The ousted doctor: 'My patients' souls matter most' - The Guardian
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2 days ago - Dr David Zigmond had plenty of time for his patients – but not for bureaucracy. Now the plug has been pulled on his surgery. Angela Neustatter ...
What changed from the excellent 40 years record in June 2015 to September 2016? Dr Zigmond had a book published, chronicling his experience of de-humanising changes in the National Health Service over his lifetime, entitled:
"They" obviously didn't like his book and "they" shut him down; overnight, without notice, and barred his patients. This is his diary of the shocking event.
My view: The doctor has been abused by vicious, poisonous "colleagues", intent on forcing people into "compliance" with their pen-pushing and computer report rules - or ruining them. It wholly illustrates the articles Dr Zigmond has been publishing for decades, mapping the takeover of caring medical services by zombie robots. This injustice needs an instant Judicial Review, before the medics and patients lose hope.
"They" obviously didn't like his book and "they" shut him down; overnight, without notice, and barred his patients. This is his diary of the shocking event.
My view: The doctor has been abused by vicious, poisonous "colleagues", intent on forcing people into "compliance" with their pen-pushing and computer report rules - or ruining them. It wholly illustrates the articles Dr Zigmond has been publishing for decades, mapping the takeover of caring medical services by zombie robots. This injustice needs an instant Judicial Review, before the medics and patients lose hope.
Intelligent Monitoring Report
Dr David Zigmond (St James Church Surgery)
St James Church (North Aisle)
Thurland Road
London
SE16 4AA
June 2015
****
EXCELLENT - 59.2% - 86.2% - 91.4% - 89.8% - 92.00% - 91.5% - 97.9% - 72.3%
GPPS004: The percentage of respondents to the
GP patient survey who stated that they always or
almost always see or speak to the GP they prefer.
(01/01/14 to 30/09/14)
59.2%
-GPPS014: The percentage of respondents to the
GP patient survey who stated that the last time they
saw or spoke to a GP, the GP was good or very
good at involving them in decisions about their care
(01/01/14 to 30/09/14)
86.2%
GPPS015: The percentage of respondents to the
GP patient survey who stated that the last time they
saw or spoke to a GP, the GP was good or very
good at treating them with care and concern.
(01/01/14 to 30/09/14)
91.4%
GPPS020: The percentage of respondents to the
GP patient survey who stated that the last time they
saw or spoke to a nurse, the nurse was good or
very good at involving them in decisions about their
care (01/01/14 to 30/09/14)
89.8%
GPPS021: The percentage of respondents to the
GP patient survey who stated that the last time they
saw or spoke to a nurse, the nurse was good or
very good at treating them with care and concern.
(01/01/14 to 30/09/14)
92.0%
Dr David Zigmond 1-495556335
Domain ID: Indicator description (time period) Observed Average Numerator Denominator Z-score Z-score range
Intelligent Monitoring Report June 2015 GPIM V102
Page 9 of 9
Caring
GPPS025: The percentage of respondents to the
GP patient survey who described the overall
experience of their GP surgery as fairly good or
very good. (01/01/14 to 30/09/14)
91.5%
GPPS001: The percentage of respondents to the
GP patient survey who gave a positive answer to
'Generally, how easy is it to get through to someone
at your GP surgery on the phone?'. (01/01/14 to
30/09/14)
97.9%
GPPS023: The percentage of respondents to the
GP patient survey who were 'Very satisfied' or
'Fairly satisfied' with their GP practice opening
hours. (01/01/14 to 30/09/14)
72.3%
.
*******
September 2016
Death by Documentation:
The penalty for corporate
non-compliance
David Zigmond
© 2016
Our
organisational efforts to assure fail-safety, uniformity and probity can easily
– in excess – turn destructive beyond anyone’s wish or anticipation. This tale
tells how such ‘mission creep’ happens and how it is sustained. The more
laws the less justice – German proverb
Background
In
the last twenty years the ethos of our Welfare services has changed
exponentially: from colleagueial supportive trust to managerial litigious
mistrust. In medical practice the erstwhile medical authorities mostly acted as
supportive administrators to doctors’ more autonomous judgements and
activities. Current management, by contrast, is increasingly about identifying
‘outliers’ and fault, and then exercising control or elimination.
