David Zigmond, Physician in psychological medicine; retired GP

Published in JHH 17.3-Beyond Covid

The more powerful the culture the more elusive it tends to be to procedural challenge Click To Tweet

Globally we are now – if belatedly and erratically – awakening to the cost of something long-forewarned: the opportunistic disrespect and disregard of the natural environment and ecosystems on which we all ultimately depend. Is the ailing and unravelling of our previously healthy NHS a microcosm of this global pattern? Is it a parallel process? If so, what should we do? On 5 September 2020 Doctors Association UK (DAUK) press-released a survey: Nearly 70% of doctors surveyed are more likely to leave the NHS over handling of [Covid] pandemic. This was a large survey and even if only half-accurately predictive is alarming of real hazard: what kind of NHS services will possibly survive?

DAUK has, in the last couple of years, frequently documented doctors’ egregious working conditions: bullying, unsupportive, uncaring, unrealistically demanding, draconian in dictatorial powers and mendacious in withholding rightful earnings. The descriptions and allegations are too numerously cited and too diversely sourced to be discounted as anomalous or transitional. The size of the problem and the fact that it is increasing indicate that we have a cultural problem. This is a substantial conundrum because the more powerful the culture the more elusive it tends to be to procedural challenge – like decisively trying to grasp wet soap.

Culture often spreads and flourishes like, say, rapidly propagating plants that depend on robust rooting and dispersal systems, both depending on a receptive terrain. If certain plants become problematically invasive we need to understand all three factors if we wish to eliminate our problem.

So what is this problematic culture? What group behaviours and mindsets are so increasing our unhappiness and discord as to possibly undo this (otherwise) much-loved and valued institution: our NHS? Sometimes personal narration can tell us more than statistics. These are the words of a veteran doctor, Dr V:

Over my professional lifetime the technology has increased enormously both in what it can do and how well and quickly it does it. So all that is vastly improved. But that’s certainly not true of the human and personal side of my work. Working relationships – both with patients and colleagues – used to be mostly a pleasure and deeply gratifying. It’s certainly not like that now: the satisfactions are much thinner and often the environment is hostile or even toxic – that was hardly ever the case in my first decades of practice.

Such reflections are typical of older doctors, now either retiring or retired. For those who are prepared to listen, these experiences make for complementary and amplifying evidence to that assembled by their younger colleagues at DAUK, those on the current frontline.

Many recent disputes have (apparently) been about pay, working hours and contracts. But are these, often, also, displacements of other, deeper frustrations? When Dr V was a young practitioner the working hours were longer and the pay equivalently poor. No-one talked of contracts, yet morale was high, well tempered trust the norm, and marathon, complex disputes very rare.

So what has happened?
Two explorations of history can help us understand. The first is recent, from here, in the last 30 years; the second from the USA’s midwest, nearly 100 years ago.

Recent history: The commercialised industrialisation of the NHS: 1990–

The Thatcher era of the late 1980s was propelled and directed by ideological zeal for the monetised marketisation of almost anything that could be so reformed. The NHS was one of the biggest targets for such modernisation – a process that we can call the ‘commercialised industrialisation’ of our NHS. Each successive government of the last 30 years has built on those Thatcher-era visions and precepts, elaborating and tightening a growing forest of procedures, regulations and so forth. This process continued to grow denser and vaster despite many years of widespread warnings from a growing number of practitioners and independent researchers that the cumulative effect of these serious reforms was increasingly unpopular, inefficient, unviable and financially expensive.

DAUK’s collective evidence and Dr V’s experienced personal voice are now the inevitable result of ignoring many years of such warnings. It seems the warnings lone have not been enough; perhaps we need more understanding – better maps – of this commercialised industrialisation. Maybe then we can leave this troubled terrain.

The most contentious (many would say fallacious) assumption of commercialised industrialisation (CI) is that complex human interactions and welfare can be commodified: they can be measured, standardised, manufactured, managed and then commercially traded like the manufactured objects and associated services we use. Thatcher and her acolytes believed that this CI would lead to a sharpness and efficiency that was lacking in the previous 40 years of a service directed by mere trust, judgement and human sense.

Overall, and certainly now in retrospect, we can see that this view drew more from ideological rhetoric than the evident reality. In those previous first 40 years the NHS had developed a record of unprecedented performance, safety and value for money among the world’s healthcare systems. Yes, that older system certainly had its unevenness, lapses and inconsistencies, but the overall pattern was of good solidity, sense and sensibility. This was the system that nurtured and mentored Dr V, the one that was so admired worldwide. It surely did not need a radical campaign of CI to deal with its (relatively minor) anomalies.

Yet this elaboration of CI culture has been the bedrock of all governments for the last 30 years. Since the millennium the growth of IT has further fortified and anchored this modus operandi: compliance to the system can be far more easily assured – enforced even – with the kind of surveillance and policing that are only possible with computers.

All these drastic changes to our post-Thatcher NHS have been dependent on three interwoven strategies:

1. The 4Cs: competition, commissioning, commercialisation and commodification – a marketised system.
2. REMIC: remote management, inspection and compliance – a policed system
3. Gigantism: scaling up and standardising whenever possible – a system of industrial capacity and efficiency.

Together these have made a thorough job of replacing a working life based on vocational spirit, work satisfaction and trusting colleagueiality. We now have, instead, one submissive to a kind of bureaucratic totalitarianism: no-one-knows-anyone-but-just-do-as-you’re-told.

