cog in The Machine.’</span></p> <p class="MsoNormal"><span>Less common – though previously almost unheard of – is the rapid and dramatic exit: the <em>coup de grace</em> of redundancy, decommissioning, CQC closure or contractual expulsion. Such are quotidian traumas in the realms of business, politics and sports management. The fact that doctors are now increasingly liable to such denouements tells us much about our changed healthcare culture.</span></p> <p class="MsoNormal"><span>So, if our retirement patterns are any kind of litmus test to predict our profession’s future, then junior doctors’ concerns will extend far beyond current disputes about pay and working hours.</span></p> <p class="MsoNormal"><span>Why do older doctors now become so enervated and disillusioned? What was different in previous decades? We can start to explain by considering this cluster of losses: the loss of time to care and relate to both patients and colleagues; the resulting loss of headspace and heartspace to make for human meaning and relationships; the inevitable loss of fraternal colleagueiality; the loss of the primacy of personal skills, understanding and trust to guide our work’s best decisions and conduct.</span></p> <p class="MsoNormal"><span>These are all losses to our <em>humanity</em>: the nourishment, stimulus and satisfactions we garner, exchange and recycle so that people can get to know and care about one another.</span></p> <p class="MsoNormal"><span>But how have we lost these things? These may be best understood as consequences of displacement. For our insistence on quantifiable, standardised, executised procedures has increasingly pushed out the innumerable, yet invaluable, aspects of our humanity that cannot be processed in this way. Deprived of its natural habitat our professional humanity first ails, then eventually dies. This is what the fractious unrest of junior doctors, and the caustic fatigue of retiring doctors, is telling us: we have – by over-management and excessive proceduralisation – rendered a world of work inimical to healthy and fulfilled lives.</span></p> <p class="MsoNormal"><span>Our NHS healthcare mostly used to function as a matrix with the ethos of a well-functioning <em>family</em>: personal bonds of familiarity and trust allowed for flexibility, natural growth and the friendly inclusion of others. But since the rise of the Internal Market, Corporate Managerialism and then the 4Cs – competition, commissioning, commodification and computerisation – we have created a network of <em>factories</em>. In these workers do what they are told: there is a cascade of executive instructions flowing from planners, designers, production engineers, production managers, performance managers and so on. The workers’ conduct and skills are defined, confined, boundaried, contracted and disciplined by executive decree. Autonomous professional judgement, wisdom, intelligence or experience become inadmissible, then obsolete.</span></p> <p class="MsoNormal"><span>This is the managed world, increasingly, that doctors are working in. From family to factory; from being guided by vocation to being controlled by corporation.</span></p> <p class="MsoNormal"><span>Our current retirement patterns tell us we are destroying the human heart of healthcare. That, surely, leads us to very bleak scenarios.</span></p> <p class="MsoNormal"><span>What can we do to avoid such a debacle? We might start by asking this kind of question: ‘how do we best understand one another’s human needs?’, rather than ‘how do we control all these other people?’</span></p> <p class="MsoNormal"><span>Charity begins at home.</span></p><div class="field field-rights"> <div class="field-label">Rights:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> CC by NC 4.0 </div> </div> </div> ourNHS uk ourNHS David Zigmond Mon, 05 Sep 2016 09:00:39 +0000 David Zigmond 105110 at https://www.opendemocracy.net Doctors have always been over-worked, but that's not what's causing the recruitment crisis https://www.opendemocracy.net/ournhs/david-zigmond/doctors-have-always-been-overworked-so-what-really-lies-behind-recruitment-cris <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>The greatest reward of being a doctor - relating to patients as fellow complicated human beings - has been lost amidst the growth of tick-box, corporatised management that treats all doctors as if they were 'duffers'.</p> </div> </div> </div> <p class="MsoNormal"><span class='wysiwyg_imageupload image imgupl_floating_none 0'><a href="//cdn.opendemocracy.net/files/imagecache/wysiwyg_imageupload_lightbox_preset/wysiwyg_imageupload/549093/doctorheart.jpg" rel="lightbox[wysiwyg_imageupload_inline]" title=""><img src="//cdn.opendemocracy.net/files/imagecache/article_xlarge/wysiwyg_imageupload/549093/doctorheart.jpg" alt="" title="" width="460" height="258" class="imagecache wysiwyg_imageupload 0 imagecache imagecache-article_xlarge" style="" /></a> <span class='image_meta'></span></span><em>Image: <a href="https://www.flickr.com/photos/62648476@N00/with/4545575241/">Flickr/ El Payo</a></em></p><p class="MsoNormal"><span>In the last twenty years I have seen my profession lose its vocational spirit and identity: heart and soul; art, intellect and wit. I do not believe these losses are primarily rooted in pay or funding, or even the volume of work, though clearly these are most easily cited by an unhappy workforce. </span></p><p class="MsoNormal"><span>Thirty years ago doctors usually worked longer hours and the remuneration was often less. What has got lost is more subtle. It is about personal identification and gratification, about the <em>relationships</em> we have with our patients and colleagues, about our work as human, rather than technical, experience. The problem is the nature of our work, rather than its volume.</span></p><p class="MsoNormal"><span>Thirty years ago I was a young GP working in the same small inner London practice I have managed – with great difficulty – to conserve. In those earlier years GPs had relatively low interprofessional status, often long and unremunerated working hours, yet much better motivation and morale. Doctors then mostly liked their work through long, stable careers, and then were reluctant to retire. Such personal–professional gratification reflected a culture that both allowed for, and gently encouraged, investment in relationships – both between doctors and patients, and within colleague-ial networks. These relationships developed and functioned relatively ‘naturally’ and informally, with a minimal amount of governmental or managerial control. Healthcare relationships were thus much like a massive extended family.</span></p><p class="MsoNormal"><span>But families are very variable: certainly not all function well or even legally. Even in the ‘best’ families there is sometimes dissonance and unhappiness. They might also not be the best human groupings for efficiency or production. </span></p><p class="MsoNormal"><span>So surely, some thought, with a modern health service, can we not get better and more homogenous outcomes by emulating manufacturing industries, competitive commerce or even military hierarchies? To do this we needed to transform the culture: from family to factory.</span></p><p class="MsoNormal"><span>This is what we have done in the last two decades. </span></p><p class="MsoNormal"><span>This very deliberate cultural transformation has been propelled along two axes: the <em>corrective</em> or <em>forensic</em>, and the <em>industrial.</em> </span></p><p class="MsoNormal"><span>The <em>corrective</em> and <em>forensic</em> imperatives are varieties of quality control. Their function is to identify, remedy or eliminate substandard, hazardous or corrupt practice (colloquially: ‘duffers’, ‘slackers’ or ‘rotters’ = DSRs). </span></p><p class="MsoNormal"><span>The <em>industrial</em> influences are those attempting to streamline and standardise activities so that they may be reliably managed and economically proceduralised. These are essential to mass production.</span></p><p class="MsoNormal"><span>The implementation of these measures has taken enormous human and economic resources. The results are very mixed.</span></p><p class="MsoNormal"><span>First, the positives. The individual DSR prevalence is probably much lower: evidently and substantially flawed practitioners are nettled much sooner. Critical diagnoses and treatments are delivered more speedily. There is more apparent transparency and accountability.</span></p><p class="MsoNormal"><span>All good, surely? Yes, but only up a point. Beyond that, more of something ‘good’ can be worse. This is often due to an ‘undertow’: powerful, countervailant forces not readily visible, yet decisive.</span></p><p class="MsoNormal"><span>It is this undertow that increasingly accounts for many paradoxes, and the perverse and unintended consequences of our highly managed system. </span></p><p class="MsoNormal"><span>Our increasingly dense and numerous appraisals, inspections, compulsory trainings, care pathways and performance indicators might reform or motivate some DSRs - but they also tire, deskill and demotivate many more who do not need such structure or guidance. In our efforts to guard against worst practice we inadvertently devitalise, even kill off, our best spirit and practice. The net losses are seriously impairing our healthcare.</span></p><p class="MsoNormal"><span>Before ratcheted management it was largely left to healthcare professionals and their peers to self-motivate. Certainly there were DSRs, but they were individual anomalies in largely sensible and benign institutions. </span></p><p class="MsoNormal"><span>Mid Staffs and its like show us how we have replaced this significant problem with something far more egregious. We now have entire institutions perverting care and concealing calumnies in order to favour their survival-slot in the larger Darwinian system. </span></p><p class="MsoNormal"><span>It is less likely to be the individual now that is a DSR: it is the bluffing but cowering institution itself. The individual has become a compliant or collusive cog. </span></p><p class="MsoNormal"><span>When coaxed to speak candidly these cogged individuals describe depersonalised, deskilled, dispirited obedience to strict, formulaic authority. Descriptions of affective attachments or creative identifications are remarkable by their absence.