These
changes are inimical to small General Practices and their unrivalled
opportunities for high quality personal and family doctoring. To serve modern
regulatory requirements GPs are now – almost entirely – corralled and managed
in increasingly large and depersonalised practices.
The
coerced demise of a long-established and previously well regarded exemplary
small practice illustrates this process, and the price we pay.
February 2014
‘That
wasn’t too bad, was it? I rather liked them. I think they liked us, here, too.
They certainly listened…’ Sara, the Practice Manager, closes the front door
behind the two exiting Care Quality Commission (CQC) Inspectors. Her sigh is
soft, tired and appreciative.
I
agree: for this first inspection we had been probed, questioned and examined
with the best kind of professional intelligence: dialogic and sharp, yet always
with a view to a greater whole – with good sense and sensibility.
They
dextrously sampled and witnessed the ethos of my small practice: engaging with
patients and my staff, often sitting watchfully and unobtrusively to see our
interactions. After that they perused and enquired about some procedural
records.
Seeming
satisfied with these, the Inspectors’ attention shifted to personal
infrastructure: how did I manage and sustain all this? What were my definite
priorities? What would I then compromise? What did this cost me, personally?
Yes,
I agreed with their questions’ implications: to keep long-term, good quality
personal healthcare is hard: it depends on well-nourished and well-perfused
headspace and heartspace. So I described our endless choreography between the
personal and institutional. And how, when it is impossible to do both, it must
be the personal that takes precedence: institutional requirements are then
relegated or sometimes avoided altogether. I gave examples: judgements to
bypass detailed data collection boxes, or contextually clumsy prescribed
care-pathways.
The
Inspectors pressed me for my explanations of such judgements, my discernments.
I drew a parallel with what they were doing with us, now: they could not sample
or know everything by exhaustive
procedure. So the skill is wise and pragmatic selection and compromise: from
the accessible parts they would apply their imaginative intelligence to
extrapolate a likely and meaningful whole, and then they would apply their best
judgement. Yes, the Inspectors agreed, there is no certainty in such human
complexity; the skill is to construct and offer our best informed and shrewdest
judgements. This is not easy – it required nuance and delicacy: too direct an
approach may destroy or disperse what we are trying to see. We are here like
naturalist-observers: often we must be stealthy, still and part of the
landscape – that way far more will come to us.
The
two Inspectors resonated with this and talked around my metaphor. ‘Yes’, the older
concluded. ‘Our approach has to be skilfully and subtly different on each
occasion – we can then see much more of the important things that are going on,
good and bad … If we don’t do that our better judgement will be blind.’
As
Sara closes the front door, she turns to me and smiles.
‘Well,
whatever their report I think they got a good sense of us’, I say.
*
The
CQC report, publicly displayed for the next two years, glowed with positive
acknowledgements.
*
February 2016
A
Clinical Commissioning Group (CCG) meeting. The atmosphere is wearied and
listless, acquiescent though fractious. The GPs forming its nucleus are
obligated to attend by the Health and Social Care Act: theoretically they have
an executive role but they feel more like political prisoners. This paradox is
important – it illustrates how our institutions have massively misconceived the
vocational psychology of healthcare: why and how we may wish to offer often
difficult care for others. The result? An ever-increasing human and community
waste and misunderstanding. Now we cannot contain, sometimes even survive, the
effects of this. For years I have publicly and recurrently warned of this. I do
so again today. I meet the usual kind of diplomatic avoidance and
mollification.
As
the meeting limps dutifully to a close, Dr C, a veteran colleague, approaches
me inquisitively.
‘Have
you been CQCd yet?’ I am struck by how the noun of this institution has been
turned into a verb, to which I now serve as a passive recipient.
‘No’,
I say simply, but I know he has a message as well as a question.
‘Well,
you should be careful. They can be very nasty…’
‘Oh,
I think I’ll be alright. I found them helpful, intelligent and sensible last
time…’ I am thankful but cheerfully disregard him.
Dr
C’s look is of irony laced faintly with pity. He gives a twitch of a shrug and
turns away.
*
July 2016
Sara
spends much longer with the Inspectors than we expected and leaves them looking
apprehensive.