The result? A dispirited alienation. This is the sorrowful pathos behind Dr V’s words, as he leaves the NHS. More hazardously it lies behind the evidence of the DAUK dossier: the fearful rage of those who are left to look after us.

Does history have anything to teach us? Consider the following.

Older history: The dust bowl: USA midwest 1930s

Crops began to fail with the onset of drought in 1931, exposing the bare over-ploughed farmland. Without deep-rooted prairie grasses to hold the soil in place, it began to blow away. Eroding soil led to massive dust storms and economic devastation… this was the dust bowl of the 1930s.

Laura Moss, America’s 10 worst man-made environmental
disasters (2019)

This is only an outline, of course. Further detail shows us how costly – both humanly and environmentally – was this ignorance, or disregard, of ecosystems. This has crucial contemporary lessons on a massive scale for all of us now on planet Earth. On the much smaller scale here, for those wanting to understand the enervation of the human ecosystem of our NHS, there are many parallels to instruct both our understanding and our possible redemption. The dust bowl was a product of unbridled human instrumentalism: the urge to massively and quickly exploit vast flat virgin prairie lands to grow wheat for rocketing profits. This‘miracle’ was achieved for a few years through the newest technologies: powerful tractors and combine harvesters, disc ploughs and artificial fertilisers. But the settler-farmers did not know, or did not care, what gave these prairies their natural sustained vitality: the deeprooted ‘buffalo grasses’ kept the topsoil moisturised and anchored in severe drought and wind; the herds of wildlife returned its nutrients.

The dust bowl was a product of unbridled human instrumentalism: the urge to massively and quickly exploit vast flat virgin prairie lands

Not attending to the complex life-needs of the prairies proved a tragic folly of expedience: first to die were the crops, then it was the people…

After the devastation came the restitution and redemption, at the end of the 1930s. President Roosevelt’s New Deal extended to these devastated prairies: first of all understanding the abused ecosystems, then restoring and protecting them with sustainable methods of limitation of crops by rotation, land enclosure and fertilisation.

The slow climb away from tragedy could only come through a thorough investigation as to its source. The cost of so crudely exploiting the ecosystems was their destruction. This offered us an important lesson and maxim: we must protect and nourish as much as we command and extract.

The disadvantage of men not knowing the past is that they do not know the present. History is a hill or high point of vantage, from which alone men see the town in which they live or the age in which they are living.

GK Chesterton, All I survey (1933)

Nearly a century later it seems we have not learned well from our history. We may not have exactly replicated another dust bowl, but nor have we heeded its important lessons: surely much of our gathering global environmental crisis was forewarned by such earlier events as the dust bowl. And currently we have plenty of scientists, journalists and luminaries to awaken those who cannot see for themselves what is happening.

Can we now learn enough and fast enough?

Let us return to our more local theme: the imminent exhausted collapse of the NHS medical workforce that DAUK has alerted us to. Does this not have striking similarities to these manmade environmental (ultimately human) catastrophes? Have not our serial ‘modernising’ NHS reforms, by their neoliberal commodification, seen healthcare in terms of command-and-control mechanisms and resources, rather than living contacts and relationships to be grown, nurtured, respected and understood? So it is that the countervailing forces of the 4Cs, REMIC and gigantism have made human meanings and contexts increasingly irrelevant. All of this is done in the pursuit of ‘efficiency’ or, more egregiously, profit.

It is the non-technical and informal aspects of our doctor– patient relationships… that provides the best work motivation and satisfaction

What, specifically, does this mean? Well, consider, for example, some of the following: the abolition of consultant-led firms, nursing schools, smaller local hospitals and GP surgeries, personal GP lists. The sum of all these subtractions is the loss of personal relationships and identifications, the kind of understanding that can enrich our kindred humanity rather than deplete it – for erstwhile modae operandi were like the prairies’ buffalo grass, anchoring and nourishing our human sense, our fertile ‘topsoil’.

The loss of personal continuity of care is a crucial example and an inevitable consequence. It is painfully evident throughout our current service, and this pain is felt by patients and practitioners alike. For many doctors this erstwhile bedrock of better care remains precariously as the kind of personal tendering and engagement that sparks and fuels their vocational spirit. It is essential to realise that this motivating spirit rarely comes from corporate compliance, institutional fear, or financial incentives.

What we unlearned in these last 30 years of corporatising reforms is the vitalising function of such personal bonds, relationships and understanding in healthcare. It is the non-technical and informal aspects of our doctor–patient relationships and colleagueial networks that provides the best work motivation and satisfaction for the professional: both the individual and their networks.

Our over-application of the 4Cs, REMIC and gigantism in our zeal for neoliberal reform is much like the everlarger tractors, disc-ploughs and fertilisers unleashed on vast, settled, fecund prairies. In both we have forced the disregarding hubris of a mistaken belief: that established eco-systems can simply be overridden and controlled. These have led, instead, to their destruction.

Maybe, as in the 1930s, we urgently need a ‘New Deal’ to help us beyond this impasse of social self-harm. On the prairies, nearly 80 years ago, they had to relearn and restore a certain kind of knowledge and practice: how best to respect natural processes and growth, nutrition and anchored stability.

References

• Many articles exploring similar themes are available on David Zigmond’s website www.marco-learningsystems.com/pages/davidzigmond/david-zigmond.html.