Monthly Archives: November 2016

Obituary for St James Church Surgery: the death of a practice

St James Church Surgery 1987-2016:
the demise of small General Practices

A personal celebration and lament

David Zigmond

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Small general practices used to be very common and mostly popular. Yet due to healthcare policies they are now increasingly rare and almost extinct. What are we losing? This is a portrait, in words and photos, of a recently closed practice.

St James Church in Bermondsey, London served as an NHS General Practice for nearly thirty years. Its closure, in August 2016, was forced by rapidly tightening regulations about working premises and practices.

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Until its demise, this small practice retained an uncompromising ethos centred around the kind of personal continuity of care that can come only from personal contacts, relationships and understandings. Early on in my stewardship – as the Principal GP – I thought that this kind of human matrix was best assured by a small, traditionally modelled family-doctor practice with a low turnover of clinical and reception staff: such a compact, stable nucleus can be far more personally manoeuvrable and responsive, than can be managed in larger practices. Yet, paradoxically, this ethos has become countercultural and, eventually, untenable.

A small but significant example: the staff decided not to have the now prevalent automated telephone greeting and ushering devices. Instead, the telephone was always answered by a friendly receptionist: voices became known, recognised and matched to the face of the patient later arriving, and be personally greeted, at Reception. Fragments of data and stories could then make larger, human wholes; personal understandings grew organically; quiet bonds of affection offered comfort, containment and support. Therapeutic influence often started with the receptionist.

Such subtle human interactions are impossible with automated devices and algorithms – yet now, almost everywhere – the cybernetic is inexorably driving out the humans.

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In these last twenty years the culture of the NHS has – despite ubiquitous and reassuring soundbites – moved away from such responsive humanity and into rigid systems managed by corporatism and industrialisation. Despite this difficult and increasing organisational estrangement, the surgery at St James consistently managed to harbour exceptionally good patient and staff experience, loyalty and safety. So this small practice survived as a bright, but doomed, island-beacon of traditional humanistic healthcare perched perilously above a rising ocean-tide of institutional depersonalisation. Eventually the tide rose faster than we could erect defences: in particular we could not cope with, or afford, the vast and ratcheting demands of compliance legislation.

Despite popular support and the very evident real-life excellence of this surgery it was deemed, by non-negotiable procedures of the Care Quality Commission (CQC), to be too anomalous for their vouch-safety. The decision to summarily close the practice in 2016 was dramatic in its emphasis and decisiveness: you can read about this in Death by Documentation1 and The Doctor is Out2.Meanwhile, do peruse these pictures of our much-loved practice: the container for so much, and so many kinds of, humanity and its vicissitudes; a conduit for so many life-events, poignant encounters and their guided supports.

As you take an imaginary wander around this once very alive, now deceased, workspace you can see easily how little the physical ambience of this clinical service resembled its more contemporary purpose-built peers. This was both fortuitous and deliberate: august spaces were filled with bright, warm colours, soft comfortable furnishings, hangings of expressionist and impressionist art, humanly crafted objects from natural materials. More typical ‘clinical’ objects, surfaces, instruments, notices and accoutrements were mostly relegated to the background, though always with convenient accessibility.

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All humanly constructed environments also convey meta-messages about values, roles or expectations. The ambience at St James said: Healthcare is a humanity guided by science; that humanity is an art and an ethos. The now prevalent, and certainly more approved, practices of modernity seem to say: Healthcare is a science administered by our regulated experts. Wait quietly.

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What effect did this have? Well, our staff and I drew much pleasure, comfort and enlivenment from our libidinal surroundings, just as the sensually aware homeowner does. Very significantly, patients would often express this too: “It’s so lovely coming in this room, it always cheers me”, or “I feel better and calmer already, just sitting here, doc…” were typical of hundreds of appreciations I heard over the years. Such exchanges fuelled our wish to come into work each morning.

