David Zigmond describes his final reflections as CQC closes down his GP practice for its refusal to be fully compliant with CQC regulations.
Author: David Zigmond
Risk management and quality assurance must always be good, surely? Not necessarily. More of something good is not always better. Sometimes we can add more problems than we take away. A complex public event and two private dialogues illustrate.
Change is scientific; progress is ethical; change is indubitable, whereas progress is a matter of controversy.
Bertrand Russell (1872-1970)
The strike was sudden, a few months ago. For several years previously I had tenaciously and publicly criticised a culture that I found increasingly draconian yet which now determines our Welfare services. I had targeted, especially, our NHS micromanagement and, by default, fault-finding inspections. My authorities now decided to turn these devices against me. Their ensuing management was clearly not micro: within days of my informally challenging a Care Quality Commission (CQC) formal inspection, the CQC – with the inexplicit collaboration of NHS England – unleashed a bureaucratic putsch. Clerical and legal teams were recruited to coordinate a deeply trawled and thoroughly prepared catch, then cache, of ‘evidence’. An emergency hearing at a Magistrates Court rapidly closed my exits: I was granted no time to procure legal representation.
The well-rehearsed team slickly unpacked their indictments for the court: files cataloguing my frequent acts of non-compliance to our ever-increasing regulations: those that I had long maintained were rendering our service so stressed as to be unworkable. In contrast the authorities insisted that each item indicated a risk to public safety and, considered together, constituted such severe hazard as to merit immediate and irrevocable closure of my practice.
I conceded selectively, yet argued strongly. Yes, in certain areas I was certainly non-compliant, though – I like to think – always open and thoughtful about this; for it is widely (though unofficially) recognised among the workforce that our ever-increasing regulation is no longer compatible with a viable and attentive service of personal care. To remain a personally caring practitioner I could not also comply with the often senselessly burdensome regulation and its requirement for endless documentation. Almost all practitioners struggle with this conundrum yet will hide its consequences from inspectors. Instead I became a conscientious objector: I decided that I needed to take responsibility for my own practice. I would assess and bear any risk, and then take responsibility for it – rather than any supraordinate authority. That is what I consider professional identity and responsibility. That is what I wished the CQC to consider carefully.
I argued, too, about the nature and reliability of CQC evidence. If I was such a definite and massive risk, why is my record so exceptionally good from all other sources, and for such a long period? And, conversely, why are so many institutions, blessed by favourable official reports, so unpopular? While the inspections may start with good motivation, they evolve, by excessive procedures, to become something akin to a static snapshot, at one particular time, restricted by a viewfinder to a particular, managerial kind of evidence. I believe that issues lying outside such procedure and compliance-dependent parameters are much more likely to contribute to well-engaged, happy – and thus good quality – safe practice.
At the time of the court hearing the CQC were exploiting new powers from recent legislation. They seemed determined, too, to ensure that the Court decided rapidly in their favour: their staff forces and armaments were all but irresistible. After a doomed asymmetrical, marathon (eight-hour) struggle, the Magistrates fashioned an expedient decision: they could be clear that my open and deliberate non-compliance constituted a breach of contract of my terms of employment. They deferred to the CQC about how that might constitute a risk to the public.
My practice was then closed immediately.
It is the end of this wearily long hearing. We all trudge slowly from the court. Without design I find I am standing next to the ‘Medical Expert’ recruited by the CQC to ‘prove’ my hazardous incompetence. This man, whom I had never met before, had spent most of the many hours in court gazing and tapping at his laptop. During the court’s ritualised exchanges he looked only at his colleagues and the court staff, never once at me. But now we are free of the court’s protocols and I feel free to approach him.
I seek fraternalism, not further combat. So I exhale emphatically with fatigue, smile with what I hope will convey convivial irony and say. ‘What a long day! I guess you don’t get many like that…’
He looks awkward and discomfited: I want to reassure him, to keep him engaged. I smile again, to indicate my disarmament.
I am relieved that he now turns to face me. He is much younger than I – by more than two decades, I think. His returned smile seems fragile and nervous, maybe apologetic. I notice a slight opening and closing of his lips: speech arrested by thought.