</span></p><p class="MsoNormal"><span>Yet our initiatives to industrialise healthcare have at times had extraordinary success. The elimination of poliomyelitis was achieved by millions of identical procedures that needed almost no attention to personal meaning, history or context. This kind of massive achievement is due almost entirely to brilliant technology and tight management.</span></p><p class="MsoNormal"><span>But elsewhere it is those jettisoned personal factors that provide most of the motivation, spirit and comfort essential to palliation and healing – not just to those who are sick, but also those who provide any continuity of care. Healthcare is often difficult and tiring work: to keep our minds sharp we must have intellectual freedom. But to keep our hearts engaged we need attachments and relationships that can grow in depth and value, both to us and the other. Our contemporary healthcare’s neglect and abandonment of this principle has led to the unimagined damage we must now repair.</span></p><p class="MsoNormal"><span>After much persistence I managed a conversation with an NHS manager, NM, about how our well-intentioned managerial systems can so easily, though inadvertently, destroy our essential human substrate. How we obliviously displace essences of our best imaginative personal care by default: a thraldom to ever-increasing administrative devices: the diagnoses, boundaried specialisms, care pathways, algorithms – the fare and decrees of Trust protocols and "best practice".</span></p><p class="MsoNormal"><span>NM is an intelligent man, but his loss of philosophical curiosity seems to me a microcosm of what I want to talk to him about. This loss is from pressure and attrition: from the endless, anxiety-auraed demands of his job and the massive system that expects compliant results but not challenging questions. He is having difficulty assimilating ideas alien to our corporatocracy: that the larger part of what I do lies outside such devices so ready to designate, manage, command-and-control.</span></p><p class="MsoNormal"><span>‘So what is this larger reality? What is it that you <em>do</em>?’ NM slows: his interest sounds genuine. I venture a complex answer.</span></p><p class="MsoNormal"><span>‘In a working day I see many different kinds of people with even more different kinds of problems. Some of these are relatively simple, they can be dealt with at face value, by our formulaic devices. But many more cannot: with these the presenting problem is encoding or masking or displacing another that might be more important. Then I have to have the time, skill and interest to decipher this and its human meaning – its subtext and context.’</span></p><p class="MsoNormal"><span>‘So what are the skills you’ve developed to do that?’ NM’s curiosity is growing.</span></p><p class="MsoNormal"><span>‘Very often, when someone sits down with me, I have less than fifteen minutes to grasp a whirling kaleidoscope of loosely related notions and then offer my most useful, though always incomplete, synthesis of understanding and suggestion …’</span></p><p class="MsoNormal"><span>‘Meaning?’ I am already losing NM.</span></p><p class="MsoNormal"><span>‘Well, I quickly have to grasp the nature and mind of the person, sometimes a couple or family. I need to imaginatively surmise what kind of language, understandings and imagery they use. Then I am in a better position to understand what we are saying to one another, and what this means to <em>them</em>: the discrepancies are often crucial. What they are <em>not</em> saying can be more important than what they <em>are</em> saying. And here is fragile territory: whether to approach the unexpressed, and if so how directly?</span></p><p class="MsoNormal"><span>‘Within a few minutes I have to address both their personal experience and understanding and my constructed meaning of diagnoses and therapeutics. Then there are the time-strata to stage manage: is my influence just for now, or am I also thinking of tomorrow, next week, month, year … or beyond? Often, too, my formulation and intervention must include others in the person’s life – sometimes they are non-existent: the ghosts of the departed or the promise of the unborn.</span></p><p class="MsoNormal"><span>‘Each time I encounter someone I am attempting this: to craft and choreograph such complex and bespoke empirical responses …’ I pause.</span></p><p class="MsoNormal"><span>‘That sounds quite a package … you must be asking a lot of questions’, NM says.</span></p><p class="MsoNormal"><span>‘Yes and no. First, my response must be not a package: I must keep it open, so that I can easily add, retrieve or change things – that’s the opposite of a package. And then, although I must keep my mind open to many possibilities, a lot of these are necessarily implicit or imaginative. Personal knowledge is only partly about stated fact; much more is about inferred meaning. So I may enquire widely but not ask many questions …’</span></p><p class="MsoNormal"><span>‘How can that be?’ NM is perplexed by the apparently irrational.</span></p><p class="MsoNormal"><span>‘Think about a skilled artist or cartoonist. Often with a few discrete and imaginative lines they can capture far more than a much more detailed and methodical depiction. Excess detail gets us to see less, not more.’</span></p><p class="MsoNormal"><span>‘How is that related to holism?’ NM is now casting imaginative lines: he knows my ethos.</span></p><p class="MsoNormal"><span>‘Holism is not about massing and then schematising lots of facts. It is riskier than that. It pursues unobvious connections and the possible meaning and influences between facts. Holism is often about the spaces between things: the interstices rather than the atoms. As with the artist, the skill is knowing when to leave things out.’</span></p><p class="MsoNormal"><span>‘Do all the recent NHS changes make that harder for you?’ NM is focused and serious.</span></p><p class="MsoNormal"><span>‘Yes! Our increasing systems and management tend to an ever-greater acquisition of data that we can then only deal with by atomisation: everything becomes reduced to parts and procedures – the opposite of holism: “the Whole is more than the sum of its parts”.’</span></p><p class="MsoNormal"><span>‘And then?’</span></p><p class="MsoNormal"><span>‘All sorts of things get lost. Relationships get lost: we don’t perceive them or have them … they become supplanted by prescribed tasks. But much of my therapeutic leverage comes from understanding, enacting and influencing relationships. And, equally important, it’s that pursuit of holism that keeps my Mojo going. Holism, like play, grows things: it’s creative. Atomism and proceduralism chops things up into they unliving: as it increases it deadens the mind and spirit.’ My voice fades.</span></p><p class="MsoNormal"><span>‘What about the new initiatives for "integrated care"?’ NM’s voice is brighter: he is trying to revivify and integrate me.</span></p><p class="MsoNormal"><span>‘Well intentioned, but doomed …’</span></p><p class="MsoNormal"><span>‘Why?’ NM’s monosyllabic question is firm and stern.</span></p><p class="MsoNormal"><span>‘Because already – so soon – “integrated care” and “holism” have been commandeered by managerial proceduralism. They become prescribed and protocoled by Trusts. They become add-ons to all the other – increasingly unsustainable – “must-do” lists: more boxes to tick. Yet essentially holism is a philosophy, an ethos, a metaphorical effusion and engagement of the heart: if we attempt to directly manage or commodify such things we destroy them. They must evolve <em>in vivo</em> but are often extinguished <em>in vitro</em>.’</span></p><p class="MsoNormal"><span>&nbsp;‘Are you saying we need less management?’ NM’s question is direct and level.</span></p><p class="MsoNormal"><span>&nbsp;‘Yes, but more discriminating and trusting… we must re-establish a culture where experienced practitioners are themselves trusted to make intelligent discriminations: to decide – in our endlessly imperfectible work – what, in each situation, is the wisest, most creative, humane and sustainable compromise.’</span></p><p class="MsoNormal"><span>‘Isn’t that risky? Won’t mistakes get made?’</span></p><p class="MsoNormal"><span>&nbsp;‘Of course, But probably not so much as our current risk-averse corporatocracy, which has left us with so little head and heart-space, and so much demoralised exhaustion.’</span></p><p class="MsoNormal"><span>&nbsp;‘So you want to radically rescind and redesign our redesign. Where would you start? What would you do?’ NM seems warily and furtively frisonned by possibility.</span></p><p class="MsoNormal"><span>‘Oh, I have many ideas, but they need many more conversations.’</span></p><p><span>I welcome them, with many others.</span></p><p>&nbsp;<em><strong>Like this piece? Please donate to OurNHS&nbsp;</strong></em><a href="http://www.opendemocracy.net/ournhs/donate" target="_blank"><strong>here&nbsp;</strong></a><em><strong>to help keep us producing the NHS stories that matter.&nbsp;Thank you.