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NHS management bodies took a very different view. Eventually the CQC would – with Olympian judgement and resolve – pre-empt any further contention over personal preference v institutional prescription: the Practice was closed by legal (Magistrates) Order. In their evidence the CQC cited previous official assessments – over several years – recurrently showing miscellaneous failures of compliance to the increasing regulations across a wide range: disabled access and facilities, documented checks of fire exits and my own (non) criminal record…

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But what of the real-life evidence? Of enormous patient and staff popularity and loyalty, excellent care and the remarkable lack of complaints, litigation, untoward events or deaths, staff sickness or accidents. These counted not at all. Nor did the power of patient choice: there were many, evidently compliant, neighbourhood practices eager to recruit but emphatically declined. Nor was heed paid to the fact that many of the regulations were far more suited to large airport-like practices with their much greater staff and patient turnover and anonymity: these made little sense for our small practice. This plea was deemed inadmissible.

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A longer view shows that the portents for such inevitable ‘constructive decommissioning’ had been gathering for many years. A decade ago we were forewarned by a lesser-powered inspectorate: you can read about it in Planning, Reform and the Need for Live Human Sacrifices3. In more recent years NHS financial plans, too, were designed for the unlikely survival of small practices.

So, St James Church Surgery – with its rich local history of human engagements, affections and memories – was finally closed by legal mandate. The fact of its long and exceptional popularity was deemed an irrelevant inconvenience. But the questions raised by this elimination are with us always: What do other people want and need? How do we (think we) know? Who decides, and how?

And more ordinarily: when you go to see a doctor what kind of space, greeting and dialogue do you wish for?

The photos of the home of this affectionately-held centre are only of the space itself: to avoid any issues of confidentiality I have not pictured the people that vitalised the place. As in the best medical consultations, we often have to imagine those crucial, though absent, others.

I hope this small gallery, in memoriam, will not only preserve cherished memories: for the future it can help generate larger questions about the complexity of what we wish for, how we jeopardise these things, and how, instead, we may secure them.

Understanding the erasure of this old, traditional bastion of family-doctoring can help fuel what should be an endless debate. How do we discern between change and progress?

—–0—–

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References

  1. Death by Documentation. The penalty for corporate non-compliance. David Zigmond (2016)
  2. ‘The Doctor is Out’, The Observer, 18.9.16
  3. Planning, Reform and the Need for Live, Human Sacrifices. Homogeny and hegemony as symbols of progress. David Zigmond (2006)

1 and 3 are available via David’s Home Page: http://marco-learningsystems.com/pages/david-zigmond/david-zigmond.htm

Note
If you want to read more about how these kinds of questions were answered for many years at St James (and many of the better small practices), the anthology If You Want Good Personal Healthcare See a Vet: Industrialised humanity. Why and how should we care for one another? David Zigmond (2015), New Gnosis (available from Amazon), explores these themes.

Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com.

Happy birthday to the NSPCR

Roger Jones

Roger Jones

Roger Jones is Emeritus Professor of General Practice at King's College, London and is the Editor of the British Journal of General Practice.
Roger Jones

The NIHR School for Primary Care research has celebrated its 10th anniversary.

Photo by MichelleBulgaria at Morguefile.com

Photo by MichelleBulgaria at Morguefile.com

Shortly after the National Institute of Health Care Research was established in 2006, with the aim of supporting applied health research for patient benefit, one of the first research Schools to be established was the National School for Primary Care Research, in 2006. The School initially consisted of the five top-scoring University Department of general practice in the most recent Research Assessment Exercise: the composition of the School has changed over the intervening years, so that it now consists of the primary care departments from Bristol, Cambridge, Keele, Manchester, Newcastle, Nottingham, Oxford, Southampton and University College London.

The school has just celebrated its 10th birthday by holding a showcase conference in the Wellcome Collection, London – not a bad choice of venue, because of the history of discovery and innovation embodied by the Wellcome Trust and also the Trust’s generous contributions to applied medical research funding over the years. Writing in the introduction to the conference programme, the Schools Director, Professor Richard Hobbs from Oxford, says that “The school was established by the NIHR in 2006 to increase the evidence-base for primary care practice. The school’s reputation to produce evidence with a patient-centred approach has influenced the development of policy, general practice, patient and public involvement and academic endeavour. Sound partnerships have strengthened the School over the years and collectively we offer a wealth of experience from a wide range of specialties and disciplines.” The School certainly has been a powerhouse of primary care research with a distinctly practical, clinical focus and a strong patient-centred ethos. It has made particularly strong recent contributions to the problems of antibiotic prescribing and resistance, and the management of atrial fibrillation and the use of prophylactic anticoagulation.

