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Another victim of A letter to the Medical Director, © 2012 David Zigmond Introduction: Increasingly complex and depersonalised healthcare services The letter has had a lengthy incubation period and is itself very long and carefully written.
Much descriptive style and content make it akin to a documentary film: it will take about an hour of attentive
reading. I hope you find it is worthy of this.
Abstracted main principles: a summary
Dr Martin Baggaley Dear Martin Eric: another victim of Hypertrophic Obstructive Management Coagulopathy.1 Mounting problems with presentations of complex distress and dependency. Damage from overuse of rigid schemes and definitions. * * * * A Foreword: Let me start with an explanation and pre-emptive apology. This letter is very long! I would like you to read it carefully: you may wish to print it off. It gathers many years' thought, observation and participation a working lifetime amidst the NHS's increasing cycles of intussusceptions, then proffered redesigns. It has taken many days to write: the importance and complexity of the issues demands far more than a short, sharp offering this might alert but could not inform. I certainly do not expect an equivalent letter in reply: even less do I want an e-mail (see later). What I will greatly value, though, is that you take time to read this letter with the spirit and attention with which it is written beyond that I look forward to more searching dialogue, between us and beyond. * * * * About the background to this letter I have been a frontline NHS medical practitioner for more than forty years (see later for details). Most of my satisfaction has come from developing artful encounters with human complexity: the heart of good consultations. For the last fifteen years, the culture has become progressively antithetical to this. I have found myself playing a bemused and frustrated victim, perpetrator or witness to healthcare services that are increasingly and adversely remote; asphyxiated by a pall of algorithmic, humanly disengaged procedures. Services and practitioners that used to provide (mostly) easily accessible, sensitive and sensible responses of containment, support and understanding have been progressively replaced by those that do not. My work in General Practice has become stymied by frequent, obstructive administrative complexities, and a parallel lack of exploratory colleagueial dialogue. Obviously, (re)designers of services had not intended or anticipated these kinds of experiences. This discrepancy between design and effect has, for several years, become increasingly evident to me and the more personally engaged practitioners of my generation. Younger practitioners and managers who have known only the current vocabulary, ethos and mindset will consequently adapt with greater confluence and little contention. The inevitable loss of enquiring critique will be grievous to both intellectual and emotional professional cultures, and thus our human quality of care. This will be illustrated shortly. I think that the latest planned reconfiguration of services by your Trust will add to these difficulties. For example, there is already evidence that breaking up the old Community Mental Health Teams into further subdivisions of diagnostically defined Clinical Academic Groups adds to abstracted, administrative burdens and tasks: a rolling 'snowball' of boundaries, territories, definitions, disputes and procedures, and a paralysing volume of defensive data and documentation. And all of these can be problematic before (and thus, often instead of) personally meaningful contact with the patient! To assure clarity I present in this letter a detailed and graphic example, to show what happens, and how. I have many similar, documented cases: they are increasing.2 As these obstructions have proliferated, it has been more difficult for me to provide sensitive and competent care. My response has been to pursue (often difficult) dialogue, to think long and hard, and now to write about these. In this letter I refer to themes I have explored elsewhere. The references are listed at the end,3 and easily accessed via my Home Page (http://www.marco-learningsystems.com/pages/david-zigmond/david-zigmond.htm). A little about myself and my relationships with colleagues I have been working in the same small General Practice for thirty-five years, for the last twenty years as a single-hander with long-term Assistants. Much earlier on I worked for several years