I push out my bridge to him: ‘Well, you and your team did your job well, for your employers. I understand the thinking and the process, but its excess has taken us deep into realms of non-sense. I cannot see what greater good can come of all this…’
My voice fades to a hiatus: I want his response.
It comes quickly. It is brief but, I think, very significant. He smiles, then slightly protrudes his lower lip with a kind of parodic, ironic gravity while inspiring deeply and audibly through his nose. At the same time he twitches a shrug and says ‘Yes, I know … I’m sorry. We are living in very changed times. All of us.’
He smiles again: it seems, to me, now more robust, genuine and tinged with fraternal sympathy. I am thinking of the paradoxical strangeness and intensity of this fleeting exchange.
He turns to exit with his colleagueial cadre, leaving me alone. I never knew his name and I never see him again. I call him Dr I: innominate.
Three months later I am seeking some kind of audience with my erstwhile employers: I want to pursue what, for half a minute, I think I shared, with furtive candour, with Dr I.
Doris agrees to see me in a neon-lit, featureless interview room far from any natural light. We are in the centre of a large, labyrinthine modern governmental building: now the administrative hub of the organisation that employed me for so long – well before construction of this building – then expelled me so sharply. Doris has been allocated seventy minutes for use of this room and I sense such constriction is another cramping frustration for her. ‘None of this is easy, David’, she says. ‘I’ll listen to what you want to say, but I’m not sure what I can do.’
Doris is about a decade younger than me; old enough to remember a more popular world of work, but young enough to be tolerant and powerfully expedient with what has so harshly replaced it. I sense an affinity of her human heart, but the restraint of her expedient mind: she has high office to protect.
I start talking to Doris about the growing crisis of morale throughout healthcare. We rapidly stimulate one another with proffered notions of the stresses: pullulating new technologies leading to ever more tests, treatments and expectations; increasing population, many with vulnerable, dependent longevity; social mobility, so instability; our increasingly litigious culture. And then our newer forms of attempting to contain and control all this (often foolishly, I think): marketisation, commissioning and micromanagement, ubiquitous requirements for compliance documentation, quantification, goals and targets, inspections and appraisals…
I say to Doris that all this is destroying the art, heart, spirit, wit and philosophy that had long motivated, enlivened and nourished our profession: that our current devices to ‘drive efficiency’ are, instead, delivering both alienated humanity and bad economics.
I sigh with sadness. ‘Doris, you will remember an earlier time in your career when – for all its failings – our much less managed system left us feeling much more wholesomely supported and motivated. We could more easily get on with what we considered important and, mostly, we liked our work. We often worked longer hours, but much more happily. It was a much healthier human environment…’
Doris is nodding her agreement; then looks down to assimilate. I want a pithy sentence, to sum up. ‘We’ve almost entirely replaced vocation by corporation: internal motivation by external incentivisation’, I say.
Doris is speedy with her caveat: ‘Yes, David, but you have to accept that’s all going or gone. Younger doctors generally aren’t interested in that. They want to be told the contractual details of their job, do it, be properly paid and then go home…’
‘Like a highly trained factory work’ I say glumly.
Doris, I think, wants to prod me with realism. ‘Look, what you need to understand is that the next generation of doctors want a better work-life balance. They don’t want to work the kind of long hours that we did…’
I agree, though with paradox: ‘Yes, but we liked our work, so the work-life balance didn’t trouble us so much. Doctors now don’t like their work, so their work-life balance becomes much more important’.
Doris is thoughtful and about to answer, but is interrupted.
There is a sharp knock on the door, followed by the entrance of a bespectacled, middle-aged, identity-tagged man. He is courteous if a little urgent, but clear and firm.
‘I’m sorry, but I’m afraid you have to stop. You’ve overrun by five minutes. The next people are waiting.’
Doris turns to me with pragmatic, but not hostile, alacrity.
‘Well that’s it, for today anyway’ she says, gathering her belongings. I wonder if her sudden stopping is done with any regret.
‘Well, I hope there’s another day. There’s so much more to say’, I say with despondent hope.
Is it progress if a cannibal eats with a knife and fork?
Stanislaw Lec (1962) Unkempt thoughts
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The publisher is the Centre for Welfare Reform.
When is Change Progress? © David Zigmond 2017.
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