Saving the NHS - JHH 13.3 by British Holistic Medical Association

Volume 13

Issue 3

Winter 2016 ISSN 1743-9493

JOURNAL OF

holistic healthcare

Saving the NHS

Can we save the NHS? David Zigmond: death by documentation Helping junior doctors survive Why we need clinical leadership Building resilient organisations Are we medicalising everyday life? Remodeling quality primary care Human five â&#x20AC;&#x201C; a tool for holistic care Care homes as if people matter Creating new social prescriptions Control or participation? Putting relationships first

JOURNAL OF

holistic healthcare About the BHMA In the heady days of 1983 while the Greenham Common Women’s Camp was being born, a group of doctors formed the British Holistic Medical Association (BHMA). They too were full of idealism. They wanted to halt the relentless slide of mainstream healthcare towards industrialised monoculture. They wanted medicine to understand the world in all its fuzzy complexity, and to embrace health and healing; healing that involves body, mind and spirit. They wanted to free medicine from the grip of old institutions, from over-reliance on drugs and to explore the potential of other therapies. They wanted practitioners to care for themselves, understanding that practitioners who cannot care for their own bodies and feelings will be so much less able to care for others. The motto, ‘Physician heal thyself ’ is a rallying call for the healing of individuals and communities; a reminder to all humankind that we cannot rely on those in power to solve all our problems. And this motto is even more relevant now than it was in 1983. Since then, the BHMA has worked to promote holism in medicine, evolving to embrace new challenges, particularly the over-arching issue of sustainability of vital NHS human and social capital, as well as ecological and economic systems, and to understand how they are intertwined . The BHMA now stands for five linked and overlapping dimensions of holistic healthcare:

marker of good practice through policy, training and good management. We have a historical duty to pay special attention to deprived and excluded groups, especially those who are poor, mentally ill, disabled and elderly. Planning compassionate healthcare organisations calls for social and economic creativity. More literally, the wider use of the arts and artistic therapies can help create more humane healing spaces and may elevate the clinical encounter so that the art of healthcare can take its place alongside appropriately applied medical science.

Integrating complementary therapies Because holistic healthcare is patient-centred and concerned about patient choice, it must be open to the possibility that forms of treatment other than conventional medicine might benefit a patient. It is not unscientific to consider that certain complementary therapies might be integrated into mainstream practice. There is already some evidence to support its use in the care and management of relapsing long-term illness and chronic disease where pharmaceutics have relatively little to offer. A collaborative approach based on mutual respect informed by critical openness and honest evaluation of outcomes should encourage more widespread co-operation between ‘orthodox’ and complementary clinicians.

Sustainability Whole person medicine Whole person healthcare seeks to understand the complex influences – from the genome to the ozone layer – that build up or break down the body–mind: what promotes vitality adaptation and repair, what undermines them? Practitioners are interested not just in the biochemistry and pathology of disease but in the lived body, emotions and beliefs, experiences and relationships, the impact of the family, community and the physical environment. As well as treating illness and disease, whole person medicine aims to create resilience and wellbeing. Its practitioners strive to work compassionately while recognising that they too have limitations and vulnerabilities of their own.

Self-care All practitioners need to be aware that the medical and nursing professions are at higher risk of poor mental health and burnout. Difficult and demanding work, sometimes in toxic organisations, can foster defensive cynicism, ‘presenteeism’ or burnout. Healthcare workers have to understand the origins of health, and must learn to attend to their wellbeing. Certain core skills can help us, yet our resilience will often depend greatly on support from family and colleagues, and on the culture of the organisations in which we work.

Climate change is the biggest threat to the health of human and the other-than-human species on planet Earth. The science is clear enough: what builds health and wellbeing is better diet, more exercise, less loneliness, more access to green spaces, breathing clean air and drinking uncontaminated water. If the seeds of mental ill-health are often planted in an over-stressed childhood, this is less likely in supportive communities where life feels meaningful. Wars are bad for people, and disastrous for the biosphere. In so many ways what is good for the planet is good for people too. Medical science now has very effective ways of rescuing people from end-stage disease. But if healthcare is to become sustainable it must begin to do more than just repair bodies and minds damaged by an unsustainable culture. Holistic healthcare practitioners can help people lead healthier lives, and take the lead in developing more sustainable communities, creating more appropriate models of healthcare, and living more sustainable ways of life. If the earth is to sustain us, inaction is not a choice.

“The Journal of Holistic Healthcare… a great resource for the integration-minded, and what a bargain!” Dr Michael Dixon

Humane care Compassion must become a core value for healthcare and be affirmed and fully supported as an essential

Three issues each year – £48 for full BHMA members. On-line members £25/year including access to all past issues.