in Psychiatry: my experiences were enduringly affecting for me; my human interest and eclectic philosophy remain undiminished. For my first twenty years as a GP before the CMHTs I had a cordial and close working rapport with hospital psychiatrists. During that period I had several dual-trained Assistant GPs working with me (as GPs) who went on to become Consultant Psychiatrists. Sadly, due to both culture and regulations, this amalgam would be impossible now. As my difficulties with new NHS psychiatric and psychological services have increased, so too have my disjunctive communications with some encountered colleagues. The pattern of these has varied with rank, in a way that is instructive. Those most junior, on the frontline, I have often found rigidly adherent to protocol and averse to any loosening or enquiring dialogue: I have come to realise that what I might experience as 'officious' might largely represent a defensive manoeuvre, to protect their own management-determined position. I encountered this kind of cul-de-sac recurrently. In my frustration I sought to short-circuit organisational resistance and engage the upper echelons. Here, of course, is greater experience and license to looser exchanges: personally, after initial wary reticence, I have found courtesy, interest and intelligence though often remaining cautiously shackled. Sometimes, in attempting to read the unspoken subtext, I have had to remind myself of the 'ordinary' reasons for avoidance and circumspection: people want to protect their role, their rank, their post, their livelihood. Dissent at times of receding resources may seem hazardous. Conformity has many components. So: how to challenge a highly flawed and misconceived system, while retaining respectful dialogue with its staff and executives? A conundrum: most of my like-minded colleagues, tired and disillusioned, expediently retired from the fray. Maybe I am lacking in their wise discretion. Hence this offering: possibly misjudged, but my best effort. Some introductory remarks to my example: 'Eric' For the usual reasons I disguise the patient with the usual devices. Likewise with members of your Trust's psychiatric centres and staff: my difficulties have been with professional roles and formulae, not with any individual's underlying integrity or competence. Indeed, one aspect of my critique is that I have been unable to access these underlying personal qualities because of the system. I convey the example in narrative form as I experienced or understood the events. The roots of psychiatry lie in experiences, variously conveyed and combined. To these we then apply our specialist language, clustering concepts and definitions: all of these are artefactual they should never to allowed to eclipse, for long, the underlying experience. Hence the 'filmic' quality of some of this account. Example: Eric diagnosis may be sometimes necessary; it is rarely sufficient 1977-2010 As a GP for more than thirty years in the same practice, I have had medical responsibility for thousands of people. Eric was one of my few 'old-timers' I'd had almost no contact with. I knew what he looked like: a tall, increasingly stooped, bespectacled man, now in his early 70s, who had always dressed with neat, quiet formality and who carried a mien of discrete compliance, of well-mannered appeasement. I remembered several glimpses spread over many years of his visits to other practitioners. Paradoxically, I had another route of acquaintance with him that was more detailed Ð though more abstract through the post: letters from specialists over many decades. Hazy memories of these were crystallised into the terminology of his disease-register and medical notes summary: 'Mature-onset Diabetes' and a 'long history of major, relapsing depression'. I remembered old letters from the 1960s: the days of outer-city Mental Hospitals, 'modern' tricyclic anti-depressants and courses of ECT. More recent letters had better news: containment and quiescence of his symptoms and punctilious compliance with prescriptions, plans and attendance. I sensed stable fragility well attended to: I had no need to intervene or understand further: if at peace, do not disturb.
* * * * 2011-2012 An urgent phone call. The receptionist, Sue, correctly recognises raw and intelligent fear in the unknown woman's voice. Sue is intelligent, in response. It is not a 'good time' for phone calls, but she puts the call through immediately. Sue has an unschooled instinct for real distress, and thus accurate precedence.
