The more rules, the more corrupt the state.
Tacitus (AD 56 – AD 120)
Dr David Zigmond had practised in the deprived area of Bermondsey, South East London, for 40 years. He has never had a serious complaint. At a Care Quality Commission (CQC) inspection on 28th February 2014 he and the practice met all of their standards (CQC 2014). However, at a repeat CQC inspection on 5 July 2016 the practice was found to be ‘inadequate’ and a ‘danger to the public’ (CQC 2016). There had been no material changes in the practice during the intervening two years, but the CQC inspection regime had changed radically. What was good in 2014 had become dangerous in 2016. The practice was forced to close through a court order four days later. The refusal of Zigmond’s request for adjournment was justified by the urgency of the alleged danger to the public.
I suggest you read Dr David Zigmond’s own remarkable account of the CQC inspections and of the magistrate’s court appearance that followed (page 6). My purpose here is to try to make sense of this: to conduct a post-mortem examination. Like the canary in the cage, it portends more serious trouble elsewhere.
The doctor: the character of the accused
The best things in life hide from the full glare of focused attention. They refuse our will.
Dr David Zigmond chose to spend his professional lifetime working as a family doctor in an area of high deprivation with complex needs and many-layered human adversities. His formative years were influenced by Michael Balint’s primacy of relationship. He kept a small patient list (and hence low income) to give him time for people. Over the 40 years in his practice, medicine dramatically changed, much of which is good and helpful. However, the increasing reliance on technology and procedure is squeezing out the personal, both with patients and colleagues. He mourns this loss and is passionate that it should not be sacrificed altogether.
Beyond his role in diagnosis and modern medical management of significant disease, he feels himself to be ‘containing’ the multiple adversities of his patients. He does this primarily through building and nurturing relationships and through using his expertise in psychiatry and psychotherapy as well as general practice. He has a remarkable memory for individuals and their stories, some of which he has woven into his writings (suitably anonymised). But being a maverick can be lonely. He has hung onto his professional sanity through his family and friends, through his writing, through his membership of the BHMA, and perhaps above all, through his work.
Human relationships and the trust and understanding that flows from them are at the heart of his work. These are built and maintained through conversation, some would say, dialogue – a particular kind of listening and responding with an open mind, much of it non-verbal. As an exemplar for non-verbal communication, Zigmond published a brief and moving essay based on his observations of an experienced vet consulting with her small animal patients. This became the title of his anthology of writings: If You Want Good Personal Healthcare, See a Vet (Zigmond 2015).
The new director: the character of the accuser
A camel never sees its own hump.
On 28 August 2013 Professor Steve Field (below), a practising GP, was appointed Chief Inspector of General Practice for the CQC. He quickly set about redesigning the inspection regime and this was launched in October 2014. By December 2015 the BMA was calling for his resignation, describing Field’s new inspection regime as ‘not fit for purpose’ (Tonkin 2016). So what is going on here? Is Professor Field forcing real improvement onto a profession that has failed to keep up with the times? Or is he misunderstanding what is ‘good’ in primary care and unwittingly making it much harder to achieve? I go with the latter, but I am a retired GP with my own strong views. So let’s look at his regime.
The inspection and the ‘grid’
There is a light in my heart but when I try to look at it with my intellect, it goes out.
The new regime marked a radical shift from a relationships orientation towards numerical data, primarily through documentary evidence. Some data is collected centrally from computer downloads – the CQC keep an Orwellian watch for ‘outliers’ through their central databank. This is not in order to learn from them! Other data is collected by the practice, including a formal presentation to the inspectors. Of course, relationships cannot be evaluated with numbers.
The data is interpreted through five domains: safe, effective, caring, responsive and well-led. Each domain is considered separately for six patient groups liable to differing needs. To produce the ratings, each of these 30 parcels of ‘evidence’ is measured against 28 regulations covering health and social care – so 84 judgements. The ratings are finally published as a ‘grid’. In his online video video (www.cqc.org.uk/content/gp-practices-and-outhours-service-providers) proudly introducing this regime, Professor Field speaks of ‘key lines of enquiry’ (a favourite police expression) and states that ‘rating is such an important part of what we are trying to do’, and, ‘unfortunately, there is unacceptable variation’. This heavily bureaucratic process seems designed for conformity and uniformity through dissection into parts – it is difficult to imagine anything less holistic. It seems that without the willingness to comply with this regime, the practice can be assumed to be a danger to the public.
