NHS England 2014: Vichy France 1941

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‘Let your mind wander in simplicity, blend your spirit with the vastness, follow along with things the way they are, and make no room for personal views – then the world will be governed’

– Zhuangzi Chuang Tzu (3rd century BC)

It is midday, late July. The sunlight is sharp and the air hot, cloying and still. In the care-worn meeting room the delegates are lunch-fuelled by paper-plated utility sandwiches. The extra glare from neon lights is unnecessary: a rarely noticed sign of institutional routine and oblivion.

This is where I must come to attend my Locality GP Clinical Commissioning Group. As a long-serving family doctor I must join this group to assure survival of my small practice, and thus my employment. Effectively, I need the protection of The Mob: like all others I was made an offer I could not refuse.

The energy in the room is torpid and listless. Trunks are slouched submissively but extremities fidget, eyes are vacant, dreaming, or avoidant.

The luckier members are busied by minute-taking, document distribution or data-presentation and dispersal. The trickiest job here is reserved for Dr C, a handsome forty-something with an easy, avuncular style of competent organisation.

I sense in him a decency which wishes to gently assert good authority yet eschew conflict. His job is not just to conduct the agenda, but to convey a sense of purpose and mission. This is not easy: the group is largely made up of conscripts.

There are two main topics from today’s presenters. The first is a large Hospital Trust that is a major ‘Provider’. Allegedly this hospital has ‘failed’ in its contractual obligations. Evidence for this is provided by streams of verbal data and clutches of charted and bullet-pointed documents. The complexity of these is not matched by equivalent discussion.

I am uncomfortable about complex statistics. Many times I have seen NHS professionals ‘cleverly’ redesignate, elide and double count with devious legality. I need to ask many, many questions about samples, sources, methods and contexts before I offer any assured clarity. This would take me days of dialogue and thought. I do not want to express a hurried view. I speak up, saying I want to ask some elementary questions.

Dr C shows his first frisson of irritation. “Didn’t you read the email documents we sent round?” he asks. His question is rhetorically toned with accusation.

“No”, I say, “I do not read any of these and will tell you why. It is because it is impossible for me to offer the kind of service I would like to receive as a family doctor and personal physician if I follow the major distraction of attempting, also, to be a competent statistical analyst, actuary or public health adjudicator…”

“Well in that case you cannot make a useful contribution to this discussion.” He thrusts quickly. I think he thinks I am silenced.

I am not: “I think your equation implies a serious error. I think very few, if any, GPs here have thoroughly read such documents …”. I turn to them: “Tell us, who of you here can willingly or competently deal with all this stuff? The problem is that a useful discussion is not possible, not that I am a useless discussant.”

A few look at me silently and nod encouragingly. More, also silent, look down and away, hoping the dissonance will pass: they hate it when parents argue.

I am disliking the process of this meeting, too. Typically the presenters speak continually for about fifteen minutes. This is followed by a few minutes’ questions choreographed by the chairman: I sense he hoped for broad consonance. If I speak for more than thirty seconds I sense Dr C’s restiveness. At fifty seconds he gestures for me to stop. At sixty seconds he verbalises this. Such a format may be adequate as a formal briefing or a press-conference. But it is dialogue I want. I cannot be of any real use, here, without it.

I cast a second baited-line.

“Even if all these poor Performance Indicators are ‘true’, there are still many questions to answer about why which need to inform us … Why and how do people like us (for they probably are) become (allegedly) deskilled, inefficient, unmotivated or disconnected?”

Many of my colleagues look confused. This neon-lit room rarely explores inner human illumination.

Dr C again: “I want to stop you there.”

I rebel: “Well, I do not want to be stopped just yet. Eventually I want real dialogue here, but until then I want to say this about our ‘underperforming provider’: such people are our erstwhile colleagues. I do not believe that strictures or punitive methods can help or remedy such difficulties. Our language and thinking now reminds me of our worst kind of psychiatry: clustering descriptions or symptoms together and then assuming we can ‘manage’ the underlying complex human problems with little human understanding or curiosity. Yes, I understand we are following official procedure. But by merely implementing government policy without freer discussion and caveat, we both collude with and conceal governmental blindness.”