</strong></em></p><div class="field field-rights"> <div class="field-label">Rights:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> CC by NC 4.0 </div> </div> </div> ourNHS uk ourNHS Europe the very idea David Zigmond Fri, 26 Jun 2015 13:48:15 +0000 David Zigmond 93900 at https://www.opendemocracy.net Lives are being lost due to the heart-failure of marketised healthcare https://www.opendemocracy.net/ournhs/david-zigmond/lives-are-being-lost-due-to-heartfailure-of-marketised-healthcare <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>MPs criticise the NHS for mental health failings this week - but the real problem is a competition-based focus on treatment rather than on care. </p> </div> </div> </div> <p><span class='wysiwyg_imageupload image imgupl_floating_none 0'><a href="//cdn.opendemocracy.net/files/imagecache/wysiwyg_imageupload_lightbox_preset/wysiwyg_imageupload/553846/unnamed_0.jpg" rel="lightbox[wysiwyg_imageupload_inline]" title=""><img src="//cdn.opendemocracy.net/files/imagecache/article_xlarge/wysiwyg_imageupload/553846/unnamed_0.jpg" alt="" title="" width="460" height="307" class="imagecache wysiwyg_imageupload 0 imagecache imagecache-article_xlarge" style="" /></a> <span class='image_meta'><span class='image_title'>image: Flickr/Thomas Lieser (https://www.flickr.com/photos/onkel_wart/)</span></span></span></p><p>People with mental health problems are receiving ‘substandard care’, <a href="http://www.theguardian.com/society/2015/mar/04/speed-up-efforts-to-improve-poor-mental-heath-care-in-nhs-say-mps">MPs complained this week</a> in a report from the All-Party Parliamentary Group on Mental Health. </p><p>Two months ago the media briefly frissoned another dark story from our NHS: <a href="http://www.bbc.co.uk/news/uk-30236927">seven recent suicides and one homicide amongst acutely mentally ill patients</a> who had been told no psychiatric beds were available for them. </p> <p>But how have these problems arisen - and what can we do about them?</p> <p>As a young psychiatrist forty years ago I heard hopeful talk about how more scientific diagnosis and specialist, focused treatment would make longer-term and residential care unnecessary. As with surgery, improved speed, accuracy, and efficiency would benefit mental healthcare (and deliver economic savings). The closure of large mental hospitals became a celebrated symbol of this. </p> <p>My view, though youthful, was jaded: we were over-reaching our medically-modelled treatments to complex human distress. </p> <p>*</p> <p>Most of these early doubts have proved dishearteningly accurate. As a now veteran inner-city GP I have seen the dismemberment, then disappearance, of our better forms of long-term containment and care. It is not just that the asylums have closed. It is that the wider ethos of ‘asylum’ – compassionate containment – has become increasingly rare. </p> <p>I find it <a href="http://www.theguardian.com/society/2015/feb/01/mental-health-care-pushed-breaking-point-lack-beds-psychiatrists-nhs-hospitals">almost impossible now</a> to find for my patients the kind of protective spaces and relationships that are essential for many kinds of healing and growth – the kinds of investment I could more easily make as a young practitioner. </p> <p>How has this happened? How – amidst our plethora of Royal Colleges, think-tanks, specialist trainings and massive resources (yes!) – have we departed so far from our better sense and sensibility? </p> <p>*</p> <p>We have failed to heed the subtle differences yet synergy between <em>treatment</em> and <em>care</em>, and have thus lost our capacity to craft our best <em>therapy</em>. </p> <p>Care comes from ethos, while treatment comes from technology. Care is about wholes and relationships, treatment is about parts and mechanisms. Care springs from – then returns to – the intersubjective, treatment remains closely tethered to the objective. </p> <p>Treatment may fix, but it is care that heals. </p> <p>In recent times we have lost the skills of blending these delicate amalgams. Paradoxically, this is due to the many and dramatic successes of our technological treatments. We have adopted such potent activities as the dominant and determining paradigm. </p> <p>Increasingly we have replaced care by treatment; personal understandings by <a href="http://www.theguardian.com/society/2015/jan/18/lib-dems-zero-suicides-nhs-blue-monday-labour-children-mental-health">formulaic care-pathways</a>. Pastoral healthcare - all those therapeutic engagements that cannot be resolved rapidly by standardised, technology-based interventions - now suffers.</p> <p>As the technologically complex sharpens and burgeons; the humanly complex is short-circuited and neglected. </p> <p>*</p> <p>Such displacement of care by treatment is seductive. Treatment seems to bypass human vagaries and uncertainties and, instead, anchors us to what can be reliably manufactured, measured and managed. But like many seductions this is hazardously specious. It obscures what we may lose – our unindustrialisable humanity – our realms of relationship, imagination, meaning and spirit, our ability to circulate with others, to heal and grow – or to endure with equanimity. </p> <p>*</p> <p>The economic costs of our loss of compassionate human containment are hard to measure but probably vast. Much distress is pleomorphic: it takes on other forms and is then dealt with by other agencies: <a href="http://www.dailymail.co.uk/wires/pa/article-2951741/Alarm-call-mentally-ill-young.html">A&amp;E departments</a>, <a href="#.VPg5iPmsVGM">other medical specialists</a>, <a href="http://www.bbc.co.uk/news/uk-31149226">police</a>, Social Services, probation, courts, lawyers, <a href="http://www.theguardian.com/society/2014/may/24/we-are-recreating-bedlam-mental-health-prisons-crisis">prisons</a> (a desperate asylum)… </p> <p>Such human and economic cost extends far beyond psychiatry. The submission of care to treatment has etiolated the entire spectrum of pastoral healthcare, including mental health, general practice, chronic disease and rehabilitation. In a culture dominated by goals, targets, financially linked points, managed procedures and care pathways there is less and less head-space and heart-space to nourish human imagination, connection and meaning. </p> <p>What then?</p> <p>To start, we become demoralized and alienated.</p> <p>Morale and sense of connection are crucial to human welfare. Several decades of research has shown how important these are in the genesis and outcome of innumerable health and welfare problems - both for patients, and staff. </p> <p>Evidence mounts of NHS healthcarers’ increasing demoralisation and burnout. We see it officially in statistics of sickness, early retirement, career abandonment, emigration, drug and alcohol abuse and litigation. We hear it informally in a steady flow of descriptions of professional loss, alienation and stress. Our healthcare ‘family’ has turned into a hostile network of siloed and fractious factories. </p> <p>Personally infused acts of care become executively managed procedures; the quiet warmth of vocation becomes the staccato clamour of career. Such accounts have common undertones: bleak loneliness, dispirited ennui and impotent anger.</p> <p>By contrast, good quality care nourishes the giver as well as the recipient, for care – unlike treatment – is rooted in human resonance. This is what we have jettisoned. </p> <p>*</p> <p>‘Seven suicides and one homicide’ was a deserving headline, yet merely the iceberg’s tip. Far beneath the surface, extending massively, lies the dying body of an ancient healthcare ethos. </p> <p>How can we resuscitate a dying culture?</p> <p>What are the best conditions to foster experiences of meaning and connection in our work?</p> <p>As with any living culture we must first depend on a nurturing substrate. Yet our NHS substrate is now formulated in a way that becomes heedless of this vitalising principle. It is a realm is now governed by institutions and language of lifeless objects. Purchasers and providers, competitive markets, commissioning, commodification, and competition between <a href="http://www.theguardian.com/society/2014/dec/17/hospitals-maternal-mental-health-charlotte-bevan">boundaried, autarkic trusts</a>. </p> <p>In such a milieu our contacts and experiences become disinvested in human interest and relationship. We are now confronted with a very difficult dilemma. To make a path back to a humanly nourishing and sustaining culture will require much demolition of many of these recent developments.</p> <p>The stakes are high: contention will be fierce.</p><p><em><strong><span>Like this piece? Please donate to OurNHS&nbsp;</span><a href="http://www.opendemocracy.net/ournhs/donate" target="_blank"><span>here&nbsp;</span></a><span>to help keep us producing the NHS stories that matter.&nbsp;Thank you.</span></strong></em></p> ourNHS ourNHS David Zigmond Thu, 05 Mar 2015 12:11:58 +0000 David Zigmond 91052 at https://www.opendemocracy.net NHS England 2014: Vichy France 1941 https://www.opendemocracy.net/ournhs/david-zigmond/nhs-england-2014-vichy-france-1941 <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>Doctors are being turned into Commissars, Apparatchiks and Healthdroids, mutely collaborating with endless health ‘reforms’. History reminds us why we must resist such totalitarianism.</p> </div> </div> </div> <p class="MsoNormal"><span>‘</span><em>Let your mind wander in simplicity, blend your spirit with the vastness,&nbsp;</em><em>follow along with things the way they are, and make no room</em><em>&nbsp;for personal views – then the world will be governed’</em></p><p class="MsoNormal"><em><em></em><span>– Zhuangzi </span><em>Chuang Tzu</em><span> (3</span>rd<span> century BC)</span></em></p><p class="MsoNormal"><span>It is midday, late July. The sunlight is sharp and the air hot, cloying and still. <strong>In th</strong><strong>e</strong> care-worn meeting room the delegates are lunch-fuelled by paper-plated utility sandwiches. The extra glare from neon lights is unnecessary: a rarely noticed sign of institutional routine and oblivion.</span></p><p class="MsoNormal"><span>This is where I must come to attend my Locality GP Clinical Commissioning Group. As a long-serving family doctor I must join this group to assure survival of my small practice, and thus my employment. Effectively, I need the protection of The Mob: like all others I was made an offer I could not refuse.</span></p><p class="MsoNormal"><span></span><span>The energy in the room is torpid and listless. Trunks are slouched submissively but extremities fidget, eyes </span><strong>are vacant, dreaming</strong><span>, or avoidant.