David Zigmond’s own account of his July 2016 CQC inspection presents a powerful evocation of the process as he experienced it (see page 6). The interaction was bizarre enough to appear comical in its tragedy. He had opted not to read their email so had gathered none of the documentary evidence, nor had he prepared a presentation. Though this decision may seem arrogant and is certainly confrontational, his actions are determined by his strong views about the primacy of the human relationship and that the essence of the therapeutic relationship cannot be represented through documents and particularly through ratings. He has made his views public in his many publications over several decades, for instance his 2012 essay From Family to Factory (Zigmond 2012), in which he argues that healthcare should be more like a family and less like a factory:
Our factory-type healthcare will deal poorly with those many human ailments that need different kinds of personal engagement for their relief and transcendence. These require healing encounters that mobilise the sufferer’s internal resources for immunity, growth and repair. These are subtle and delicate activities and – importantly – cannot develop in a factory culture, whose structure and function both depend on rigidity (like a vehicle chassis). They can only emerge and thrive in a family-type milieu where structure and function and strength are linked to flexibility and elasticity (like a tyre).
Perhaps the CQC had failed to read this or any other of his numerous works! In short each party, deeply believing they are right, became separated from the other by a seemingly irreconcilable gulf, but only since the new CQC inspection regime. Zigmond, the artist-doctor, and Field, the calculating inspector, both failed to properly research and understand the other. The tragic outcome might have been averted if each had stopped to dip into the other’s world.
Bureaucratic control and the triumph of reason
Bureaucracy strangles or criminalises moral impulses.
Zygmunt Bauman (p10)
Fortunately, there are many great thinkers who can help us to understand how the CQC arrived at their system. The idea of keeping order by compulsion – in this case through bureaucratic control backed by law – is often attributed to Thomas Hobbes through his great work of 1651, Leviathan. This often quoted passage comes from chapter 13.
…men have no pleasure (but on the contrary a great deale of griefe) in keeping company, where there is no power to overawe them all … and which is worst of all, [are in] continual fear, and danger of violent death; and the life of man, solitary, poor, nasty, brutish, and short.
Hobbes paints a picture of disintegration of society in the absence of ‘power to overawe’ the people. Over the years, this has led to varying degrees of state-sanctioned oppression, some physically violent, others mentally coercive. The underlying assumption is that morality can come only from reason: the oppressors demand that, ‘Instead of following their feelings people should be taught, and forced if need be – to calculate.’ So wrote the political philosopher and ethicist, Zygmunt Bauman in his extended and highly critical essay on 20th century values, Alone Again: Ethics After Certainty (p4). Bauman continues (p4):
[From the point of view of reason,] for every problem there is by definition one, and only one, true, reason-dictated solution, but a virtually infinite variety of erroneous ones; where reason does not rule, ‘everything may happen’, and thus the whole situation is hopelessly beyond control…. Morality, like the rest of social life, must be founded on Law, and there must be an ethical code behind morality, consisting of prescriptions and prohibitions. Teaching or coercing people to be moral means making them obey that ethical code. By this reasoning, becoming moral is equivalent to learning, memorising and following the rules.
Modernity came up with two great institutions meant to achieve that purpose; to assure the prevalence of morality through following the rules. One was bureaucracy, the other was business.
The relevance of this to David Zigmond’s predicament is obvious. Bauman goes on (p5):
This kind of action directed by a codified reason of rules is described as procedural rationality. What counts is following the procedure to the letter. What is decried and punished more than anything else is twisting the procedure to suit individual preferences or affections.
This ‘family’ practice stands out against such conformity. It occupies the converted north aisle of an 1830s church – and Zigmond’s consulting room is full of artworks of many kinds. All this quirkiness seemed to bother no one at the practice: it felt like a welcoming family. But through CQC eyes it will have appeared ‘out of control’. An insistence on control produces a chilling narrowness of intention and ruthlessness in execution.
Left hemisphere versus right hemisphere
The more certain our knowledge the less we know.
Roger Scruton (1996)
A second way of understanding is through the differences in function of our two cerebral hemispheres. Each makes its own contribution to how we perceive reality, how we think, our way of being in the world. We vary greatly in our preference for one hemisphere or the other. Our two protagonists, Dr David Zigmond and Professor Steve Field, both intelligent, but seeing the world very differently. Here, I offer a glimpse of the ideas put forward by Iain McGilchrist (2012). In his evidence-packed and remarkable book, The Master and his Emissary, he makes the case for the right hemisphere as master and the left as emissary, though as we shall see, the emissary is inclined to take over.
Fundamentally, this is about how we pay attention to the world: ‘…we create the world by attending to it in a particular way’ (p151). The left hemisphere provides a focused view, whilst the right’s view is ‘broad with flexible attention’ (p39–40). So the left goes for detail and the right, the bigger picture. Closely related is the left brain’s preference for understanding by ‘wresting things from their context’ – literally ‘abstracting’ from reality – then categorising into component parts. This neatly excludes the often messy relationships between things (p49–50). So the left likes to take reality apart and recreate it as a system that can be controlled.