* * * * Within an hour, Eric and Dora are sitting with me. Eric's deflation, hopelessness and anguish are painfully and immediately apparent: his slow movement, enfeebled voice, depleted gaze and burdened gait all convey intense and incarcerated despair. Words delicately baited may later amplify or explain. Dora's presence and prescience are what I had imagined from our brief telephone contact: unintrusively engaged, lovingly watchful, fearful of tragic catastrophe. I sense in Eric some fresh personal trauma causing this dramatic collapse: some kind of rupture; an internal haemorrhage of hope and faith. I need his words to explain: they are like frightened small fish sheltering in the darkened deep. I have to be still awhile, and patient. His words begin to surface; I lean forward, gently, to catch them:
The words almost collapse at the back of his throat and are exhaled plaintively and weakly, as if he is dying. They choke to a halt with inhaled, silent sobs. Dora is calmer, now she is sharing this enervated burden. I turn to look at her. She returns a knowing gaze. She does: she starts to explain:
I realise I am dealing with broken vital connections, and a still-active volcanic personal ancient history, of which I know nothing. I must understand the essence of Eric's world, and story, very quickly. Within fifteen minutes I have deciphered much: I am simultaneously gratified by understanding and disturbed by what I have understood. * * * * Eric was the youngest of five boys in a traditional, poor London docker's family. His mother, in her forties when he was born, ailed throughout Eric's infancy and died when he was three. He was cared for by a younger sister of his dead mother, Aunt Ada, until the onset of the Blitz. By the time his neighbourhood was shattered and ablaze, he and his four brothers and father had all dispersed, separately, away from London: Eric and three brothers were evacuated to families throughout the Home Counties, the oldest brother and father joined the Merchant Navy, hoping to stay together. They did not; father perished in an attack on the Arctic Convoy. Eric's wartime childhood as an evacuee was abject, grief-struck and fearful. He was moved several times to different families for reasons dictated to him, but little understood by him. His experiences of care were various kindness, affection, hostility, cruelty, indifference but never predictable, dependable or within his control. He could not understand the difference between death, separation, abandonment or punishment. He learned to survive by appeasement, submission, invisibility. His memories of his mother and Aunt Ada brought grief that was rarely consoled: he learned, too, to appear to be brave. At the end of The War, at the age of eleven, he returned to his orphaned family of older brothers, in the resuscitated ruins of London's Docklands. Eric's brothers were kindly and protective with Eric, though tougher than he: they had had long-enough and robust mothering. For his sense of protection and belonging, he followed his Band of Brothers to work in the Docks, soon after leaving school. Eric's brothers and a few of his more thoughtful workmates were his social and family life, for several decades: he never made sexual relationships with women a dangerous and painful yearning, a Bridge Too Far. Eric's depressive breakdowns, in his thirties and forties, were possibly related to fresh abandonments: by his brothers who left him, each to move away from the Docklands to spawn their own families. By his fifties his 'family' consisted of his now distant, elderly, often ailing, brothers and a few retiring, soon-to-vanish, fellow dockers. As his livelihood, companionship and brothers died, this vulnerable, inarticulately yearning, self-deprecating elderly man feared the waning of his solitary life, unknown and unwitnessed. Nancy had recognised this with discrete intuition, and for several years provided the kind of family surrogacy that provides humble but deep affiliation and palliation, yet has no official designation. Nancy, it seems, was guided by a basic tenet of care: that to be known to another, with intimacy and volition, is one of the most powerful balms for human distress. With evident sense and sensitivity Nancy had with necessary professional safeguards and boundaries contained and symbolically cradled this eternally grieving, unmothered old man. Nancy's humbly potent humanity, though, had invidious flaws: it is undesignated and unmeasurable; not part of a recognised generic care pathway. Ipso facto, Nancy should not be doing this work: Eric should go elsewhere, to a place of prescribed and recognised 'treatments'. The consequences of this 'rationalised management'? An avoidably, yet now primitively disturbed and distressed elderly man whose life I now fear for. What will I do? * * * * What I can. My attentions to, and on behalf of, Eric have been multifarious, and for many months. My more direct endeavours have been akin, I imagine, to Nancy's to compassionately contain, respond and guide: to comfort, palliate and help him reclaim some hope for his increasingly meagre life. Due to his feelings of unsafety now, with the Mental Health Teams, I have been seeing him every two weeks: I accept I may need to do this indefinitely. I am sadly aware that there are now few GPs who would take this initiative, or accept this responsibility. What would happen to Eric elsewhere? I have directed my attention more widely, too. I have wanted to understand and define the institutional misperceptions and misconceptions: how, with apparent good intent, do we deliver such miscarriages and perversions of care? I have had to be resilient and assiduous in my (re)search, motivated not only by Eric's individual and affecting predicament, but also an increasing number of other patients describing similar dislocations of human understanding by Specialist Services.2 Over many months I have made numerous phone calls to various Psychiatric Teams. I have had to be patient, persistent and assertive to generate substantial dialogue. Face-to-face contact has been harder, success had been sporadic yet labour-intensive. This Odyssey has two parallel paths of seeking exploratory dialogue with Psychiatric Services while securing restitution of care for Eric. Both are long and difficult. This following description thus attempts salience, not completeness. Precise details will be found in our respective records.2
* * * *
I spoke initially to Nancy, then to both the Clinical Manager and the Consultant Psychiatrist at the Mental Health Team. With all three there was a layered carapace to their responses. First, wary bewilderment: why would a GP want to enter their territory with such energy of concern and enquiry? Then institutional deflection and edict: "The Team has assessed and decided ...". "The Care Pathway, directed by agreed Trust Protocol ..." and other armoured phrases of unpeopled authority. With skill and patience I was able to get to the cramped and uncomfortable person trapped behind the armour. Nancy seemed wary, weary, circumspect then relieved in her brief confiding:
The others, with less direct knowledge of Eric, went through the same process of deflection, dissemblance, then confidance and dispirited contrition. Again, my tricky choreographic riddle: how to maintain respectful colleagueial relationships, while indicating clearly and strongly my wide-ranging disagreements with their policies and decisions? My clarity and resolve and anxious concern were refuelled unhappily; by the accuracy of my predictions: Eric's abject misery became so uncontained that he was admitted to a Psychiatric Unit. Given his early experiences of care by strangers and the nature of current admission centres, his likely reaction was also easily predicted: iatrogenic damage was deepened. The cost to NHS resources is considerable; to human welfare much greater.