JOURNAL OF

holistic healthcare

Contents

ISSN 1743-9493

Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Published by

Update. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

British Holistic Medical Association West Barn, Chewton Keynsham BRISTOL BS31 2SR contactbhma@aol.co.uk www.bhma.org

Saving the NHS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Reg. Charity No. 289459

Mike Dixon

Death by documentation: The penalty for corporate non-compliance . . . . . . . . . . . . . . . . . . . . . . . . . 6 David Zigmond

Bring back joy in work – what junior doctors need to survive . . . . . 12

Editor-in-chief David Peters petersd@westminster.ac.uk

Olivia Jagger

Clinical leadership – the aspirin for an ailing NHS? . . . . . . . . . . . . . . . . 15 Daghni Rajasingam

Editorial Board Peter Donebauer Ian Henghes Dr William House (Chair) Professor David Peters Dr Thuli Whitehouse Dr Antonia Wrigley

How to enable organisational resilience: Ideas from a conversation at the Centre for Resilience. . . . . . . . . . . . 19

Production editor

William House

Edwina Rowling edwina.rowling@gmail.com

Advertising Rates 1/4 page £130; 1/2 page £210; full page £400; loose inserts £140. Rates are exclusive of origination where applicable. To advertise email contactbhma@aol.co.uk

Venetia Young

Islands of hope Configuring for abundance: Bromley-by-Bow, NUKA and Fife SHINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Diagnosis: Are we medicalising human experience? A radical review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Alice Redfern

Healthcare system transformation coupled with optimising individual and population health and wellbeing An opinion from a busy GP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Campbell Murdoch

Products and services offered by advertisers in these pages are not necessarily endorsed by the BHMA.

Triumph of the relational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Design

Marie Polley

karenjigsawdesign@gmail.com Cover illustration Theo Peters http://theopeters.co.uk

Printing

Michael Taylor

Social prescribing – movement of the people? . . . . . . . . . . . . . . . . . . . . . 36

The family doctor and the grid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 William House William House . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Spinnaker Press

Reviews. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Volume 13 ● Issue 3 Winter 2016

Unless otherwise stated, material is copyright BHMA and reproduction for educational, non-profit purposes is welcomed. However we do ask that you credit the journal. With this exception no part of this publication may be reproduced in any form or by any other means – graphically, electronically, or mechanically, including photocopying, recording, taping or information storage and retrieval systems – without the prior written permission from the British Holistic Medical Association. Every effort is made to ensure the accuracy of material published in the Journal of Holistic Healthcare. However, the publishers will not be liable for any inaccuracies. The views expressed by contributors are not necessarily those of the editor or publisher. 1

Editorial Saving the NHS: the need for rebel talent By now many of you will have read, perhaps in The Observer a few weeks ago (Neustatter 2016), how in a fast-moving putsch at the end of summer, the Care Quality Commission (CQC) closed David Zigmond’s GP surgery. Its inspectors decided (despite no serious patient complaint having been made against him since he started there in 1987) that this small and personal family practice was ‘unsafe’, and should be shut down immediately. Though the CQC has an important role, and has in the past inspected David’s premises sympathetically, this year’s visitors were less well-disposed. Dr Zigmond – as he explains in this issue of JHH – readily admits he was not dancing to their tune, nor hitting (or even trying to) their bureaucratic targets. Worse, he not only refused to play the game, but voiced his misgivings about the way the many new rules – not least the Quality Outcome Framework (QOF) and top-heavy command and control management – have warped family medicine. Whether or not his dismissal was intended to discourage similar dissent in the ranks, the upshot has been Bermondsey’s loss of a much loved and long-serving GP; and this, at a time when morale is at an all-time low in typical target-chasing computerised practices. By contrast Dr Z (a self-confessed old-school family doctor who still uses written notes) continued to love his work. Are we missing a connection here? And isn’t it ironic that soon after the CQC padlocked David’s front door, NHS Chief Executive Simon Stevens announced that the QOF ‘is now nearing the end of its useful life … and has for the most part descended into too much of a box ticking exercise’ (Matthews-King 2016). Most GPs will agree with him, at the same time wondering though, how they will survive if QOF income disappears, shackled as they have been to the QOF since 2004 when GPs were first rewarded for hitting particular targets: cholesterol- and blood pressure-reduction among them. But, as usually happens when a complex ecosystem is messed about with, there have been unintended consequence. As GP Campbell Murdoch tells us in this issue, chasing after financial brownie points has distorted the way GPs approach their work. The reductionist, pharmaceutical style of prevention, which has come to occupy so much of their time, has left many GPs – knowing full well that the QOF has medicalised many times more lives than it has saved – feeling straitjacketed and demoralised. Two silver linings can be glimpsed here, either of which might have saved Dr Z, for if the QOF is redundant can GPs still be rewarded for providing genuinely high-

