Tag Archives: St James Church Surgery

Letter to Dr Sarah Wollaston – prevention of suicide and continuity of care

David Zigmond was a small practice GP in south London 1977-2016. You can
read Obituary for St James Church Surgery here.

This is an edited extract from a letter to Sarah Wollaston MP, Chair, Parliamentary Health Select Committee.

Prevention of Suicide. The crux of personal continuity of care

Late in December I heard a radio discussion (BBC Radio 4, Today) about how our community and its designated services might best prevent suicide. All the participants, including you, talked with clear sense about evident truths: our need for adequate (and increasing) funding, the need for skilled vigilance in primary care and in charitable organisations, easy access to joined-up, well-trained specialist services… No surprises and no real contention.

What I did not hear was anyone emphasising the importance throughout pastoral healthcare – so particularly with the desperately emotionally anguished – of personal continuity of care. No substantial attention was paid to the harm done by serial reforms and modernisations which, generally, have made such personal care increasingly difficult, now often impossible.

Pastoral healthcare has become increasingly misunderstood, neglected and impoverished.

Yet recognising and understanding these losses is essential for any therapeutic reparation and engagement. Since my medical qualification more than forty years ago the medical technologies have undoubtedly got better, but the healthcare relationships that administer these are often worse. How this has happened is complex: the consequences, certainly, are unintentional. The result is that, overall, treatments of structural diseases continues to improve, but pastoral (personal) healthcare – that which cannot be quickly fixed by technology – has become increasingly misunderstood, neglected and impoverished. Within this rubric mental healthcare is a prime example.

In the 1970s I worked as a young psychiatrist. Mostly we were able to provide a kind of flexible and personally attuned care with personal continuity, which has since been driven out by modern systems. This erstwhile care was largely provided by consultant-led general psychiatric ‘firms’ together with family doctors (rather than ‘primary care service providers’) who then worked in much smaller practices with identified patients (‘personal lists’). Both provided cornerstones where patients and practitioners could, through repeated and easier contact, develop bonds of naturally evolving personal knowledge and understanding. Most sufferers of mental health problems and experienced practitioners agree that such personal continuity is essential to the kinds of relationships that can enable first, trust and comfort, and then healing, repair and growth. This work is delicate and nuanced so becomes much more difficult – if not impossible – where there is not the time or context to develop these bonds. It can be helpful to see the evolution and nature of such bonds – between sufferers and healers – as bearing a close resemblance to those that evolve in well-functioning families: both are held together by developing relationships of trust and affection.

Such a ‘family’ ethos of providing pastoral healthcare has been made more and more unviable by our successive reforms and modernisations. With few exceptions, such ‘progress’ is defined by increasing systemisation so that the vagaries of personal meaning, relationship and attachment are replaced by rapid devices for ‘logical’ process: diagnosis, despatch and packaged intervention. Influence by bespoke individual understanding becomes displaced by generic prescribed ‘treatments’. But with this kind of human complexity we usually find that the greater our efforts of direct control, the less our understanding. If we are heedless of this we risk killing – however inadvertently – the human heart and natural habitat of our pastoral healthcare.

Modernisation programmes have become – paradoxically – antitherapeutic.

This change of care ethos from a kind of family nexus to a factory-like complex of contracted ‘service providers’ has increased massively in the last two decades – the last half of my long career in Psychiatry and General Practice. In that time I have seen now both services have become depersonalised in proportion to their systemisation. What does this mean? Increasingly, people do not know one another: contacts more rarely become deeper relationships, not just between doctors and patients, but also between colleagues. Data storage and transfer may be rapid and complete, but the slower, subtler, human processes of growing meaningful attachment, affection and containment have been largely driven out by our reforms. So such modernisation programmes have become – paradoxically – antitherapeutic. Hundreds of conversations I have had with older practitioners and patients support this view – the exceptions are apologist colleagues in management posts.

What are the devices that have transformed our healthcare family into a factory: from understanding natural processes to driving industrial protocols?

One source is our illusion that we can treat healthcare as a commodity, utility or manufactured object. From this other things have necessarily evolved: a consumerist view, attempts to monetise and proceduralise all care so that it can be commissioned, traded and controlled. Hence the Internal Market, the purchaser-provider split, autarkic competing NHS Trusts, Clinical Commissioning Groups, commercial-type incentivisations, the Health and Social Care Act (2012) … the list continues to grow. We have been very clever at fashioning such reforms, but very unwise not to see an ineluctable flaw: their destructive human and social effects.

This dehumanising systemisation of services is seriously demoralising and has led to our poor staff recruitment, sickness, drop-out, burnout, premature retirement … and suicide.

Our corner-stoned 4Cs – competition, commissioning, commodification and computerisation – have all been much vaunted as assuring more accountable, equitable and efficient healthcare yet have rendered us general practice and mental health services with poorer human contact, engagement and attachment. This dehumanising systemisation of services is seriously demoralising for staff. The work becomes increasingly stressed and impoverished of deeper (human) satisfaction: this has led to our poor staff recruitment, sickness, drop-out, burnout, premature retirement … and suicide. How can complexly distressed patients possibly do well in a service that is itself so sick?