The introductory presentation to the conference was given by Professor Martin Roland, University of Cambridge, who was the first Director of the newly-founded School. Martin surveyed the key milestones in primary care research, beginning with the appointment at the University of Edinburgh of Richard Scott to the first chair of general practice in the world. Before running through the pantheon of the heroes of academic general practice, Martin paused to reflect on the malignant influence of one of the great villains of the piece, Lord Moran. He might have been Churchill’s physician, but he absolutely had it in for general practice. Famously, when he was giving evidence to the Doctors’ and Dentists’ Remuneration Committee of the BMA on the subject of merit awards, he was asked whether he agreed with the proposition that the two branches of the medical profession, general practice and consultancy, were not senior or junior to each other, but were on a level. Moran replied “I say emphatically no! Could anything be more absurd? I was Dean of St Mary’s Hospital Medical School for 25 years, and all the people of outstanding merit, with very few exceptions, aimed to get on the staff. There was no other aim, and it was a ladder off which some of them fell. How can you say that the people who fell off the ladder are the same as those who got to the top of it? It seems to me so ludicrous”.

Martin went on to describe the contributions of David Morrell, my own predecessor in the chair of general practice at Guy’s and St Thomas’s, and John Fry, the legendary single-handed GP from Beckenham, who laid the descriptive basis for clinical practice in primary care in the UK – two great founding fathers of general practice research. He explained how John Howie , Richard Scott’s successor in Edinburgh, negotiated for over 12 years to bring the Service Increment for Teaching funding out of the hospitals into general practice to support undergraduate medical education, how David Mant’s 1997 report on R& D in primary care exposed the order of magnitude under-funding and under-staffing of academic general practice and set a target for the proportion of R&D spend on primary care research, and how the Medical Research Council Topic Review, in the same year, led by Nigel Stott, focused the attention of the Council on research in general practice for the first time.

A previous director of the Wellcome Trust, Sir Mark Walport, produced his report in 2005 which transformed clinical academic training and in the same year the NIHR was established. The success and influence of academic general practice continued to increase, although it now may well have plateaued: only last year it was thought necessary to write an editorial for the BMJ entitled “Academic general practice: Visible? Viable? Invaluable”, and nothing can be taken for granted about the way in which general practice is viewed by the hospital specialties. In her recently-published report for Medical Education England “By choice – not by chance” Professor Val Wass reports on a “very powerful anti-GP rhetoric” in the medical schools and “an unpleasant cultural lack of care and respect for general practice”. Moran’s ladder casts a long shadow.

Looking ahead, Martin Roland thought that we should give some consideration to three questions. Are we, and do we want to be, the same as or different from academic colleagues in other disciplines? On the whole academic primary care leaders have thought it more appropriate, with more to gain, if we complete on an even playing field, but we must ensure that the playing field truly is even. Second, we should look inwards, and ensure that we are focusing on doing work of the highest international quality, likely to bring in the best Research Excellence Framework returns, which is genuinely useful to clinical practice in primary care. Finally we must think about ways of engaging across the NHS with other professionals, once again to ensure that research remains relevant to the needs of a rapidly changing health service.

A discussion session after the presentation touched on the relevance of academic primary care research to “real” GPs, their involvement in research networks and research projects, and their need for evidence-based practice. It is likely that proportionately more general practitioners are involved in research networks and in primary care research in the UK than almost anywhere else in the world, and by and large clinicians and primary care teams welcome the expanding evidence base for patient care in general practice. The NIHR School for Primary Care Research has achieved much already, and is likely to make a strong contribution in the years ahead.

A short break for tribalism, war and dodgy goddesses.