The right hemisphere understands holistically, using recognition of patterns compared with an exemplar from memory – unique individuals are seen in their wholeness and in their context. This enables the right hemisphere to be comfortable with unknown territory, ambiguity and uncertainty. The right, then, is vigilant and more likely to spot the unexpected, while the left gets on with its counting and categorising the parts – more on this later.
When the right hemisphere finds something new that interests the left hemisphere, the latter tends to ‘grasp’ it The family doctor and the grid WAYS OF KNOWING 44 © Journal of holistic healthcare ● Volume 13 Issue 3 Winter 2016 for itself (p40–42, p113). This links to the left hemisphere’s interest in utility – finding things that are useful – especially ‘tools, mechanisms and whatever is not alive’ (p55 – emphasis added). Meanwhile the right hemisphere’s affinity is for living things and for the ‘betweenness’ that exists with the other (p93).
If your right hemisphere is alert at this moment, you will have recognised the similar patterns of left hemisphere function and the CQC’s regime under Steve Field. Here is McGilchrist on a world dominated by the left hemisphere without the balancing effects of the right (p209):
The left hemisphere is competitive, and its concern, its prime motivation, is power…. [If it were to have primacy] the world would change into something quite different. And we can say fairly clearly what that would be like: it would be relatively abstract and disembodied; relatively distanced from fellow-feeling; given to explicitness; utilitarian in ethic; over-confident of its own take on reality, and lacking insight into its problems – the neuropsychological evidence is that these are all aspects of the left hemisphere world as compared with the right.
Through its executive control of speech and thirst for power it is quite easy for the left hemisphere, the ‘emissary’, to assume dominance. The great 20th century philosophers, Ludwig Wittgenstein and Martin Heidegger both warned of the importance of ‘the primacy of context over rules and system-building, [and] of practice over theory; so right hemisphere over left. Sadly, and unfortunately for David Zigmond, we have allowed the opposite to take root in our society.
We are prisoners of expectation
For a balanced and wise approach to the world, particularly in medicine, we must pay competent attention to both the whole and to the parts. This story of the doctor and the inspector shows errors in both directions, but predominantly the inspector’s obsession with the parts.
Missing the wood for the trees – obsession with data
The CQC’s exclusive focus on the parts caused the holistic aspects of Zigmond’s practice to be misunderstood or ignored, or perhaps not noticed. Some interesting and very well-known research into selective inattention clarifies this. The best known is the ‘Invisible Gorilla’ test first conducted by Simons and Chabris in 1999. This research shows that concentration on one simple visual task (here it was counting the passing of a ball amongst a group of people) results in more than half of viewers not noticing something quite different happening in their visual field (a gorilla-suited person walking on and thumping their chest). The counting task engages predominantly the left hemisphere which likes counting and is poor at unexpected events. The CQC inspectors were trained to pay close attention to the details so likewise, will have seen only what they were expecting to see – trouble with the parts. The public report on the Zigmond practice shows this very clearly. Zigmond’s exemplary attention to patients and staff as unique and whole individuals is almost lost and receives no discernable credit. Test your own ability to see the unexpected! (www.youtube.com/watch?v=IGQmdoK_ZfY).
Missing the trees for the wood – the wrong system
By attending predominantly to the whole we are more likely to miss some of the details? The alleged breaches in Zigmond’s CQC report are mostly of this sort, and apart from lacking certain items of emergency equipment, they are overwhelmingly about ‘systems’. For instance, the practice had 20% higher than expected A&E attendances but no analysis of this; and no written system for following up patients attending A&E with a mental health problem. Zigmond’s defence here would be that knowing the patient well and therefore knowing what specialist approach would help is little use if that approach is not available locally. There are many other similar examples. The inspectors were inspecting the ‘system’ as they expected it to be. But a practice that functions like a family has less formal ways of getting things right and enhancing safety; ways that rely more on trust, respect and local knowledge. Haphazard they may seem, but there is likely to be better staff relationships and an orientation towards the unique person, reflected in warmth of greeting, more eye contact (with the person, not the computer) and more time to listen. The whole team will know the patients and their foibles. Perhaps these are also ‘details’, but surely of a different order. A fully CQC-compliant practice may miss these: they are immeasurable, so subject to selective inattention. Focusing on abstract, rational data at the expense of ‘non-rational’ knowledge has an opportunity cost. The abstract-rational is part of a left hemisphere contrivance, mostly irrelevant to the real purpose of this practice.
The absence of computerised evidence that a practice is safe for patients is not proof that it is dangerous. The accuser must prove guilt, not the accused prove innocence.