</span></p><p class="MsoNormal"><span>The luckier members are busied by minute-taking, document distribution or data-presentation and dispersal. The trickiest job here is reserved for Dr C, a <strong>handsome forty-something</strong> with an easy, avuncular style of competent organisation. </span></p><p class="MsoNormal"><span>I sense in him a decency which wishes to gently assert good authority yet eschew conflict. His job is not just to conduct the agenda, but to convey a sense of purpose and mission. This is not easy: the group is largely made up of conscripts. </span></p><p class="MsoNormal"><span>There are two main topics from today’s presenters. The first is a large Hospital Trust that is a major ‘Provider’. Allegedly this hospital has ‘failed’ in its contractual obligations. Evidence for this is provided by streams of verbal data and clutches of charted and bullet-pointed documents. The complexity of these is not matched by equivalent discussion.</span></p><p class="MsoNormal"><span>I am uncomfortable about complex statistics. Many times I have seen NHS professionals ‘cleverly’ redesignate, elide and double count with devious legality. I need to ask many, many questions about samples, sources, methods and contexts before I offer any assured clarity. This would take me days of dialogue and thought. I do not want to express a hurried view. I speak up, saying I want to ask some elementary questions.</span></p><p class="MsoNormal"><span>Dr C shows his first frisson of irritation. “Didn’t you read the email documents we sent round?” he asks. His question is rhetorically toned with accusation.</span></p><p class="MsoNormal"><span>“No”, I say, “I do not read any of these and will tell you why. It is because it is impossible for me to offer the kind of service I would like to receive as a family doctor and personal physician if I follow the major distraction of attempting, also, to be a competent statistical analyst, actuary or public health adjudicator…”</span></p><p class="MsoNormal"><span>“Well in that case you cannot make a useful contribution to this discussion.” He thrusts quickly. I think he thinks I am silenced.</span></p><p class="MsoNormal"><span>I am not: “I think your equation implies a serious error. I think very few, if any, GPs here have thoroughly read such documents …”. I turn to them: “Tell us, who of you here can willingly or competently deal with all this stuff? The problem is that a useful discussion is not possible, not that I am a useless discussant.”</span></p><p class="MsoNormal"><span>A few look at me silently and nod encouragingly. More, also silent, look down and away, hoping the dissonance will pass: they hate it when parents argue.</span></p><p class="MsoNormal"><span>I am disliking the process of this meeting, too. Typically the presenters speak continually for about fifteen minutes. This is followed by a few minutes’ questions choreographed by the chairman: I sense he hoped for broad consonance. If I speak for more than thirty seconds I sense Dr C’s restiveness. At fifty seconds he gestures for me to stop. At sixty seconds he verbalises this. Such a format may be adequate as a formal briefing or a press-conference. But it is dialogue I want. I cannot be of any real use, here, without it.</span></p><p class="MsoNormal"><span>I cast a second baited-line.</span></p><p class="MsoNormal"><span>“Even if all these poor Performance Indicators are ‘true’, there are still many questions to answer about <em>why</em> which need to inform us … Why and how do people like us (for they probably are) become (allegedly) deskilled, inefficient, unmotivated or disconnected?” </span></p><p class="MsoNormal"><span>Many of my colleagues look confused. This neon-lit room rarely explores inner human illumination.</span></p><p class="MsoNormal"><span>Dr C again: “I want to stop you there.”</span></p><p class="MsoNormal"><span>I rebel: “Well, I do not want to be stopped just yet. Eventually I want real dialogue here, but until then I want to say this about our ‘underperforming provider’: such people are our erstwhile colleagues. I do not believe that strictures or punitive methods can help or remedy such difficulties. Our language and thinking now reminds me of our worst kind of psychiatry: clustering descriptions or symptoms together and then assuming we can ‘manage’ the underlying complex human problems with little human understanding or curiosity. Yes, I understand we are following official procedure. But by merely implementing government policy without freer discussion and caveat, we both collude with and conceal governmental blindness.”</span></p><p class="MsoNormal"><span>After sixty seconds. Dr C’s jaw tightens. “I really can’t have you taking over the meeting like this …”</span></p><p class="MsoNormal"><span>“I am not trying to ‘take over’ any meeting, but I am pushing for less edited exchanges – yes, sometimes difficult conversations – and that requires a certain equality of transmission and audience. I definitely do not want these smoothed-out briefings.”</span></p><p class="MsoNormal"><span>At eighty seconds, Dr C’s ire is mounting. I stop.</span></p><p class="MsoNormal"><span>There is another speaker. She is talking about the population’s misuse and overuse of Accident and Emergency departments. There is the inevitable talk of procuring new data and systems and endless audits to fuel our statutory requirement to present ‘solutions’. Yet this is an elaborate folly, for with this kind of problem there are not solutions, only our wisest, workable compromises. This seems inassimilable to modern systems-thinkers. </span></p><p class="MsoNormal"><span>I want to share some of this. I dodge past Dr C’s curfew.</span></p><p class="MsoNormal"><span>“We have been recycling very similar concerns, investigations and documents for more than twelve years. Some truths emerge and remain constant and clear. For example, all GPs can do is offer accessible, friendly and competent consultations and then draw clear attention to the correct use of emergency and out of hours services. The important thing that has changed – and worsened the situation – is the effect of the Market. We talk of ‘Integrated Services’ with other sectors, but this is countervailed by a system that is competitive and divisive … and then, of course, mistrustful. We must carefully review this bigger picture and its history…”</span></p><p class="MsoNormal"><span>Forty seconds. He stops me: a more irate interception. “We really don’t have time for all this and, in any case, this is not the correct meeting for such things…”</span></p><p class="MsoNormal"><span>“That’s the problem!” I interrupt his interception. “There is now no ‘correct meetings for such things’. We have been made mute and compliant. That is why I am, here, so defiant and verbal.”</span></p><p class="MsoNormal"><span>Dr C is glowering. I stop. </span></p><p class="MsoNormal"><span>*</span></p><p class="MsoNormal"><span>Consider this. Before the last General Election in 2010 the Conservative Party stated with explicit clarity that it would not introduce any major reorganisation into the NHS. But Andrew Lansley MP had spent many years with others, designing and harbouring other plans. </span></p><p class="MsoNormal"><span>Once in power, as Health Secretary, he unleashed them. With formidable stealth, guile, ambition and deceit he pushed through the <em>Health and Social Care Act 2012</em>, facing only confused and disorganised opposition. Few understood the complex nature and implications of this Act. But Lansley’s <em>Blitzkrieg</em> success turned to a personal pyrrhic victory for <em>he </em>probably had not fully understood the implications of his Act. He was unable to contain the questioning and angry dissent that followed people’s clearer perception and realisation of what the Act entailed. The political Victor became a liability: a replacement was needed. Jeremy Hunt’s skills of diplomacy and damage-limitation have saved the government from more immediate hazard.</span></p><p class="MsoNormal"><span>Beyond the political arena Lansley’s pyrrhic victory has much worse consequences for practitioners and patients. Professional support for his ideas was always meagre. Yet generally the profession is now settling into a three-tier system of Commissars, Apparatchiks and Healthdroids. This, paradoxically, is very similar to the old anti-marketised Soviet Union.</span></p><p class="MsoNormal"><span>Lansley had a brief party. The rest of us face a long period clearing the mess.</span></p><p class="MsoNormal"><span>The deceit involved in the coup procuring this Act was far more thorough, dishonest and deliberate than the usual fickle expedience behind improvisatory changes of tack and U-turns. It was long conceived and disguised: this was more malfeasance than Realpolitik. Such chicanery in public affairs is certainly immoral: it should be illegal. Yet it is already receding beyond shared memory: it should not.</span></p><p class="MsoNormal"><span>My altercations with Dr C are legacies of this expertly crafted betrayal. They are conflicting reactions: expedient pragmatism versus ideology of conscience.</span></p><p class="MsoNormal"><span>Dr C is saying: “<em>Keep your heads down and don’t make trouble. Meanwhile I and my lieutenants will garner the most workable arrangement we can manage with the authorities. This is our best chance. Don’t spoil it.”</em></span></p><p class="MsoNormal"><span>I am saying: “<em>We have been passed a poisoned chalice and then trapped into being its custodians. This act of deceit and folly is still poorly apprehended and understood by many, including government and its agencies. Collusion can only be temporarily beneficial: ultimately, it is radically damaging both to personal healthcare and democratic politics. We must refuse this chalice and articulate clearly why we do so.”</em></span></p><p class="MsoNormal"><span>*</span></p><p class="MsoNormal"><span>The meeting ends with uneasy energy but correct and clear formality. Dr C walks with purposeful swiftness to his car. I wish to extend an emergency bridge, to ensure we can reach each other over these troubled waters. I get to him just as he is entering his car. He sees me, swiftly closes the door and opens its window: a smaller portal for exposure.