In the last few years of my work in the NHS I have found it increasingly difficult to offer the kind of personally synergistic, comforting, containing, healing work I used to manage so readily with colleagues. The reasons for this are largely found in our organisational reforms – the kind of thing I have outlined above. Potential suicides pose our trickiest and starkest healthcare questions and tasks. There is always more to think about, to do and undo.

“Too big to talk about”: Organisational momentum and its paralytic wake

David Zigmond was a small practice GP in south London 1977-2016. You can
read Obituary for St James Church Surgery here.

Corporatism often enlarges and entrenches itself by increasing demands for compliance. Eventually though, unchecked, this will sicken any organisation. Such is now evidently ailing our NHS. A brief glimpse from a small conference provides a sample.

November 2016, London. A small conference of (mostly junior) doctors. The brief: to better survive the increasing stresses of their work. They are being mentored, guided, enabled and reassured by evidently concerned and sympathetic senior clinicians and cohort managers.

Supportive, ventilatory and distracting strategies are suggested: these may palliate, encourage and help endurance.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are. An older patrician-clinician, Dr O, is able to reassure with statesmanlike knowledge and know-how. Yes, appraisals are an unpleasant, inordinate and major stress for many doctors, Dr O agrees. But he can personally help with this: he knows how the system operates, and who operates it: Dr X, for example. Dr X is very senior in the appraisal hierarchy and wants to be helpful to our many needlessly and haplessly struggling doctors. He can pass on many tricks, feints and shortcuts to neutralise the formidable administrative obstacles and find easier ways to demonstrate the compliance now essential for professional survival. Yes, Dr O continued, these are testing and perilous times but there are those – like Dr X – who will provide sanctuary, ‘a safe house’, help with ersatz documentation. The important thing is that we find ways to tender what we must: to survive.

As I listen to these exchanges I recall heroic stories from World War II: of resistance movements stealthily sheltering, then smuggling to safety, downed allied airmen; of Oscar Schindler duplicitly providing false documentation and work to protect those otherwise doomed. Dr X seemed, to me, like Schindler and Dr O his discrete emissary.

All these efforts, albeit unintentionally, perpetuate a bad and destructive system.

I admired all these caring and protective seniors and the responsibility they showed for the welfare and survival of their juniors. Yet I was doubtful of the larger benefit that would come from these sincere and substantial efforts: to help these tired and craven doctors to pass muster, comply to regulations they experience as draconian, and then survive-by-adaptation with the mandatory documentation. All these efforts, albeit unintentionally, perpetuate a bad and destructive system. Adaptation via obedience can easily turn to collusion.

I attempted, with respectful diplomacy, to say this. I summarised briefly: “I really like the comforting care, support and healing that’s being offered between you. But something much bigger is being ignored: the unsustainable, toxic and oppressive environment we all have to work in. These forces overwhelm and fatally undertow all our attempts to mitigate or repair…”

I had wanted to offer a brief profile of the component-agents of our pathogenic healthcare culture: how the 4Cs – commercialisation, commodification, corporatisation and computerisation – are driving out the human and vocational heart of our work; how our erstwhile (mostly) humanly gratified professional ‘families’ are displaced by managerially driven and depersonalised systems of ‘factories’; how our health services’ administrative devices all drive the larger system that is so ailing and alienating us. The entire Internal Market, Commissioning and Inspection cultures, in their many guises, all contribute: autarkic NHS Trusts, financially-based competitive commissioning; burgeoning performance-related targets with their necessary machinery for monitoring, data, negotiation and penalties; the resulting, ever-increasing need for compliance, surveillance, policing, documentation and (to mop up any surviving outliers) strictly regulated professional appraisal and validation …

But the chairperson arrested the beginning of this flow. She judged it well beyond the scope of this meeting: how may clinicians now best survive?

***

During a short break a veteran manager approaches me. “I know what you want to say. Almost everyone here would agree with you. But there’s nothing we can do about these things: they are far too big for us to influence them”, she says with fraternal commiseration. “In any case, this is not the right forum”, she adds with cautioning advice.

“Well, there never is a ‘right forum’ for discussion of these crucial things now. This recurrent exclusion is not accidental. It is the tip of a systemic iceberg: it tells us much about the size and nature of our problems. Paradoxically, our lack of open discussion indicates why we must talk candidly. And if not now, when?”, I replied.

The manager seems attentive to this but says nothing. She meets my gaze and offers me a brief smile. To me this seemed unjoyfully complex: contrition, appeasement, fear, alliance, apology, irony and respectful pity. I smiled back, wondering what she saw.

She turned to join Dr O. They re-entered the conference room.

—–0—–

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

 

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.