Tag Archives: CQC

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?

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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.

BJGP article on practices in special measures: CQC response

Devin GrayDevin Gray is a National Medical Director’s Clinical Fellow and a GP trainee, interested in driving system-level change to achieve better care and outcomes for patients.

This article was co-authored with Professor Nigel Sparrow OBE, Senior National GP Advisor and Responsible Officer, CQC and Professor Steve Field CBE, Chief Inspector of General Practice, CQC.

Thank you for the BJGP article, “CQC Inspections: unintended consequences of being placed in special measures”.The CQC welcomes opening the door to dialogue and discussion about practices being placed in special measures and wholeheartedly agrees with the need to work effectively together in enabling improvement.

Improving care under pressure

With unprecedented pressures in General Practice and across the whole NHS, we are aware of the context. Preparation for a CQC inspection may feel to some GPs as yet another task there is little time or resources for. So why engage with regulation?

At the CQC we are passionate about improving standards of quality and safety in healthcare. Through our work, we are for the first time able to provide a comprehensive description of what good care looks like.2 We support change and improvement by identifying and championing examples of good and outstanding practice, as demonstrated by our Outstanding Practice Toolkit,3 and by celebrating innovative ways of working in an ever resource-squeezed environment.

The intention of special measures

We do not underestimate the difficulties of being rated as inadequate for practice staff and patients. The intention of placing a practice in special measures is to make patients, providers and commissioners aware that we have serious concerns and to identify the need for urgent support. The special measures framework allows the CQC and NHS England to work together to ensure a timely and coordinated response to inadequate practices. It also provides clear timescales for addressing inadequate care, which was identified as missing in the case of Mid Staffordshire NHS Foundation Trust,4 allowing practices to access the support they need to get “back on a path to recovery and then to excellence”.5

The key is effective leadership

We have found that the vast majority (84%) of England’s GP practices are providing a good or outstanding service to their patients, with 12% rated as “requiring improvement”. So why are 4% of practices falling significantly short? As highlighted in the CQC’s recent State of Care report6, the key may be in leadership.

The CQC assesses the leadership and organisational culture of providers, rating them on how “well-led” they are. By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

As highlighted in your article, every practice in special measures has been rated inadequate in the “well-led” key question (in addition to being rated as inadequate in one or more of the other key questions – safe, effective, caring or responsive). Perhaps there is no better time to be considering the role of effective leadership in providing high-quality care as well as guiding practices through these difficult times.

“The NHS needs leadership of the highest calibre if it is to respond successfully to financial and service pressures that are unprecedented in its history.”7

The first practice to come out of special measures was only recently announced. The process of regulation has driven impressive levels of improvement in this practice in the six months since its initial inspection: “In contrast to our last inspection, we found a group of
GPs and nurses providing clinical care at the practice who were enthusiastic, motivated and co-operating well with one another8 and four of the five key questions ratings improved.

The process of turning a struggling practice around no doubt involves significant time and effort. Improvement does not happen overnight, and it does not happen without effective leadership. Investing in leadership has shown time and time again9 to pay off in the ongoing running of a well-led organisation that delivers good care to the population it serves.

Getting the right support at the right time

As mentioned in your article, there can be local awareness of issues long before the CQC inspects. In some cases, practices themselves have not been surprised by the rating. The CQC strongly supports the early identification of problems within a practice and early investment in support, rather than waiting for an inspection itself to raise the profile of the issues. This will involve closer collaborative working with Clinical Commissioning Groups (CCGs), NHS England and other members of the local health economy.

“At a time when there is growing interest in integrated care and partnership working between the NHS, local authorities and third sector organisations, collective leadership in local health systems has never been more important or necessary.”7

Looking to the future

As our health care economy continues to evolve, and new models of care emerge, the CQC is committed to understanding how we can best work together to support and champion change, and improve quality of care. Crucially, as a profession we must not let regulation act as a barrier to innovation.

Whilst there will be a few practices that need little more than hard resources to improve standards, our findings support a strong argument to be investing in leadership within practices. This has been a central theme in supporting Acute Trusts in special measures, and should be for General Practice. In recognition of this, the CQC is working collaboratively with other organisations to improve our assessment of leadership and organisational culture going forward.

We welcome the RCGP’s commitment to leadership development and its Pilot Scheme has clearly been doing essential work. Nevertheless, we must take more collective responsibility in identifying struggling practices early, championing innovation, driving improvement, and providing long-term support.

Deputy Editor note: If you do have any general points that you wish to put to the CQC please leave a comment. In the spirit of the article and the desire to have an open discussion they have promised to respond. However, please keep these to the general rather than raising specific concerns about specific practices.

References

1. Rendel S, Crawley H, Ballard T (2015) CQC inspections: unintended consequences of being placed in special measures, Br J Gen Pract DOI: 10.3399/bjgp15X686809
2. CQC: GP Practices Provider Handbook Appendices. March 2015
3. http://www.cqc.org.uk/content/examples-outstanding-practice-gps (accessed 6/10/15)
4. The Francis Report (Report of the Mid-Staffordshire NHS Foundation Trust public inquiry) and the Government’s response. December 2013
5. Department of Health: Hard Truths. The Journey to Putting Patients First. January 2014.
6. CQC: State of health care and adult social care 2014/14. October 2015.
7. The King’s Fund: Developing Collective Leadership. May 2014
8. http://www.cqc.org.uk/content/gp-practice-exits-special-measures-following-improvements-patients-1 (accessed 6/10/15)
9. The King’s Fund Commission: The Future of Leadership and Management in the NHS. No More Heroes. May 2011