</span></p><p class="MsoNormal"><span>“Dr C, I just want to say that what I say and do is not, ever, personal – though it is personally difficult. I am sorry for those difficulties, but I think what I am saying is becoming increasingly important as it becomes increasingly neglected and circumvented. <em>Because</em> of these difficulties we must find the courage and flexibility to have these struggles publicly…”</span></p><p class="MsoNormal"><span>Dr C looks angry and hurt: “I think you’re just very rude.”</span></p><p class="MsoNormal"><span>“What is your understanding of ‘rude’?” This is a genuine enquiry.</span></p><p class="MsoNormal"><em><span>“That</span></em><span> is rude. How you behaved in the meeting.”</span></p><p class="MsoNormal"><span>“Well, what I did was certainly counterconventional and outside usual exchanges. Our institutional routes of exchange have rapidly stifled any bold questioning or challenge.&nbsp;</span><span>Candour is often risky, but the risks of not being candid are often greater…”</span></p><p class="MsoNormal"><span>“Well in my book, it’s just plain rude.” Dr C puts the key in the ignition. I might cast one last line.</span></p><p class="MsoNormal"><span>“Look”, I say, “all these recent reforms – the last in particular – have managed to corral us into short-term and craven compliance, but we are rapidly losing the identity and integrity, the heart and soul – and now the wider intellect – of our profession. I hear this so often privately, but never in these meetings. Why?”</span></p><p class="MsoNormal"><span>I pause to look at him, but he averts his gaze. I want to finish. “It is the most difficult conversations that are the most interesting and ultimately rewarding. You and I could have several: I would like that.”</span></p><p class="MsoNormal"><span>Dr C is gazing fixedly at his dashboard instruments, as if they might have instructive data for this situation.</span></p><p class="MsoNormal"><span>“Maybe”, is the single word, but I imagine “never” in his clipped tone. I notice his tight-knuckled grip on the steering wheel.</span></p><p class="MsoNormal"><span>“I really must get on now.” He presses a button. The electric window slides up and closes. He looks away.</span></p><p class="MsoNormal"><span>Isaac Newton reportedly said that tact is the art of making a point without making an enemy. I think Newton would have been ahead of me at this stage.</span></p><p class="MsoNormal"><span>*</span></p><p class="MsoNormal"><span>As I turn I find Dr E unexpectedly waiting for me.</span></p><p class="MsoNormal"><span>Dr E is an elegant, bright shadow: an enigma. He has an intelligent gaze set in an expression of astringent humour. I have sat with him in dozens of meetings over many years. He sits always in watchful silence. I sense his complex intelligence, but have never heard it.</span></p><p class="MsoNormal"><span>Dr E now seems to want to talk to me. I am again struck by his unflustered immaculacy: the coolest man fresh from a hot cauldron.</span></p><p class="MsoNormal"><span>He makes subtle gestures for me to follow. “Oh”, I ask, “can you give me a lift?”. “Sure, sure…” he seems to have anticipated this.</span></p><p class="MsoNormal"><span>We are sitting in a slinky, swoopy, shiny air-conditioned large Mercedes: a silent haven of peace.</span></p><p class="MsoNormal"><span>He turns a warm fraternal smile towards me and pats the steering wheel softly.</span></p><p class="MsoNormal"><span>“You know, you’ve been saying these things for some time … They are very interesting and I agree with you wholeheartedly. I think you know that…”</span></p><p class="MsoNormal"><span>He is like a cat, I think: quiet, precise, contained. </span></p><p class="MsoNormal"><span>“How would I know that?” I ask, a genuine question.</span></p><p class="MsoNormal"><span>“I think you do”. Feline economy.</span></p><p class="MsoNormal"><span>“But if you’ve agreed with me for so long, why don’t you say so publicly?” Another genuine question, but now implicated with a plea.</span></p><p class="MsoNormal"><span>“There is no point in making trouble. They know what they want to say, what they want to do. They are only interested in endorsements and minor suggestions: otherwise they do not want to hear anything. I come here because I have to: it is a statutory requirement. I have loved my work and I want to go on with it: I don’t want trouble. So I say nothing.”</span></p><p class="MsoNormal"><span>“Like the Three Monkeys”, I say.</span></p><p class="MsoNormal"><span>He beams another smile, more conspiratorial: “Exactly. But I survive.”</span></p><p class="MsoNormal"><span>“So, all our politically correct blather is already fuelling a new Oligarchy”, I frown.</span></p><p class="MsoNormal"><span>“It is how our world works now. Unless you want to be a manager, just find a tolerable spot and be quiet…”</span></p><p class="MsoNormal"><span>We lapse comfortably into an intimate silence. He knows this locality well, but I notice he has taken a very long route. </span></p><p class="MsoNormal"><span>*</span></p><p class="MsoNormal"><span>The next day Veronique is sitting in my surgery. I have known her for thirty years. Her determinedly upright carriage, tastefully bright clothing and engaging, quick mind do not convey her painful widowhood or her eighty-two years. But her eyes often recede into ancient pools of sorrow and flitting wariness.</span></p><p class="MsoNormal"><span>When she was a ‘happily married’ middle-aged woman she told me the human story behind her well-guarded persona. </span></p><p class="MsoNormal"><span>She was eight years old at the time of the Fall of France. Her father was the Mayor of a small southern French market-town. Veronique’s family until then remains memoried by images of harmony, laughter, popularity and comfort. Those blessings abruptly end with the German occupation: she would never again experience such felicitous security.</span></p><p class="MsoNormal"><span>Her father had a grave dilemma: whether to expediently submit to the inevitable (cooperation with the invaders), or whether to heroically cleave to his principles (perilous defiance of the invaders). He chose the former: he felt a protective mission for his family and his regional kith and kin. “This is for the best, you’ll see”, he had reassured.</span></p><p class="MsoNormal"><span>This ‘greater good’ was first thorny, then elusive, and then clearly impossible. Compromises became betrayals, collaboration became treachery. By the end of the War the town’s paterfamilias was turned into a figure for pillory and contempt – sometimes by those who had sought favour before the turning of the War’s tide. </span></p><p class="MsoNormal"><span>Veronique’s father was not tried, though he was stripped of his Office and his furniture business collapsed. He retreated into a shuffling and nearly mute melancholy, leaving his family socially ostracised. Mother was abject with shamed grief, Veronique friendless and spat at. At her earliest adult opportunity Veronique left them, and made her life, home and marriage with an Englishman.</span></p><p class="MsoNormal"><span>Years ago she had, with me, tearfully unpacked some of her grief for the father she had lost, and who had lost himself. She was also grieving for her childhood friends and neighbours who had lost themselves – first by expedient collusion with her father, and then by disownership of their complicity, and then blustering, expedient blame.</span></p><p class="MsoNormal"><span>Seventy years after the national collaboration crumbled, Veronique is describing to me her disturbed sleep and bowel function: a familiar pattern. I ask a few medical questions. Her symptoms are ‘functional’: like a spitting semi-somnolent volcano from a deep and ancient subterranean source. I cannot stop this deep-rooted turbulence, only quieten some of its quakes. Then – possibly – I can encourage conduits that bring words and thoughts of personal meaning.</span></p><p class="MsoNormal"><span>Veronique knows I cannot cure her, but she continues to want me to know of her plight, struggles and sorrows. She wants some form of witness and shared understanding. In the crucial events of her childhood such human connection was not there. Seventy years later it is important that I provide it.</span></p><p class="MsoNormal"><span>This is very complex, but we do not need to say much.</span></p><p class="MsoNormal"><span>“Do you think it’s my usual troubles, doctor?”</span></p><p class="MsoNormal"><span>“Yes, I do, Veronique. I can give you some tablets to calm your night-time mind and gut, but their source is beyond my reach…”</span></p><p class="MsoNormal"><span>“So, it’s my ghosts again …” her sorrow is fringed with playful recognition.</span></p><p class="MsoNormal"><span>“Yes”, I say, “they will probably outlive us both.” </span></p><p class="MsoNormal"><span>*</span></p><p class="MsoNormal"><span>For years Alan’s quiet and intelligently respectful medical work was both respected and rewarded by promotion to senior positions in executive and academic bodies. Recent years have disappointed him as he has seen his vocational ethos eroded by an alien cultural tide. He now talks of retirement: it would be earlier than he had wanted.</span></p><p class="MsoNormal"><span>I am telling him of my recent discordances. He listens with supportive attention for a while and then starts drumming his fingers. </span></p><p class="MsoNormal"><span>He meets my gaze.</span></p><p class="MsoNormal"><span>“Of course, I agree with you. And I’ve tried – in my own way – to politely say similar things when I can, but it makes no difference. It’s like trying to talk to a herd of buffalos stampeding in another direction. And I’m not like you: I can’t cope with all these kinds of conflict and unpleasantness…”</span></p><p class="MsoNormal"><span>His voice sinks then strengthens again. “But I suppose one has to think positively: that – eventually – there will be a backlash.” </span></p><p class="MsoNormal"><span>I am struck by the personal disengagement and slippery vagueness of his language.