* * * *
In my effort to keep Eric's distress closer to drama than tragedy, I contacted you in your role of Clinical Director for the Mental Health Trust. Your response was prompt, concerned and pragmatic: you delegated one of your experienced and Senior Deputies, Dr Y, who would communicate with me. Dr Y did contact me in a way that was remarkably unremarkable: he sent me a long e-mail. Remarkable? Unremarkable? Which? The e-mail combines immediacy and precision of signal with remoteness of human contact: no face, no voice, no location, no touch. Yet it is increasingly used automatically, even in such humanly-demanding situations; it has become a part of our culture. But is such signalling communication? If so, what kind? What for? Dr Y's e-mail was polite in taking control. It proceeded like an Instruction Manual, assuming that I needed his executive explanation, guidance and help. Some anomalies made this most improbable. He started by acknowledging that his reply was mostly based on his perusal of electronic records: he had never met Eric, "but I do have a lot of experience with such patients". As if I do not? Proceeding to address me like a silent Tannoy System, Dr Y then raised the possible therapeutic options of various psychotherapies for Eric. This line of thought seemed (to me) to assume a common simplistic notion of 'psychotherapy' as a sequestered, distilled, specialist activity that has to be designated and delivered systematically. Eric (and I would say most people I see who are distressed) do not want or need that kind of schematised activity. They do, however, want contacts that are psychotherapeutic: contacts that develop trust, hope, understanding, meaning, structure and safety. Nancy had been doing this with Eric, very appositely, for years. I could see this clearly within minutes of talking to Eric. Even Sue, my receptionist, rapidly intuited much the same. Yet various managers of Specialist Services could not, or would not allow themselves, to see this. Why? My theory: because Nancy's unschooled and undesignated therapeutic contact lay outside currently prescribed algorithms and care pathways: that which is not prescribed now becomes proscribed. Dr Y's long and tendentious e-mail concluded, with a kind of magisterial authority, by instructing me about this man he had never met: "Overall, the type of all-embracing care that secondary care tends to offer can often entrench such personality characteristics". What does this mean? Like most general statements about human experience, motivation or Fate, this is a notion that is bound to be true, sometimes. But an opposite proposition is also sometimes true. The art and wisdom of practice comes from the creative and pragmatic editing and synthesis of such partial truths. So, Dr Y's statement, which may sometimes be usefully true, is now rendered hazardous by its introduction as 'Overall', which implies hegemony, like a Monarch reigning 'over all'. This is not pedantry: a crucial and difficult part of our work in Mental Health is to always look for exceptions to our predicated patterns. Without skilful handling of these paradoxes, important misunderstandings will be frequent. Eric is a stark example of this, and how it happens. Dr Y's long and didactic e-mail seemed heedless of this. He paid no attention to the personal nature of Eric or my engagement with him: Eric will need some kind of innominate, but bespoke, humanely imaginative containment until the end of his life. This is not rare, yet is rarely acknowledged. Over many years of working with the mentally distressed, I see that this kind of innominate approach has been crucial. How do we assure space and resources for such unpackaged, difficult-to-measure-yet-made-to-measure, free-form compassionate contact with others? In the longer term, in contrast, I have found the currently vaunted time-limited, designated packages of care to be of evanescent interest and shallow effect. What I wanted and needed from Dr Y was some sophistication of dialogue. What I got was a default-type of e-mail: now so ubiquitous as to be a new convention. In this culture of screen-before-person practitioners are now deluged by an inassimilable quantity of such signals. Few get read with good attention; even fewer intelligently discussed. Yet, if we look closely, we can see anomalies and absurdities which few would intend. This happened here: with Dr Y, myself and Eric.