David Misselbrook

David Misselbrook

David Misselbrook was a South London GP for 30 years. He was involved with GP training, CPD development and medical ethics. He now teaches Family Medicine and ethics for RCSI Bahrain.
David Misselbrook

img_4067-copyBahrainis are migratory, especially during the annual Ashoora holiday. Ex-pats and locals alike flee the country, squeezing through Bahrain’s easygoing airport like a cork from champagne. Cyprus is beguilingly close, so there we landed for a couple of days R and R. The Greek goddess Aphrodite beat us to it, allegedly emerging from the sea at Aphrodite’s rock, between Limassol and Paphos. Aphrodite’s subsequent progress is recorded, comic book style, in astounding mosaics on view in Paphos. I guess mosaics were the digital medium of the day – every floor tells a story. But assuming local legends to be correct, Aphrodite was not well advised about hotels. Emerging from the sea she had to travel 30 miles to the Baths of Aphrodite for her shower. This looked romantic but not too hygienic. (Also not very private, hence I suppose the dodgy mosaics.) I confess that the shower in our hotel was preferable.

I’m not sure exactly when Aphrodite wafted by, but Cyprus certainly does history in depth. The remains of a nine thousand year old Neolithic stone built settlement have been excavated at Choirokoitia, thoughtfully situated en route to the airport. The settlement is an extensive village of circular stone huts built on a hill. It is in an excellent defensive position, surrounded by a stout stone wall. So presumably this was to enable the inhabitants to sleep soundly, defended from stray cats, mountain lions, and the odd time-expired velociraptor? Except that the entrance is clearly designed to defend it from other people. So here we have it. The human race – successfully threatening one other for thousands of years.

Cyprus seemed to sum up the human condition. Such beauty, happy sunshine, more myths than you can shake a Doric column at, war, bloodshed and brute tribalism. Cyprus is still partitioned into Greek and Turkish parts by the Green Line – a weeping scar across the face of Europe. As we drove up to Nicosia a huge Turkish flag dominated the view, painted on a mountainside to the north. You can see it from space. Rather insensitive to the Greek neighbours? Not for the relatives of the 87 unarmed Turkish civilians massacred in the nearby village who then made it and maintain it as a memorial. In all some 2,000 civilians died and tens of thousands were displaced. And this is not the seventh century, this was Europe in 1974.

img_4099Arriving at Nicosia we cross through the mighty old Venetian walls, many times the height of Choirokoitia. Yet in the middle of this European capital city streets suddenly stop, blocked by seemingly cobbled together barriers of oil drums, cement and barbed wire. Handsome old buildings crumble gently into the no man’s land beyond. These two half-cities carry on like a man with a severed corpus callosum who can no longer recognize his own hand, yet seems to think it’s business as usual.

I was fascinated by Steven Pinker’s thesis in The Better Angels of Our Nature. Written in 2012 he cites evidence that overall humans are becoming less violent. I confess I can’t get it myself. It seems a bit too reminiscent of Fukuyama declaring “the end of history” after the fall of the Berlin Wall. Humankind engages in unending outbreaks of violence. Whether we wish to put this down to our inner chimp, original sin or a fallen nature seems to be pretty much a matter of language. I am thankful to live in a western lacuna of peace and comfort, but I would be a fool not to recognize its fragility, its contingency. And this decade seems to illustrate painfully what Francis Schaeffer termed the age of “personal peace and prosperity”; I’m ok, comfortably smug, whilst half the world is in uproar or poverty.img_4356

Humans appear to be incurably tribal when stressed. Faith hope and love are shown the door at the first sneeze of a financial meltdown or regional instability. Like junk food and junk bonds we know tribalism is wrong but just can’t stop. The Venetian walls of Nicosia are a fine old sight – they have been defused but molder on, their moats turned into gardens and car parks, mere reminders of a primitive past. But the oil-drum-and-concrete wall through the heart of Nicosia is a bizarre and sorry sight, a reminder of our primitive present. And we live in a world seemingly attracted to more walls. Tribalism seems buried deep in all our hearts. Our walls develop but our human nature does not.