‘They’re
very different to those we had last time. They don’t really want to discuss
anything – just check documents and endless certificates. Some of them – the
more obscure ones – I couldn’t find…’ A contrite hand rises to console her
mouth.
It
is now my turn. The Inspectors enter my room. After necessary greetings and seatings,
a rhetorical question:
‘Your
Presentation?’
‘I’m
sorry … what’s that?’
‘It’s
the preliminary part of what you should have prepared for this CQC inspection.
We informed you of this in a detailed email. Don’t you read them all?’
‘No,
I don’t. Certainly not all. Not if I want to stay alive in this job…’
‘What
does that mean?’ their uneasy incomprehension already glares with disapproval.
‘Well,
it’s an enormous problem. Everybody knows it, but we can’t tackle it. The
ever-increasing electronic traffic numbs our brains, dumbs our speech and often
displaces off-screen reality. Email encephalopathy is an enervating
institutional disease. If I want to save my time, my Mojo and my sanity then I
must be selective … Anyway, I think my semi-deliberate lack of preparedness is
better now for us all.’
They
are both busy note-keeping, their questioning frowns seem mirrored. One of them
asks: ‘How can not preparing something be better?’
‘Well,
I can explain. In my experience “presentations” easily become feints of PR:
careful conjurings, editings and polishings. Slick packages. Choreographed
distractions and distortions to get the other person to see what we want them
to see, and conceal or opacify all else. An inspection is wonderful host
territory for all this. No, I don’t want to perpetuate this “spin culture”: I
think it has replaced, often dangerously, more natural and authentic dialogue
in our NHS. I don’t want to do that here, or anywhere.
‘So,
let’s talk: a conversation. That way
you’ll get a more real view of our struggling, flawed but wholesome little
world here and my role in it: what I do well and happily; what I do not; the
compromises I make; the rewards I get; how I hold it – and myself – together …
I want to be candid: warts and all…’
I
pause, to see if they are receptive. There is a jerk of the scribbling pen – a green
flag to continue.
I
go on to talk of the complex challenges – and gratifications – of providing
bespoke, personal continuity of good medical care in our inner city. My human results
reflect what I believe is mostly good work: extremely high patient satisfaction
rates since records began, no serious complaints (ie requiring a formal
hearing), stable and enduring staff expressing affectionate loyalty, low staff
sickness rates and no substantial accidents…
‘How do you achieve that, then?’ asks an Inspector.
‘By
assuring my priorities: personal contact and understanding – relationships. If they’re good, the rest
usually follows: morale, cooperation, attentive intelligence … But what we have
to secure first is headspace and heartspace: those are essential. Other things
much less so.’
‘What
is less important?’
‘Ah!
That’s where we come to what I’m not
so good at: what I selectively relegate or discard.’
‘What
are those things?’
‘Oh,
mostly formalities to demonstrate corporate compliance: contextually unuseful
and irrelevant data-inputting, some health and safety meetings or trivial
regulations, sticking rigidly to Care Pathways when I deem them
counter-productive. All that tick-box stuff…’ My hand flips away.
‘Give
us an example.’
‘Well,
I haven’t had a staff-minuted meeting about a Muster Station in case of fire.
The premises are small, with four rooms, one straight corridor, a front door
and a rear emergency door. It is quite clear what we should do: go to the exit
away from the fire.’
‘But
there are more serious omissions. For example you have no evidence of Child
Protection Training…’
I
sigh with encumbered irritation. ‘Well, I went for an afternoon course.’
‘Well,
where is your Certificate?’
‘Probably
stuffed in a bag somewhere. I’m sorry. Look, that course was so useless for me
it wasn’t worth certifying. I was in a hot room with about a hundred
practitioners of very varied grades and experience. For three hours we were
lectured and instructed by a specialist nurse and social worker. They said,
basically: “Children are neglected and abused more than we realised. Obviously
this is serious and often stealthily concealed. This happens more with
struggling, conflicted or unstable families – but certainly not only. Be
vigilant. Contact us.”
‘I
know this well. I’ve been working thoughtfully with families for years. I don’t need to take half a day away from
my work to be crop-sprayed in this way. What I do need – and what has now vanished – is easy access to an
experienced colleague who personally advises and sees things through, both with
me and the patients…’
The
silence has grown leaden and glowering.