</span></p><p class="MsoNormal"><span>“Yes, but what is a ‘backlash’? And what is ‘eventually’? Anything effective is going to need clear and explicit opposition. Who? How? When? …” I am showering sparks of defiance.</span></p><p class="MsoNormal"><span>Alan looks at me but does not speak. He spreads his empty hands, palms outwards and upwards, toward me. I read the wordless message: “<em>Not me, Not now. I have done what I can. Over to you. My hands are empty, but they are clean.”</em> </span></p><p class="MsoNormal"><span>*</span></p><p class="MsoNormal"><span>&nbsp;</span><span>My last week’s exchanges with Dr C, Dr E, Veronique and Alan have converged in my mind. How difficult, messy and ultimately disappointing is democracy – yet how much worse the more expedient systems turn out to be.</span></p><p class="MsoNormal"><span>Many years ago – when it was much less necessary – I found ready discussion with my colleagues about such matters. Increasingly we now cannot find time or see the relevance. </span></p><p class="MsoNormal"><span>Is my cacophony with Dr C an early example of Alan’s delegated ‘backlash’? Could it even be an answer to our current Health Secretary’s recurrent plea for a ‘change of culture’? And could such change ever be orderly?</span></p><p class="MsoNormal"><em><span>'<em>If I am not for myself, who will be for me?<br /></em></span><span>&nbsp;If I am only for myself, what am I?<br /></span><span>&nbsp;If not now, when?'</span></em></p><p class="MsoNormal"><em><em><span></span></em><span>– Rabbi Hillel Hababli (1</span>st<span> century AD)</span></em></p><p class="MsoNormal"><span><em>&nbsp;</em></span></p><p class="MsoNormal"><em><span></span><span>‘</span><em>The reasonable man adapts himself to the world:&nbsp;<br /></em><span>the unreasonable one persists in trying to adapt the world to himself.&nbsp;<br /></span><span>Therefore all progress depends on the unreasonable man’</span></em></p><p class="MsoNormal"><span><em>– George Bernard Shaw (1903) <em>Man and Superman</em></em></span></p><p class="listparagraph">This is an edited version of a piece by <a href="http://www.marco-learningsystems.com/pages/david-zigmond/david-zigmond.htm">David Zigmond</a>.&nbsp;</p> ourNHS ourNHS David Zigmond Tue, 02 Sep 2014 12:48:32 +0000 David Zigmond 85636 at https://www.opendemocracy.net Depression needs more than mass-produced talking treatment https://www.opendemocracy.net/ournhs/david-zigmond/depression-needs-more-than-massproduced-talking-treatment <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>Has there really been a breakthrough in talking treatments for depression as claimed, or are formulaic policies driving out more humane interactions with the mentally unwell?</p> </div> </div> </div> <p class="s4"><span class="s5">Earlier this month eminent academic psychologist Professor David Clark</span><span class="s5">&nbsp;broadcast&nbsp;</span><span class="s5">authoritative</span><span class="s5">&nbsp;hope to the many sufferers of depression. He informed us how current scientifically formulated, measured and monitored Cognitive Behaviour Therapy (CBT) is positively</span><span class="s5">&nbsp;</span><span class="s5">transforming the efficiency and economy of our care.</span></p><p class="s4"><span><span class="s5">But this picture is a misleading&nbsp;</span><span class="s5">exaggeration</span><span class="s5">. I know this from several decades working in the NHS with the&nbsp;</span><span class="s5">mentally</span><span class="s5">&nbsp;anguished.&nbsp;</span><span class="s5">Yes,&nbsp;</span><span class="s5">CBT certainly has much to offer in terms of apparent clarity, comprehensibility, reproducibility and thus mass-production. Little wonder it has ready&nbsp;</span><span class="s5">allure</span><span class="s5">&nbsp;for service designers,&nbsp;</span><span class="s5">economists</span><span class="s5">&nbsp;and politicians.</span></span></p><p class="s4"><span><span class="s5">However human fear (anxiety) and&nbsp;</span><span class="s5">dispiritedness&nbsp;</span><span class="s5">(depression) is often not so straightforward as Professor Clark wishes to believe. He tells us 98% of his studied patients&nbsp;</span><span class="s5">completed</span><span class="s5">&nbsp;pre- and post-treatment measurements (questionnaires)</span><span class="s5">, and these were predominantly positive in outcome.</span></span></p><p class="s4"><span><span class="s5">If this is true, it is an extremely select group: most mental</span><span class="s5">ly</span><span class="s5">&nbsp;anguished people that I see are struggling to find a personal language for their experiences. They do not want, nor are they able to cooperate with</span><span class="s5">,</span><span class="s5">&nbsp;that kind of systematic self-objectification – at least at first. There are&nbsp;</span><span class="s5">other&nbsp;</span><span class="s5">problems with such measurements</span><span class="s5">. Such self-reports are highly contentious and corruptible, albeit unwittingly.</span></span></p><p class="s4"><span><span class="s5">How for example do we factor&nbsp;</span><span class="s5">in</span><span class="s5">&nbsp;the shamed avoidance of ‘masked depression’</span><span class="s5">?</span><span class="s5">&nbsp;O</span><span class="s5">r the&nbsp;</span><span class="s5">person</span><span class="s5">&nbsp;who wishes to please, interest, avoid or punish authority figures? Or the subtle influences of the practitioner whose prospects and finances may be dependent on the results?</span></span></p><p class="s4"><span><span class="s5">A CBT approach can undoubtedly help some: those whose life or psychological problems can be approached in a more structured</span><span class="s5">&nbsp;and explicit way by words and&nbsp;</span><span class="s5">systems-thinking</span><span class="s5">. But there are many more mentally anguished who respond to other less measurable and&nbsp;</span><span class="s5">less&nbsp;</span><span class="s5">verbal human activities: providing safe sanctuary, trustworthy e</span><span class="s5">ngagement and finely tuned&nbsp;</span><span class="s5">unin</span><span class="s5">trusive</span><span class="s5">&nbsp;understanding and guidance. Most worryingly, such unmeasurable but humane activity in our NHS has become increasingly rare</span><span class="s5">: often driven out by the kind of structured approaches vaunted by Professor Clark.</span></span></p><p class="s4"><span class="s5">In this respect I disagree with Professor Clark – there have not been ‘massive developments’ in the science of therapeutic psychology: instead, the burgeoning is of measurements, systems and informatics. I wish I could share his didactic optimism.</span></p><p class="s4"><span class="s5">&nbsp;</span></p><p class="MsoNormal"><em><strong><span>Like this piece? Please donate to OurNHS&nbsp;</span></strong></em><a href="http://www.opendemocracy.net/ournhs/donate" target="_blank"><strong><span>here&nbsp;</span></strong></a><em><strong><span>to help keep us producing the NHS stories that matter.&nbsp;Thank you.</span></strong></em><strong><em><span></span></em></strong></p><fieldset class="fieldgroup group-sideboxs"><legend>Sideboxes</legend><div class="field field-related-stories"> <div class="field-label">Related stories:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> <a href="/ournhs/louise-mccudden/take-our-treatment-or-well-stop-your-benefits-tories-threaten-mentally-ill">Take our &#039;treatment&#039; or we&#039;ll stop your benefits, Tories threaten mentally ill</a> </div> <div class="field-item even"> <a href="/ournhs/peter-beresford/only-parity-for-mental-health-is-that-it-is-being-cut-and-privatised-as-well">The only &#039;parity&#039; for mental health is that it is being cut and privatised as well</a> </div> </div> </div> </fieldset> ourNHS ourNHS Mental health David Zigmond Thu, 24 Jul 2014 12:15:10 +0000 David Zigmond 84687 at https://www.opendemocracy.net Renationalisation of the rail services? Why not start with the NHS? https://www.opendemocracy.net/ournhs/david-zigmond/renationalisation-of-rail-services-why-not-start-with-nhs <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>Labour is flirting with the idea of renationalising the railways - but it should start by renationalising the NHS.</p> </div> </div> </div> <p class="MsoNormal"><span class='wysiwyg_imageupload image imgupl_floating_none 0'><a href="//cdn.opendemocracy.net/files/imagecache/wysiwyg_imageupload_lightbox_preset/wysiwyg_imageupload/549093/british rail.jpg" rel="lightbox[wysiwyg_imageupload_inline]" title=""><img src="//cdn.opendemocracy.net/files/imagecache/article_large/wysiwyg_imageupload/549093/british rail.jpg" alt="" title="" width="400" height="265" class="imagecache wysiwyg_imageupload 0 imagecache imagecache-article_large" style="" /></a> <span class='image_meta'></span></span><em><a href="https://www.flickr.com/photos/24736216@N07/">Image: Flickr/Roger Wollstadt</a></em></p><p class="MsoNormal"><span>The Labour Party is, <a href="http://www.theguardian.com/politics/2014/may/03/rail-state-control-ed-miliband">we are told</a>&nbsp;this month, considering a long-journeyed return: back to the nationalisation of rail services. Some claim this will offer better long-term value, efficiency and safety.</span></p><p class="MsoNormal"><span>Many would welcome this, but there is a puzzling anomaly. Why do we not instead start with renationalising the NHS? Surely the contentious market principles of competitive commissioning are even less suited to human healthcare than to human transport. This is an important distinction, and our failure to recognise the difference between the mechanical and the human has led to a new tranche of serious NHS problems.</span></p><p class="MsoNormal"><span>For twenty-five years we have had successive governments push through legislation to extend the operation of the NHS as a ‘market’. Yet almost all senior practitioners with long prior experience agree about the human and economic cost that follows our depersonalised fragmentation of the NHS. The Royal Colleges have consistently taken this view.