Instead of trusting the artist, our natural inclination is to distrust and dismiss, threatened as we are by an unknown and potentially dangerous novelty we can’t comprehend. George Bernard Shaw quoted by Will Gompertz (2016 p173)
A creative artist depends on their right hemisphere more than most. During my own career as a GP I gradually became more artist than scientist. So I now look to the arts for inspiration and instruction. Doctor-as-artist can offer us different ways of envisioning health and sickness, for instance through telling a different story. Canadian sociologist, Arthur Frank, argues in his book The Renewal of Generosity: Illness, Medicine and How to Live (2004) that our culturally ready-made stories are letting us down. ‘A new story – a new possibility of being a physician – has to be created’. This new story must be able to integrate the material body with our ‘heart’: the part of us that is deeply connected to all of nature.
Arts writer and broadcaster Will Gompertz (whose father was a GP), devoted a chapter of his book, Think Like an Artist (2016), to the artist’s chair, ‘an essential piece of studio furniture’. The purpose, says Gompertz, is to sit back and take a longer view. ‘When artists sit down in their chairs they switch personas: they stop being the creator and turn into the critic.’ (p178) David Zigmond does just this with his writing.
The creative arts pervade our culture and creativity is deeply embedded in our nature. Even politicians will use them when it suits; but they are given precious little credence in healthcare. Yet artists ‘command a means of making meaning’. Meaning-making is central to medicine, especially general practice. Like other artists, doctors strive to ‘give form to the formless’ (House 2015). Medicine-asart requires creativity, imagination and seeing beyond the details – all right hemisphere functions.
The wonderful little book, Transformative Innovation – a Guide to Practice and Policy, by Graham Leicester (2016), approaches the dichotomy of wholeness and fragmentation in terms of love and fear respectively. He suggests that love and fear are ‘not simply ways of being in the world but also ways of knowing it (p38). In our story, Steve Field knows through gaining control and his world becomes a series of objects. But …’human beings do not take kindly to being treated this way’ and we see alienation leading to a vicious cycle driven by ‘anxiety, insecurity and fear’. In contrast David Zigmond knows through participation and thus experiential knowledge. So ‘instead of trying to control our complex world, [he] participates in it. [He] relishes diversity, welcomes surprises, looks for the ineffable and appreciates the richness and the unique quality of all things.’ This virtuous circle is driven by ‘love, empathy, compassion and relationship.’ (p39)
There are islands of change in our troubled world, where participation and love are beginning to flourish. David Zigmond’s practice was one of those. I describe some of the others in another article in this issue (see page 21). So we can take heart and know that the seeds we have sown over many years are now taking root.
I finish with David Zigmond’s own words. These were spoken to his accusers after the marathon court case that marked the end of his practice.
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.’
- Bauman Z (undated) Alone again ethics: after certainty. London: Demos.
- CQC (2016) Dr David Zigmond: Letter of the Chief Inspector of General Practice. Available at: www.cqc.org.uk/location/1-495556335/ reports (accessed 12 November 2016).
- CQC (2014) Inspection report: Dr David Zigmond. Available at: www.cqc.org.uk/sites/default/files/old_reports/1-495556335_Dr_David_ Zigmond_INS1-505215047_Scheduled_28-03-2014.pdf (accessed 12 November 2016).
- Frank A (2004) The renewal of generosity: illness, medicine and how to live. London: The University of Chicago Press.
- Gompertz W (2016) Think like an artist: and lead a more creative, productive life. New York: Harry N. Abrams.
- House W (2015) Too much diagnosis … and not enough art – the gift of narrative to medicine. JHH 12 (1) pp 26–29.
- Leicester G (2016) Transformative innovation. Axminster: Triarchy Press, pp 22,39).
- McGilchrist I (2012) The master and his emissary. London: Yale University Press.
- Scruton R (1996) Modern philosophy: an introduction and survey. London: Cornerstone.
- Simons J, Chabris C (1999) Gorillas in our midst: sustained inattentional blindness for dynamic events. Available at: http://www.drjoebio.com/ uploads/1/8/1/3/1813500/gorrila_in_our_midst.pdf (accessed 12 November 2016).
- Tonkin T (2016) Call for CQC chief Steve Field to resign. BMA online. Available at: https://www.bma.org.uk/news/2015/december/call-for-cqcchief-steve-field-to-resign (accessed 12 November 2016).
- Zigmond (2015 ) If you want good personal healthcare – see a vet: industrialised humanity: why and how we should care for one another? Whitstable: New Gnosis Publications.
- Zigmond (2012) From family to factory. Available at: www.marcocom/pages/david-zigmond/n14.8.14_From_Family.pdf (accessed 12 November 2016).