One
of the Inspectors, Dr S, a neatly suited and formally mannered man in his
mid-fifties, clears his throat. ‘We have found other areas of concern. In
Mental Health. Your under-diagnosis of Depression and Dementia. This may
indicate your lack of providing a good service to certain patients.’
‘Oh,
I don’t think so. Look, when someone contacts me anguished with, say, a broken
love-bond, an inassimilable bereavement, a humiliating impasse at work, or a
haunting from old traumas, I am not going to spend that delicate time with them
filling in a formulaic – often clumsy – depression or risk-factor analysis. If
I do that I may gain points with the compliance system, but at the risk of
losing the patient. So, to avoid all that, I code such people differently:
“Emotional Problem”, “Work Stress”, “Family/Marital Problem”, etc. In carefully
using those kinds of discernments I believe I am then freer to provide better
care. Inconveniently for our current systems, that involves trusting the
practitioner with those many deviations … But we do have to trust to make those decisions.’
‘So,
you don’t see a place for the recommended diagnoses, templates and pathways?’
The Inspector’s voice is dry.
‘Well,
only sometimes. It’s complicated, of course. My skills must have the
professional autonomy to decide about this
patient, now: is organisational
compliance here likely to be helpful, unnecessary, or even deleterious?’
‘And
your approach to dementia: is it similar?’
‘Oh,
yes! And for similar reasons…’
‘Being?’
‘Complexity
and context. Failing cognition is only rarely decisively treatable by doctors.
Yes, we can help with certain risk factors. We certainly should offer our most
informed guided support and advice. But ‘Dementia’ becomes mostly a relational
and social problem: does the declining person have robust, and intelligently
affectionate care-taking from significant others? Who are they? Do they need guided support? and so on …
It’s the same for all of us, when we decline with age…
‘These
problems increase with our ageing population. As a frontline GP I have to
rapidly identify and weave these myriad and delicate threads to create a
personally meaningful, useful and accessible whole. But I can only do that well
when I can use my human and technical skills freely – when I am the choreographer. An institutional template often obstructs
all this…’
‘So,
again, you choose to depart from established procedure?’
‘Yes,
sometimes. It’s a tricky paradox. With these kinds of problems I can be a better doctor when I avoid doing what the institution might
expect. I choose when and how to override institutional procedures…’
Dr
S is looking at me with quizzical caution.
‘But
I am very thoughtful about how I do so’, I quickly add, as an insulating
caveat.
‘I’m
sure. But nevertheless you do feel you have the right to “cherry pick”, when
you choose?’
‘Yes,
that’s true’, I answer simply and softly, though I am already sensing a darker
subtext to the question.
‘Thank
you. I have no more questions.’ Dr S looks down at his notepad: his smile, to
himself, seems consummate.
This
meeting has been difficult but I want an amiable farewell: I chat as we are
disbanding.
I
ask Dr S ‘Are you still in practice?’
‘Oh
no. Not for three years now.’
‘Why
did you retire?’
‘Well,
I’d accumulated a very good pension, so I could leave easily!’, he beams. ‘I’m
just doing this [CQC inspections] now.’
‘From
practitioner to judge’, I say: a serious banter.
‘Yes,
I’m doing a University Masters Degree in CQC Inspections’, he answers, with
enthusiasm.
‘Ah’,
I respond simply, with rather less enthusiasm.
‘And
what keeps you going, in your fortieth year as a GP?’, he enquires, as if he
cannot imagine.
‘It’s
like a happy second family here, this small practice. Through all our joys and
sorrows we get to know one another: patients, receptionists, clinicians. And
amidst this, with my human and technical skills, I can sometimes be really
helpful. At other times we can, at least, be a personal comfort, support and
witness to Life’s inexorable sorrows. We all here want to come to work in the
morning. Where else could I get such satisfactions?’
Dr
S registers his own simple ‘Oh’ and shoots me a brief smile that is bemused but
not hostile. He is now standing at the door, about to leave.
I
offer my hand, to say farewell. His grasp seems reticent and ambivalent.
*
The
coup de grace was coordinated with
brilliant and shocking efficiency: a lightning strike worthy of Blitzkrieg.