</span></p><p class="MsoNormal"><span>Yet governments have persisted in engineering an NHS ‘market’, through &nbsp;such commercialising devices as competitive commissioning and autarkic NHS Trusts. Cumulatively these measures have been highly destructive to the quality of continuity of care, the morale and the trust of staff. From my own long-serving GP practice I have hundreds of documented cases to illustrate these organisational follies.</span></p><p class="MsoNormal"><span>Personal knowledge and continuity of care may matter little in the carriage of passengers. It matters a great deal in the care of the complex human interweavings of the ailing body, mind and spirit. The NHS Market is like Communism: a failed ideological experiment. Such ideologies may start with some aspirational ideas of merit. But they are only partial and conditional truths. Our failure to heed the difference between guidance and dominance has led to our failed massive social experiments.</span></p><p class="MsoNormal"><span>Yes, a reconstituted national British Rail could possibly offer us greater economy, choice and comfort. What an intelligently refederalised NHS would offer us would be much more. Here is another anomaly: why do we still hear no substantial challenge to the existence of the NHS 'market' from our usually glad-to-be-contentious opposition politicians?</span></p><p class="MsoNormal"><strong><em><span>If you liked this piece, you can sign up for OurNHS’s weekly update<span>&nbsp;</span></span></em></strong><a href="http://eepurl.com/uZeSf"><strong><em><span>here</span></em></strong></a><strong><em><span>, join our Facebook<span>&nbsp;</span></span></em></strong><a href="https://www.facebook.com/OurNHSoD"><strong><em><span>here</span></em></strong></a><strong><em><span> or follow us on Twitter<span>&nbsp;</span></span></em></strong><a href="https://twitter.com/OurNHS_oD"><strong><em><span>here</span></em></strong></a><strong><em><span>.</span></em></strong></p><fieldset class="fieldgroup group-sideboxs"><legend>Sideboxes</legend><div class="field field-related-stories"> <div class="field-label">Related stories:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> <a href="/ournhs/allyson-pollock-david-price/why-we-need-political-campaign-to-reinstate-nhs-in-england">Why we need a political campaign to reinstate the NHS in England</a> </div> </div> </div> </fieldset> ourNHS uk ourNHS David Zigmond Mon, 19 May 2014 10:59:50 +0000 David Zigmond 82935 at https://www.opendemocracy.net Autoasphyxiation - Who’ll stop the market suffocating the NHS? https://www.opendemocracy.net/ournhs/david-zigmond/autoasphyxiation-who%E2%80%99ll-stop-market-suffocating-nhs <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>The toxic burden of the market is dooming the NHS to disintegration and depersonalisation - yet GPs coralled into Clinical Commissioning Groups aren’t even allowed to question it.</p> </div> </div> </div> <p class="MsoNormal"><span>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.</span></p><p class="MsoNormal"><span>&nbsp;</span><span>An executive officer is addressing us with well-worn competence. His messages are clearly sound-amplified and powerpointed onto the screen behind him.</span></p><p class="MsoNormal"><span>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. </span></p><p class="MsoNormal"><span>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?” </span></p><p class="MsoNormal"><span>There is an inert fugal silence, like waking from a light anaesthetic. I want to galvanise myself, so I raise my hand to speak:</span></p><p class="MsoNormal"><span>“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. </span></p><p class="MsoNormal"><span>“This – and then its subsidiary procedures of Competition, Commissioning and Commodification – make better kinds of holistic integrated care almost impossible.&nbsp;</span><span>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?” </span></p><p class="MsoNormal"><span>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…"</span></p><p class="MsoNormal"><span>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.”</span></p><p class="MsoNormal"><span>&nbsp;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?”</span></p><p class="MsoNormal"><span>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. </span></p><p class="MsoNormal"><span>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.” </span></p><p class="MsoNormal"><span>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…”</span></p><p class="MsoNormal"><span>Jocelyn looks openly and genuinely puzzled: “In what way?”</span></p><p class="MsoNormal"><span>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&amp;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. </span></p><p class="MsoNormal"><span>“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.</span></p><p class="MsoNormal"><span>“Oh, <em>that</em>!” she says, as if irritated by familiarity. “You can’t change <em>that</em>. 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.</span></p><p class="MsoNormal"><span>“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.</span></p><p class="MsoNormal"><span>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.”</span></p><p class="MsoNormal"><span>My democratic heroism limpens.</span></p><p class="MsoNormal"><span>Jocelyn enters the brightly lit conference hall. I escape in the opposite direction: a fugitive, alone and into the dark and silent car park.</span></p><p class="MsoNormal"><span>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.</span></p><p class="MsoNormal"><span>&nbsp;</span></p><p class="MsoNormal"><strong><em><span>If you liked this piece, you can sign up for OurNHS’s weekly update<span>&nbsp;</span></span></em></strong><a href="http://eepurl.com/uZeSf"><strong><em><span>here</span></em></strong></a><strong><em><span>, join our Facebook<span>&nbsp;</span></span></em></strong><a href="https://www.facebook.com/OurNHSoD"><strong><em><span>here</span></em></strong></a><strong><em><span> or follow us on Twitter<span>&nbsp;</span></span></em></strong><a href="https://twitter.com/OurNHS_oD"><strong><em><span>here</span></em></strong></a><strong><em><span>.</span></em></strong></p> ourNHS uk ourNHS David Zigmond Tue, 18 Feb 2014 11:24:16 +0000 David Zigmond 79436 at https://www.opendemocracy.net Does the NHS need a 'new broom' from the private sector? https://www.opendemocracy.net/ournhs/david-zigmond/does-nhs-need-new-broom-from-private-sector <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>New NHS boss Simon Stevens will inherit an NHS in crisis. Will his outsider status and private sector experience be just the new broom the NHS needs - or is that part of the problem?</p> </div> </div> </div> <p class="MsoNormal"><span>Against a mounting litany of concerns about the NHS, some seem to be pinning their hopes on Simon Stevens, David Nicholson's replacement as the new leader of the NHS. </span></p> <p class="MsoNormal"><span>For example in a recent letter to the Independent Ann Kemp (<em><span>Outsider right choice to lead NHS</span></em>, 26 October 2013) expresses confidence that because Stevens is an experienced outsider this will endow his perspective with greater clarity and realism than those blinkered by a working lifetime in the NHS. </span></p> <p class="MsoNormal"><span>I am one of the partially-sighted latter and I disagree with much of her argument and prophesy. Yet I hope she is right – after four decades of medical practice I shall need my successors to care for me. I hope they will do it better than we do now.<br /> <br /> My experience of ‘outsiders’ contribution of wisdom, initiative and innovation to NHS operations and culture seems very different to Ann Kemp’s. What is the legacy of twenty-five years of industrial gurus, business consultants and monetarist economists? An increasingly industrialised and depersonalised healthcare in thrall to the 3Cs: commodification, competition and commercialisation.<br /> <br /> What has this meant? Since the radical purchaser-provider split, and then the machinating machinery of the Internal Market, we have a service that, increasingly, can deal with the technical but not the personal. A service that manufactures treatment procedures but cannot nurture healing relationships. One which slickens protocols, but neglects care. </span></p> <p class="MsoNormal"><span>In our new corporatised, marketised NHS, healthcarers’ careers may be sharply successful, but are now rarely deeply and quietly vocational. Our mental healthcare seems to have lost interest in the essential complexity of human attachments and meanings, in favour of rigid, centrally determined packages of ‘treatment’. Increasingly large General Practices do not know their own staff, let alone their patients. </span></p> <p class="MsoNormal"><span>Hospitals vaunt Foundation Trust status, employ Spin Doctors to ply glossy brochures, induce favourable reports from Inspectors and Commissioners, and then specious statistics to assure economic and diplomatic survival. </span></p> <p class="MsoNormal"><span>Meanwhile – in these same hospitals – the real doctors abjectly witness and perpetuate shocking failures of care with silent, bemused acquiescence. This is the Shadow of the <em>Internal</em> Market’s alluring persona – a sullen fragmentation of, and disidentification from, our sense of personal vocation, responsibility and care.<br /> <br /> Mid-Staffs may be a particularly horrible example of all this, but it is one of many – their value is to show us where the 3Cs can mislead us in healthcare.<br /> <br /> Such are the perverse and unanticipated fruits of those who urge us to submit complex <em>human needs</em> <em>Welfare</em> to accelerated industrial expedience or commercially fuelled competition. Few working in healthcare wanted or supported such changes; it was the outside ‘experts’ who enjoined. But our struggle for survival ensures expedience, then social conformity. Healthcare workers will clamber aboard what is afloat and rapidly learn to be Commissars, Apparatchiks or mere Healthdroids. That is how we produce our industrialised healthcare atrocities.