* * * *
Let us distance ourselves and look with an alien, intelligent eye. What do we see? In a highly complex arena of mental distress, where individual understanding must be key to any success, a delegated manager electronically transmits abstracted judgements and decisions. He has spoken to neither the patient, nor either of the most involved practitioners, both of whom are highly experienced, competent and intelligent. He is addressing one of them now, but does not draw on their knowledge and experience of their work or the patient. His view is, rather, distilled from absent persons' computerised records, and then submitted to 'authoritative' patterns of generic recommendations (to which there must always be many exceptions). The role of this sequestered manager is not to engage in a mutually informative dialogue with those involved. Instead, he 'posts' a long, monologous electronic signal, with intent to instruct and command. A related image occurs to me: of an Air Traffic Officer in a control tower. He is looking into a screen at symbolic representations of distant aircraft, to which he sends vectoring instructions. I have little doubt that this may be the best format for Air Traffic Control. But electronically mediated remote control for mentally distressed humans? What kind of psychiatry does this lead to? We have here sampled what is coming. For many years I worked in and alongside Mental Health Services where such formulaic management hardly existed, but intelligent colleagueial personal contact was abundant, welcome, even enjoyed. In all the places I worked, until recently, I witnessed the likes of Eric receiving flexible and humane care: schematic designation might have been comparatively meagre, but the human understanding and its quiet satisfactions much greater.
* * * *
I have been striving to reconnect with maybe even begin to regenerate this older, more humanly-earthed professional culture. Due to my frustrations with this I contact you. But due to your business (I imagine) you delegate my request for dialogue to a trusted lieutenant, Dr Y. He, quite unintentionally (I believe) then rapidly re-enacts the bulk of my problems and discontent with NHS Institutions: he resorts to a device which short-circuits any personal contact, understanding or complexity: without further ado he transmits a didactic e-mail, defining reality to me, and for me. I don't mind this approach if I am enquiring about train times, but I want to talk about Eric. I am reminded of a Woody Allen aphorism: "Confidence is what you have before you have understood the problem". Dr Y's rapid acting-out of my critique amused me as an exquisitely timed though inadvertent parody; but it simultaneously dismayed me with further evidence of the ubiquity of the problem. Yet there is hope. I phoned Dr Y to describe my experience and view of his actions. With hesitant friendliness he has agreed to meet me. I have hope, too, that you have read this long-journeyed and thought-marinaded marathon letter with good attention. I hope that dialogue will be broadened and deepened, between us and beyond us. Lastly, I hope you do not answer this with a formulaic e-mail! With best wishes David Zigmond Principal GP, Bermondsey
Further reading: explanatory notes 1. This neologistic parody derives from 'Hypertrophic Obstructive Cardiomyopathy' a cardiac condition where the heart muscle becomes maladaptively overdeveloped. The muscular wall of the heart becomes so thick that the heart can neither fill nor eject efficiently: it becomes impaired by its own muscularity. There is an important analogy to the overdevelopment of schematic and managerial components in personal healthcare. 2. Eric's real identity is, of course known to me and relevant Trust professionals. Full records are available for enquiry. Likewise, I have very full documentation of similar cases. 3. This very long letter contains many overlapping themes that I have written about in greater detail elsewhere. Rather than littering the text with numerous references, I have instead listed below the articles with brief guiding notes. I hope this adds to readability. All these articles are accessible via my Home Page (http://www.marco-learningsystems.com/pages/david-zigmond/david-zigmond.htm).
David Zigmond would be pleased to receive your FEEDBACK
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