It
came three days later, on a Friday night at 6pm. My receptionist received a
call from a Senior Officer at the CQC notifying me of their intention to close
my Practice on the next working day, Monday morning. The charge is that my
Practice was found by Inspectors to be massively and irremediably unsafe and
must be closed immediately. This would be done by an emergency legal procedure,
through a Magistrates Court Order.
At
the time – until a few hours before the set hearing – I was on a brief holiday,
in France. I was uncontactable and oblivious of these rapid and shocking (for
me) developments. Tired from a very long train journey I was unprepared and
disorientated by such overwhelming and draconian measures.
I
arrive flustered, hurried and alone to the Court. The CQC has assembled massive
and well-armed forces to encounter my unsupported and unbriefed solitary
enfeeblement: a solicitor, a barrister, a CQC Director, a CQC Compliance
Officer and a Medical Expert (in what?). They all have hundreds of pages of meticulously
prepared and filed ‘evidence’ against me. I cannot see how they could have
assembled such thoroughly destructive documentation between them within three
working days: there must have been much prior briefing and planning.
I
immediately ask the Magistrates for an adjournment, but the barrister is
adamant that this should not be granted: that my Practice is so extremely
hazardous that the public need immediate
protection, by its closure. Public safety must here, exceptionally, take
precedence over natural justice. The Magistrates acknowledge they have never
encountered this problem before and, bewilderedly, opt for safety. They rule in
favour of the barrister: whatever complexities emerge, at least the public will
now be protected.
This
Court hearing will turn out to be extraordinarily long – eight hours. The Chair
of the Magistrates will later describe what is (for them) unprecedented length
and difficulty.
Throughout
the long day there are Court adjournments for respite and procedure. Outside
the courtroom I am expected to wait, seated, in a bare ante room which I must
share with my CQC prosecutors, my assailants. This is awkward and they
understandably create maximum physical distance, avoid looking in my direction
and mutter very discreetly amongst themselves. In another context I would think
they looked amiable. To loosen the tension a little I say: ‘Look, we can see
how difficult this is and I want to make it a bit easier, just for now. I can
see you are all “just doing your job”, following procedure. Yes, that’s hard
for me, but I shall argue my case and bear no personal animosity toward you.
None of you know me, so I understand that – for you – it’s a technical and
institutional matter.’
I
notice two of them look at me briefly, signal a tentative smile and say a quiet
‘Thank you’. They seemed touchingly grateful for this: mercy from the
condemned.
*
In
this strangely cohabited space the ‘other side’ give me copies of the
voluminous prosecution documents. I have time only to briefly peruse some of
them: a thorough reading and response would take me days.
Very
soon I can see the professional profile they have constructed: reckless or
feckless, casually or deliberately unsafe, uninsighted, disobedient and
unreformable – in short a gross and intolerable liability to any public
service. With ironic gloom I conjure cartoon scenarios. A uniformed senior policeman
in front of TV cameras issuing a statement: ‘We have been warned of the great danger this man poses. Members of the
public should not approach him directly, but instead immediately contact the
authorities’. Or a shouting tabloid headline: Dangerous Doc Exposed! Authorities find years of concealed danger to
the public. How many have died?
In
my brief time for perusal I can merely identify some misattributions or
inaccuracies. Maybe I will have the opportunity to designate them: many will go
unchallenged.
But
my more substantial legal vulnerability lies elsewhere: I have already
frequently acknowledged deliberate and thoughtful non-compliance. I will never
deny this.
My
self-defence – however much I am allowed – will have to also address this. So, in
the courtroom, I offer a few parries and corrections to (what I think are)
documented errors. My main thrust, though, is an appeal to natural justice, as
opposed to strict legality.
Yes,
I argue, all can easily see areas of non-compliance. I have long argued that
this, selectively, must be done if we are to provide our best personal care for others and
(importantly) ourselves: that over-regulation,
paradoxically, is destructive to much of our best healthcare. I have vigorously
argued the reasons for this, often, in public, and in many publications.
The
lawyers prompt my return to their combat arena of legalities – their many
showcased items – but I am trying to break away, to view the bigger picture –
the whole – the overall integrity of myself and my Practice.