After sixty seconds. Dr C’s jaw tightens. “I really can’t have you taking over the meeting like this …”

“I am not trying to ‘take over’ any meeting, but I am pushing for less edited exchanges – yes, sometimes difficult conversations – and that requires a certain equality of transmission and audience. I definitely do not want these smoothed-out briefings.”

At eighty seconds, Dr C’s ire is mounting. I stop.

There is another speaker. She is talking about the population’s misuse and overuse of Accident and Emergency departments. There is the inevitable talk of procuring new data and systems and endless audits to fuel our statutory requirement to present ‘solutions’. Yet this is an elaborate folly, for with this kind of problem there are not solutions, only our wisest, workable compromises. This seems inassimilable to modern systems-thinkers.

I want to share some of this. I dodge past Dr C’s curfew.

“We have been recycling very similar concerns, investigations and documents for more than twelve years. Some truths emerge and remain constant and clear. For example, all GPs can do is offer accessible, friendly and competent consultations and then draw clear attention to the correct use of emergency and out of hours services. The important thing that has changed – and worsened the situation – is the effect of the Market. We talk of ‘Integrated Services’ with other sectors, but this is countervailed by a system that is competitive and divisive … and then, of course, mistrustful. We must carefully review this bigger picture and its history…”

Forty seconds. He stops me: a more irate interception. “We really don’t have time for all this and, in any case, this is not the correct meeting for such things…”

“That’s the problem!” I interrupt his interception. “There is now no ‘correct meetings for such things’. We have been made mute and compliant. That is why I am, here, so defiant and verbal.”

Dr C is glowering. I stop.

*

Consider this. Before the last General Election in 2010 the Conservative Party stated with explicit clarity that it would not introduce any major reorganisation into the NHS. But Andrew Lansley MP had spent many years with others, designing and harbouring other plans.

Once in power, as Health Secretary, he unleashed them. With formidable stealth, guile, ambition and deceit he pushed through the Health and Social Care Act 2012, facing only confused and disorganised opposition. Few understood the complex nature and implications of this Act. But Lansley’s Blitzkrieg success turned to a personal pyrrhic victory for he probably had not fully understood the implications of his Act. He was unable to contain the questioning and angry dissent that followed people’s clearer perception and realisation of what the Act entailed. The political Victor became a liability: a replacement was needed. Jeremy Hunt’s skills of diplomacy and damage-limitation have saved the government from more immediate hazard.

Beyond the political arena Lansley’s pyrrhic victory has much worse consequences for practitioners and patients. Professional support for his ideas was always meagre. Yet generally the profession is now settling into a three-tier system of Commissars, Apparatchiks and Healthdroids. This, paradoxically, is very similar to the old anti-marketised Soviet Union.

Lansley had a brief party. The rest of us face a long period clearing the mess.

The deceit involved in the coup procuring this Act was far more thorough, dishonest and deliberate than the usual fickle expedience behind improvisatory changes of tack and U-turns. It was long conceived and disguised: this was more malfeasance than Realpolitik. Such chicanery in public affairs is certainly immoral: it should be illegal. Yet it is already receding beyond shared memory: it should not.

My altercations with Dr C are legacies of this expertly crafted betrayal. They are conflicting reactions: expedient pragmatism versus ideology of conscience.

Dr C is saying: “Keep your heads down and don’t make trouble. Meanwhile I and my lieutenants will garner the most workable arrangement we can manage with the authorities. This is our best chance. Don’t spoil it.”

I am saying: “We have been passed a poisoned chalice and then trapped into being its custodians. This act of deceit and folly is still poorly apprehended and understood by many, including government and its agencies. Collusion can only be temporarily beneficial: ultimately, it is radically damaging both to personal healthcare and democratic politics. We must refuse this chalice and articulate clearly why we do so.”

*

The meeting ends with uneasy energy but correct and clear formality. Dr C walks with purposeful swiftness to his car. I wish to extend an emergency bridge, to ensure we can reach each other over these troubled waters. I get to him just as he is entering his car. He sees me, swiftly closes the door and opens its window: a smaller portal for exposure.