David Peters Editor

quality care newly redefined in holistic terms? For instance, and at the risk of enshrining the tick-box yet again, why not develop criteria for whole person care and remunerate GPs for practicing holistic prevention – real lifestyle medicine, linked to community building and social prescription. These are ways forward you will read about in this issue. The second glimmer of hope shines in from the unlikely direction of the latest Harvard Business Review, one of the management world’s thought leaders. In her headlining article Let your workers rebel, management researcher Franscesca Gino (2016) reminds us that ‘to be successful and evolve, organisations need to strike a balance between adherence to the formal and informal rules that provide necessary structure and the freedom that helps employees do their best work. The pendulum has swung too far in the direction of conformity.’ Conformity she claims, comes to dominate in organisations principally because people fall prey to social pressure, become too comfortable with the status quo and the usual ways of thinking and doing. More and more they prioritise information that supports their existing beliefs and ignore anything that challenges them. Does this explain why frontline workers in health and social services have become accustomed to a destructive and austere orthodoxy even when its coercive strictures erode their individuality and the passion that first called them into this work? With the imminent demise of the QOF and in the light of HBR’s views on rebel talent, perhaps the hyper-regulation tide is turning, and not only for GPs: Isabelle Trowler, chief social worker for children and families, has said the government wants social workers to be able to exercise their professional judgement without too many rules getting in their way (Tickle 2016). Since all true progress depends on innovation spiced with wisdom, we now need regulation processes that won’t constrain the transformation health and social care so urgently call for. To re-humanise healthcare, we need clinical guidelines that embrace professional knowledge and acknowledge diversity, and holistic approaches to performance-related pay that drive genuine quality improvement. A less conformist CQC might have appreciated Dr Zigmond’s rebel talent and been curious about the unconventional course he steered to become such a popular and committed family doctor. Left to thrive, might it have been possible to distill his love of the work, and use the essence to reinvigorate primary care? As things stand the best we can hope for, in his reluctant retirement, is that he will find time to teach. On November 25 he won the 2016 Leadership Awards positive deviant leader category. We congratulate him (www.leadershipawards.org.uk/awards-finalists-2016). For references see page 3

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Volume 13 Issue 3 Winter 2016

UPDATE

Choosing wisely

NICE is nice to CAM

This new website looks at commonly used tests, treatments or procedures that have questionable benefits. The site is designed to support a conversation between doctors or nurses, and patients who want to have a careful discussion about risks and benefits. The big five questions all patients should ask are:

Following NICE’s consultation on its proposed update to the guideline for supportive and palliative care in adults we are pleased to report that NICE has taken into account the very large number of well-considered responses made by CNHC and a wide range of organisations across the sector. Rather than remove complementary therapies, NICE has decided to keep the original guideline (CSG4) in place and develop a separate guideline for end of life care. This means that existing guidance on complementary therapies remains in place.

• • • • •

do I really need this test, treatment or procedure? what are the risks or downsides? what are the possible side-effects? are there simpler, safer options? what will happen if I do nothing?

www.choosingwisely.co.uk

WHO war on sugar Perhaps prompted by our recent food and lifestyle issue of JHH J WHO upped the ante in its fight against sugar on October 11, World Obesity Day. It called for governments to bring in subsidies for fruits and vegetables and to tax unhealthy foods, in particular sugary drinks. New WHO recommendations are backed by expert opinion worldwide and 11 systematic reviews confirming that financial disincentives improve the ways people eat and so prevent chronic diseases. WHO headquarters is now walking its talk by banning sugary drinks. www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)318979/fulltext?rss=yes

Save the date The College of Medicine’s June 2016 conference Food: The forgotten medicine was a sellout, and dozens of delegates wrote to praise the groundbreaking content. The College is now planning its second conference for 14 September 2017 at the Royal Society of Medicine – more details coming shortly. To express an interest and receive emails as the programme emerges go to http://bit.ly/2gkg107

New integrative medicine diploma A new diploma from the Portland Centre for Integrative Medicine (PCIM) in Bristol aims to provide an accredited qualification as an integrative medicine (IM) practitioner. ‘IM is a holistic, evidence-based approach which makes intelligent use of all available therapeutic choices to achieve optimal health and resilience for our patients. The model embraces conventional approaches as well as other modalities centred on lifestyle and mind-body techniques like mindfulness and nutrition.’ The diploma, which is certified by Crossfields Institute and supported by the College of Medicine, is the only one currently available in the UK. See www.collegeofmedicine.org.uk/postgraduate-diploma-integrativemedicine/

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www.cnhc.org.uk/index.cfm?page_id=2&news_id=392

But not so NICE about acupuncture NICE is no longer recommending acupuncture on the NHS for low back pain, according to its latest guidelines. The reversal of its 2009 guidance comes after a review of scientific trials suggested that although acupuncture could improve pain, function and quality of life more than standard care in the short term, it was no better than sham acupuncture. Dr Mike Cummings, medical director of the British Medical Acupuncture Society, said, ‘It’s unfortunate that the methods used on this occasion have led to a negative recommendation…. partly to do with the decision to put the biggest emphasis on the difference over sham … [the problem being that] all physical therapy shams tend to be active because you have to touch patients.’ It is well recognised that sham acupuncture is more effective than standard care.