<br /> <br /> Expert outsiders providing rapid and felicitous healthcare reorganisation? Not again, thanks.</span></p><p>&nbsp;</p> ourNHS ourNHS United Health Privatisation David Zigmond Wed, 13 Nov 2013 09:34:23 +0000 David Zigmond 76879 at https://www.opendemocracy.net David Zigmond https://www.opendemocracy.net/content/david-zigmond <div class="field field-au-term"> <div class="field-label">Author:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> David Zigmond </div> </div> </div> <p>David Zigmond is a GP in London. He is also trained in psychiatry and psychotherapy. His writings on themes of humanism and healthcare can be found <a href="http://www.marco-learningsystems.com/pages/david-zigmond/david-zigmond.htm">on his website</a>.</p><div class="field field-au-shortbio"> <div class="field-label">One-Line Biography:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> David Zigmond is a GP in London. He is also trained in psychiatry and psychotherapy. His further writings on themes of humanism and healthcare can be found on his website. </div> </div> </div> David Zigmond Wed, 18 Sep 2013 10:21:14 +0000 David Zigmond 75450 at https://www.opendemocracy.net NHS decisions, Eurovision-style https://www.opendemocracy.net/ournhs/david-zigmond/nhs-decisions-eurovision-style <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>Transparency, Accountability and Democracy can seem like a protective triumvirate for public decision making, but these can easily turn shallow, demotic and false.</p> </div> </div> </div> <p class="MsoNormal"><span><span class='wysiwyg_imageupload image imgupl_floating_none 0'><a href="//cdn.opendemocracy.net/files/imagecache/wysiwyg_imageupload_lightbox_preset/wysiwyg_imageupload/549093/4-scoreboard.jpg" rel="lightbox[wysiwyg_imageupload_inline]" title=""><img src="//cdn.opendemocracy.net/files/imagecache/article_large/wysiwyg_imageupload/549093/4-scoreboard.jpg" alt="" title="" width="400" height="333" class="imagecache wysiwyg_imageupload 0 imagecache imagecache-article_large" style="" /></a> <span class='image_meta'></span></span></span></p><p class="MsoNormal"><em>Image: Eurovision Scoreboard, 1960</em></p><p class="MsoNormal"><span><strong>‘<em>We do not wish ardently for what we desire only through reason’</em></strong></span></p><p class="MsoNormal"><strong><span><em>&nbsp;</em></span><span>– La Rochefoucald (1665), </span><em>Maxims</em><span>&nbsp;</span></strong></p><p class="MsoNormal"><span>I have seen the future, and I want to go back to bed<em>.</em></span></p><p class="MsoNormal"><span>Recently I attended the first working meeting of our GP Clinical Commissioning Group. At the end of a working day, dozens of GPs sat with mostly fatigued and bovine obedience as we were guided through some power-pointed slick but humanly-dull portrayals. First of our barren yet hazardous current financial terrain, and then the administrative and constitutional complexities of the organisation we have been corralled to devise, our Clinical Commissioning Groups. The obedience was due to an unspoken ultimatum: manage or perish.</span></p><p class="MsoNormal"><span>The new commissars – like Emperors’ messengers – did their best to sound determined and positive. But their efforts sounded to me like staged postures of will rather than currents of real enthusiasm. The complexity of the topics was more than most of these tired GPs could readily engage with or assimilate. Deadened eyes and slumped postures indicated bodily presence but mental absence. Be present or be disappeared.</span></p><p class="MsoNormal"><span>*</span></p><p class="MsoNormal"><span>After being given this map of the new order we were set our first task: to decide on which local healthcare problems we should prioritise. We were all sat at round tables of about ten doctors; each table had a predesignated leader. Each person was given the same paper-list of thirty healthcare problems with brief explanatory notes as to their putative importance. All groups were instructed to peruse and discuss this list and then, individually, to choose the four we considered more important, and then rank them.</span></p><p class="MsoNormal"><span>Each person then clicked buttons on issued electronic devices to silently transmit their ranked choices. A giant electronic smart-board quickly collated and summarised the top four ranked and collectivised priorities for all participants. We were given twenty-five minutes to reflect on, discuss and decide from among these thirty healthcare problems.</span><span>&nbsp;</span></p><p class="MsoNormal"><span>I was uneasy with this. To me, <em>all</em> of the problems had interesting and hidden complexity, and also unobvious connections. To any one of them I could extend hours of exploratory thought and discussion. But this is agribusiness, not organic farming; and our professional tables have become like cattle-pens. Quick herding and milking is what is required. Intelligent discussion is an irksome and irrelevant procrastination. Prompt and quantified results are the goal.</span></p><p class="MsoNormal"><span>I demur, attempting to point out that this ingenious and rapid mass-choreography is discrepant with the subtle complexity of the tasks. But I am sidelined as an eccentric anomaly because by now the computer is proclaiming the GPs’ collective decision. And the chairman – an affable, gracious and intelligent man – now has a nervous stage-smile as he constructs some kind of blessing for us all and our new project.</span></p><p class="MsoNormal"><em><span>Bingo!</span></em><span> We have Majoritarian Healthcare.</span></p><p class="MsoNormal"><span>*</span></p><p class="MsoNormal"><span>I understand the chairman’s attempted glow of beneficence. He had carefully planned and completed this first step onto the new staircase to locality democracy: one based on transparency and accountability. Yes, I respect the intent behind this, but doubt what it yields. For these tired and over-multitasked GPs are slewing into speedy, whimsical, expedient decisions – responding to a mandate and under time constraints. They are making such judgements, and in such a manner, because they are told to not because they want to or have felicitous wisdom. Also, importantly, they want to go home.</span></p><p class="MsoNormal"><span>The depth, form and rapidity of evaluations reminds me of the <em>Eurovision Song Contest</em>. I suggest - only half-joking - that I fear our collectivised wisdom will make a similar quality of contribution to healthcare culture as the Eurovision makes to music. Many look (or pretend to look) perplexed, a few laugh with joyous relief and release, more speak to me afterwards: ‘I’m really pleased you said that … I really agree, but no, I don’t want to step out of line … I have to safeguard my job…’</span></p><p class="MsoNormal"><span>Everything has its price. Sometimes we do not want to see the bill. Yet someone will have to pay.</span></p><p class="MsoNormal"><span>&nbsp;*</span></p><p class="MsoNormal"><span>How did our Health Service work before such attempts at internal markets and local autarkies? In the older, more federal, more macro-socialist system – say thirty years ago – who decided priorities and payments? And how? It seems to me that few knew then, and far fewer know now.</span></p><p class="MsoNormal"><span>As a young practitioner I had a few glimpses that formed an impression that has since been subject to decades of decay. Yet some recent archaeological research supports my memories.</span></p><p class="MsoNormal"><span>My recovered impression is this: the NHS was run by wise Mandarins. These were usually experienced, older, intelligent, thoughtful, little-known Civil Servants. They were unideological, though principled. Unpartisan though committed to their task. Non-specialist though could quickly understand the different assumptive worlds. They often provided high quality diligent service for a working lifetime in a world not yet insistent on visible indices of transparency, accountability and democracy.</span></p><p class="MsoNormal"><span>Such an opaque, inscrutable and unelected system lasted for decades: it should have been a scandal. And yet it now looks as if such a potentially incompetent and corrupt regime managed their smaller world with quietly competent beneficence, and with much smaller resources.</span></p><p class="MsoNormal"><span>For me this earlier Mandarin-managed service was – compared to now – a blessing of stability, sense and sensibility, pragmatic flexibility and accessible authority. It certainly was not perfect and there were some stupid or bad practitioners, but the <em>systems</em> were not stupid or bad. The systems now are frequently both, stymying even the better practitioners’ competence, efficiency and humanity. </span></p><p class="MsoNormal">*</p><p class="MsoNormal"><span>We are now driven by systems with good moral rhetoric but poor human understanding and connection. This is a fascinating and cruel paradox. How do we account for it? Here we must enter the world of speculative, motivational and group psychology – an exploration beyond this writing. The following though – a seemingly unlikely parallel – may be edifying. I present it as a question: Why are Northern European elected Republican Presidents so often corrupt or criminal; by comparison, why are Northern European unelected constitutional monarchs usually so diligent and respected? If we understand this we can perhaps understand a little more of what is most unstraightforwardly important about humankind.</span></p><p class="MsoNormal"><strong><span>&nbsp;</span><em><span>‘The truth is rarely pure and never simple’&nbsp;</span></em></strong></p><p class="MsoNormal"><strong><span>- Oscar Wilde (1895), </span><em>The Importance of Being Earnest</em></strong></p> ourNHS uk ourNHS Cuts - dismantling the NHS Privatisation David Zigmond Wed, 18 Sep 2013 10:12:13 +0000 David Zigmond 75449 at https://www.opendemocracy.net