Despite
the lawyers’ stymies, the Magistrates ensure some (if inadequate for me) time to
do this. What is this bigger picture? Well, it’s much longer, too. I attempt a
brief, well-documented profile: thirty-nine years as a Principal GP; never a formal complaint needing a
hearing; excellent long-lasting and warmly appreciated staff and close
colleagueial relationships; never – until now – any litigation; never
on-premises serious accidents; far-above average patient experience feedback,
consistently and for many years; robust good health and humour; highly regarded
and well-known academic and journalistic output; similarly acclaimed teaching …
The Magistrates are attentive.
I
continue. With all this – for decades, and no sign (yet) of personal decline –
what is the real life evidence that I
am a serious risk, professionally or environmentally? Wouldn’t that now be long
evident, and from many sources?
No,
the barrister argues, you are flagrantly unsafe. All the regulation and
requests for documentation are there to assure safety. Therefore, if you do not
comply fully you become unsafe.
So,
I reply, I am guilty (of unsafety) unless I submit to all your procedures and
then get a certificate of compliance from you (the CQC) saying I am safe. Guilty
unless proven innocent: innocent only by submission – a stark inversion of
natural justice! Doesn’t this – the self-referring system of proceduralism –
eventually become a folly of officious abstraction? Isn’t that what is
happening here? No, the barrister assures the Court: such devices are there for
our communal protection.
I
take a contiguous, but different, tack and then appeal to the Bench: my
exceptionally good real-life record (ie not the one abstracted recently by the
CQC) has been possible only because I
have created the professional autonomy to decide on priorities with my Practice
and patients. That is my skill and my ethos – to employ my good faith and
judgement to make the best compromises. Our current error – as enacted by this
CQC action – is to assume that every possible risk, problem and adverse
situation can be prevented or solved by ever-increasing regulations of
compliance, monitoring, management and penalties. The truth of this is very
limited, but we (eg the CQC) are exerting this principle far beyond these
limits. The resulting trespass is egregiously – though inadvertently – damaging
of healthcarers’ vocational ethos, spirit and healthy colleagueiality. Hence
our evidence of another kind throughout the NHS: collapse of staff morale,
health, career longevity, satisfaction, recruitment … Overstrict parents rarely
produce what they, or anyone else, say they want.
This
– increasingly for a decade – is what I have been trying to avoid. This is why
– very selectively and conscientiously – I have openly chosen non-compliance.
To serve as a good personal and family doctor I must sometimes compromise or
discard my unworkably dense matrix of regulation.
Real-life
General Practice – like so much of our lived (rather than abstracted) lives –
is the art of the possible. Only rarely is it completable or perfectible. To
suppose otherwise will teach us painful lessons: that is what we are struggling
with, here and far beyond.
I
am relieved and grateful to the Magistrates for allowing me the time to say all
this. Even more so that they seemed genuinely interested and supportive,
despite their professionally neutral demeanour.
Not
so, not surprisingly, the barrister. All this, he says, is beside the
prosecution’s argument and evidence: that I have been knowingly disregarding –
flouting even – of clear regulations. Other argument, explanation or mitigation
is irrelevant.
Within
this narrow legal frame I can see he is right. I am guilty as charged. My heart
sinks.
I
am wanting to say: ‘But the whole
(evidence from life) is more than the sum of its parts (evidence from procedures). We must – whenever we can – pursue
and grant precedence to the whole.’ I look around the Court. After many hours I
can see it is now wearied to a standstill. I do not think they can be further
receptive to me. I decide to say nothing.
The
Magistrates adjourn for their final, private conference.
*
Another
thirty minutes. We are assembled for the summary and verdict.
The
senior Magistrate delivers this: ‘In my twenty-seven years on The Bench I have
never encountered a case of such length, interest and complexity. Yet at the
end of the day we are all subject to the law, and this Court’s task is to
administer the law, not to express opinions about any such laws or
regulations.’
She
turns to look at me directly: ‘It is with reluctance, but necessarily for this
reason, that we find for NHS England and against the doctor. To his credit the
doctor has been open and honest – both verbally and in documents – about his
failure of compliance to clear regulations, but this becomes indefensible in terms
of his contract of employment. NHS England is thus legally entitled to
immediately effect its remedial procedures.’
*
After
eight hours we all leave slowly, sagging with fatigue.