“Dr C, I just want to say that what I say and do is not, ever, personal – though it is personally difficult. I am sorry for those difficulties, but I think what I am saying is becoming increasingly important as it becomes increasingly neglected and circumvented. Because of these difficulties we must find the courage and flexibility to have these struggles publicly…”

Dr C looks angry and hurt: “I think you’re just very rude.”

“What is your understanding of ‘rude’?” This is a genuine enquiry.

“That is rude. How you behaved in the meeting.”

“Well, what I did was certainly counterconventional and outside usual exchanges. Our institutional routes of exchange have rapidly stifled any bold questioning or challenge. Candour is often risky, but the risks of not being candid are often greater…”

“Well in my book, it’s just plain rude.” Dr C puts the key in the ignition. I might cast one last line.

“Look”, I say, “all these recent reforms – the last in particular – have managed to corral us into short-term and craven compliance, but we are rapidly losing the identity and integrity, the heart and soul – and now the wider intellect – of our profession. I hear this so often privately, but never in these meetings. Why?”

I pause to look at him, but he averts his gaze. I want to finish. “It is the most difficult conversations that are the most interesting and ultimately rewarding. You and I could have several: I would like that.”

Dr C is gazing fixedly at his dashboard instruments, as if they might have instructive data for this situation.

“Maybe”, is the single word, but I imagine “never” in his clipped tone. I notice his tight-knuckled grip on the steering wheel.

“I really must get on now.” He presses a button. The electric window slides up and closes. He looks away.

Isaac Newton reportedly said that tact is the art of making a point without making an enemy. I think Newton would have been ahead of me at this stage.

*

As I turn I find Dr E unexpectedly waiting for me.

Dr E is an elegant, bright shadow: an enigma. He has an intelligent gaze set in an expression of astringent humour. I have sat with him in dozens of meetings over many years. He sits always in watchful silence. I sense his complex intelligence, but have never heard it.

Dr E now seems to want to talk to me. I am again struck by his unflustered immaculacy: the coolest man fresh from a hot cauldron.

He makes subtle gestures for me to follow. “Oh”, I ask, “can you give me a lift?”. “Sure, sure…” he seems to have anticipated this.

We are sitting in a slinky, swoopy, shiny air-conditioned large Mercedes: a silent haven of peace.

He turns a warm fraternal smile towards me and pats the steering wheel softly.

“You know, you’ve been saying these things for some time … They are very interesting and I agree with you wholeheartedly. I think you know that…”

He is like a cat, I think: quiet, precise, contained.

“How would I know that?” I ask, a genuine question.

“I think you do”. Feline economy.

“But if you’ve agreed with me for so long, why don’t you say so publicly?” Another genuine question, but now implicated with a plea.

“There is no point in making trouble. They know what they want to say, what they want to do. They are only interested in endorsements and minor suggestions: otherwise they do not want to hear anything. I come here because I have to: it is a statutory requirement. I have loved my work and I want to go on with it: I don’t want trouble. So I say nothing.”

“Like the Three Monkeys”, I say.

He beams another smile, more conspiratorial: “Exactly. But I survive.”

“So, all our politically correct blather is already fuelling a new Oligarchy”, I frown.

“It is how our world works now. Unless you want to be a manager, just find a tolerable spot and be quiet…”

We lapse comfortably into an intimate silence. He knows this locality well, but I notice he has taken a very long route.

*

The next day Veronique is sitting in my surgery. I have known her for thirty years. Her determinedly upright carriage, tastefully bright clothing and engaging, quick mind do not convey her painful widowhood or her eighty-two years. But her eyes often recede into ancient pools of sorrow and flitting wariness.

When she was a ‘happily married’ middle-aged woman she told me the human story behind her well-guarded persona.

She was eight years old at the time of the Fall of France. Her father was the Mayor of a small southern French market-town. Veronique’s family until then remains memoried by images of harmony, laughter, popularity and comfort. Those blessings abruptly end with the German occupation: she would never again experience such felicitous security.