I
extend a friendly hand to each member of the hit-squad. They initially stiffen
warily with surprise, but then loosen as they perceive my gesture is unusual,
but not an ironic trick. I smile and say: ‘You did a difficult job well for
your employers. Of course, I don’t agree with what you’ve done: for me, this
may be the law, but it’s not justice. I understand the principle, but see only,
and much, damage from this decision. I have so many mixed feelings about all
this, but not about you: not personally.’
For
the first time each individual holds my gaze. They each smile with a sweet-sad
sincerity and say a lingering and deliberate ‘thank you’.
At
the end of all this very long procedure we have – only now and briefly –found
and recognised our common humanity.
I
feel a tug of intense grief: it is mixed strangely with relief.
*
Notices
are put up on the front door of my Practice informing of its closure of
services and where patients may now go.
As
I walk away from the front door Ronald approaches me. I knew him as a docile
adolescent and he now approaches me as a thickset middle-aged man with a
cumbersome gait and a habitual aura of trusting – but never really articulated
– anxiety. This is evidently worse now.
‘I’ve
heard, doctor … Can’t you be my doctor any more?’
‘No.
Not from now on. I’m really sorry. But I’m pleased I was able to offer a bit of
help over the years…’ I am trying to buoy us both up, offer us both something
positive.
‘But
why is that? Don’t you want to go on?’ I think Ronald hopes that his question
will bring a reversal. His eyes glisten with stemmed tears.
‘Oh,
no. The Authorities have decided I’m not modern enough. I’m not really what
they want. There’s all sorts of regulations I have to follow…’
‘Can’t
you do that?’ His question sounds pleading.
‘Probably
not. I’d exhaust myself and I wouldn’t be able to be the kind of doctor I
believe in … how I’ve tried to be with you all those years.’
‘So
they think they know, better than you, how to be my doctor, do they?’ His voice
is earnest and slow: this sounds like a real question, without guile or
rancour.
I
respond in kind. ‘Yes, I think that’s right. You see, they pay the money, so
they make the rules.’ I try to sound simple, neutral and benign. I exclude much
else.
*
Later,
outside the NHS City Gates, my severed professional head will be displayed on a
spike. It will not need much comment or explanation to spread the necessary
message. Corporations can function only with hegemony, and hegemony necessarily
must have compliance, and when have we ever achieved mass compliance without
publicly displayed, draconian penalties?
*
‘Oh
dear! That’s terrible news … I’m so
sorry. How did it happen?’
Dr
E, a young doctor now senior in my CCG, sounds genuine in his shock, kindness and
commiseration. He is an intelligently humane man but stressed, I think, by the
diplomatic strain and responsibility of shepherding very difficult schemes of
governance that he (privately) does not believe in. With delicate and opaque
skill he has signalled this to me previously, while always ensuring protective
ambiguity.
‘I’m
really sorry’, his voice lowers further with the repetition and sadness. ‘You
know this is going to leave a massive gap for us. You’re going to be greatly
missed…’
‘How
so?’ I am touched and a little perplexed: I have previously sensed his wish for
me to be more silent, or even absent.
‘Well,
you’re the one who always said the bold and challenging things other people
want to, but never would. You’re older and you’ve had this honest – some would
say tactless – courage. But these things needed to be said … now there won’t be
anyone to say them…’ His voice fades into a faint desolation.
‘Why
don’t you, E?’, I ask, trying to revive him.
E
is silent for several seconds before side-stepping: ‘Yes, but how are you David? Do you have enough support?’
He is sounding brighter and stronger.
*
As
I enter my exile I await a formal CQC report: a pillory, a publicly displayed
penalty for non-compliance.
I
am thinking that there are times in life when we must choose between personal
integrity and survival. I am grateful that this – my most serious test – has
been encountered so late in my career.
I
am thinking, too, of the elemental questions of all relationships and welfare:
what do other people want and need? How do we (think we) know? Who decides, and
how?
-----0-----
Some eyes
need spectacles to see things clearly and distinctly: but let not those that
wear them therefore say that nobody can see clearly without them.
– John Locke, An
Essay Concerning Human Understanding (1690)
The young
man knows the rules: the old man knows the exceptions.
– Portuguese proverb
Interested? Many
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on www.marco-learningsystems.com
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