Her father had a grave dilemma: whether to expediently submit to the inevitable (cooperation with the invaders), or whether to heroically cleave to his principles (perilous defiance of the invaders). He chose the former: he felt a protective mission for his family and his regional kith and kin. “This is for the best, you’ll see”, he had reassured.

This ‘greater good’ was first thorny, then elusive, and then clearly impossible. Compromises became betrayals, collaboration became treachery. By the end of the War the town’s paterfamilias was turned into a figure for pillory and contempt – sometimes by those who had sought favour before the turning of the War’s tide.

Veronique’s father was not tried, though he was stripped of his Office and his furniture business collapsed. He retreated into a shuffling and nearly mute melancholy, leaving his family socially ostracised. Mother was abject with shamed grief, Veronique friendless and spat at. At her earliest adult opportunity Veronique left them, and made her life, home and marriage with an Englishman.

Years ago she had, with me, tearfully unpacked some of her grief for the father she had lost, and who had lost himself. She was also grieving for her childhood friends and neighbours who had lost themselves – first by expedient collusion with her father, and then by disownership of their complicity, and then blustering, expedient blame.

Seventy years after the national collaboration crumbled, Veronique is describing to me her disturbed sleep and bowel function: a familiar pattern. I ask a few medical questions. Her symptoms are ‘functional’: like a spitting semi-somnolent volcano from a deep and ancient subterranean source. I cannot stop this deep-rooted turbulence, only quieten some of its quakes. Then – possibly – I can encourage conduits that bring words and thoughts of personal meaning.

Veronique knows I cannot cure her, but she continues to want me to know of her plight, struggles and sorrows. She wants some form of witness and shared understanding. In the crucial events of her childhood such human connection was not there. Seventy years later it is important that I provide it.

This is very complex, but we do not need to say much.

“Do you think it’s my usual troubles, doctor?”

“Yes, I do, Veronique. I can give you some tablets to calm your night-time mind and gut, but their source is beyond my reach…”

“So, it’s my ghosts again …” her sorrow is fringed with playful recognition.

“Yes”, I say, “they will probably outlive us both.”

*

For years Alan’s quiet and intelligently respectful medical work was both respected and rewarded by promotion to senior positions in executive and academic bodies. Recent years have disappointed him as he has seen his vocational ethos eroded by an alien cultural tide. He now talks of retirement: it would be earlier than he had wanted.

I am telling him of my recent discordances. He listens with supportive attention for a while and then starts drumming his fingers.

He meets my gaze.

“Of course, I agree with you. And I’ve tried – in my own way – to politely say similar things when I can, but it makes no difference. It’s like trying to talk to a herd of buffalos stampeding in another direction. And I’m not like you: I can’t cope with all these kinds of conflict and unpleasantness…”

His voice sinks then strengthens again. “But I suppose one has to think positively: that – eventually – there will be a backlash.”

I am struck by the personal disengagement and slippery vagueness of his language.

“Yes, but what is a ‘backlash’? And what is ‘eventually’? Anything effective is going to need clear and explicit opposition. Who? How? When? …” I am showering sparks of defiance.

Alan looks at me but does not speak. He spreads his empty hands, palms outwards and upwards, toward me. I read the wordless message: “Not me, Not now. I have done what I can. Over to you. My hands are empty, but they are clean.”

*

 My last week’s exchanges with Dr C, Dr E, Veronique and Alan have converged in my mind. How difficult, messy and ultimately disappointing is democracy – yet how much worse the more expedient systems turn out to be.

Many years ago – when it was much less necessary – I found ready discussion with my colleagues about such matters. Increasingly we now cannot find time or see the relevance.

Is my cacophony with Dr C an early example of Alan’s delegated ‘backlash’? Could it even be an answer to our current Health Secretary’s recurrent plea for a ‘change of culture’? And could such change ever be orderly?

'If I am not for myself, who will be for me?
 If I am only for myself, what am I?
 If not now, when?'

– Rabbi Hillel Hababli (1st century AD)

‘The reasonable man adapts himself to the world: 
the unreasonable one persists in trying to adapt the world to himself. 
Therefore all progress depends on the unreasonable man’

– George Bernard Shaw (1903) Man and Superman

This is an edited version of a piece byDavid Zigmond.