Health and climate change WHO estimates that 12·6 million deaths (23% of all deaths worldwide) in 2012 were attributable to modifiable environmental factors, many of which could be influenced by climate change or are related to the driving forces of climate change. The Lancet has launched its Countdown on Health and Climate Change – a 15-year investigation involving 16 collaborating research institutions around the globe which will publish research on the risks and opportunities of climate change and climate change mitigation every year. http://sustainablehealthcare.org.uk/news/2016/11/lancet-givessustainable-healthcare-global-spotlight

References from page 2 Gino F (2016) Let your workers rebel. Harvard Business Review, October. Available at: https://hbr.org/cover-story/2016/10/let-your-workers-rebel (accessed 6 November 2016). Matthews-King A (2016) QOF has reached the end of its useful life, says NHS chief.’ Available at: http://www.pulsetoday.co.uk/your-practice/qof/qof-has-reached-theend-of-its-useful-life-says-nhs-chief/20033054.fullarticle (accessed 6 November 2016). Neustatter A (2016) The ousted doctor: ‘My patients’ souls matter most’. The Observer, 18 September. Available at: www.theguardian.com/society/ 2016/sep/18/ the-ousted-doctor-my-patients-souls-matter-most (accessed 6 November 2016). Tickle L (2016) Social workers in fierce row over children’s bill. The Guardian, 18 October. Available at: www.theguardian.com/society/2016/ oct/18/social-workersfierce-row-childrens-bill (accessed 6 November 2016).

SO LU T IO NS

Saving the NHS Mike Dixon Chair, College of Medicine

I have been actively engaged in health policy for 20 years, chaired the NHS Alliance for 18 years, was President of NHS Clinical Commissioners and am Senior Fellow in Health Policy at HSMC Birmingham. In recent years I have become interested in the non-biomedical way of improving health and care. I am convinced that a sustainable health service requires medicine to reach beyond its narrow conventional boundaries and begin to call on the full range of activities that affect individual health and healthy communities. So I see social prescribing as a key growth point for this kind of integration, and this year I became National Clinical Lead for Social Prescription (NHS England). With the BHMA and the College of Medicine leading this charge, I hope our two organisations will work ever closer and make our messages ever stronger in the mainstream.

As demographic shifts increase demands, even as budget austerity squeezes supply, there are only three ways to save the NHS. Simply improving our efficiency won’t work: the NHS is already one of the world’s most cost-efficient health services. Therefore, further cuts in provision seem inevitable unless the NHS gets a bigger share of GDP or co-funding is allowed. The third possibility is for the NHS to motivate people to care better for themselves, care for others through volunteering, and increasingly make nonbiomedical alternatives to costly health service interventions available.

There are only three ways to save the NHS. All three will demand a radical change in national thinking with all the accompanying pain and challenges to vested interests. The NHS is caught in what health experts call ‘the scissors of doom’. Spiraling costs due to an increasingly elderly population, more patients with long-term disease, more costly interventions and an increasingly demanding patient population. These demands are not being met by a proportional increase in funding. The inevitable result is increasing waiting times, longer A&E waits and a mismatch between what clinicians can offer and what patients are led to expect, which leads to frustration, unhappiness and clinical burnout. Currently, the NHS is offering only two solutions, neither of which is likely to work because neither have ever worked before. The first is the claim that we can get a quart out of a pint pot by simply improving our efficiency. Undoubtedly there are efficiency savings to be made, whether it be by increasing the number of operating sessions per week per surgeon, or greater use of technology, or by employing an extended staff in primary care, or by stopping scams such as companies charging outrageous prices for common generic drugs. All these savings need to be made and are being made but it is a lie to pretend that improving efficiency is the one

answer to saving the NHS. The UK NHS is regarded as the most costefficient health service in the developed world (Commonwealth Fund Reports this year and last) and if the drive for ever greater efficiency is demoralising clinicians and managers and leading to increasing shortages of both as they choose to leave the NHS, then there will soon come a point when further saving are really counter-productive. Sustainability and transformation plans (STPs) are supposed to be the NHS’s best option for radical service redesign and efficiency savings. But those leading NHS provision are already saying that STP plans are overambitious, and their critics say that STPs are in reality nothing more than cost-cutting. So as the penny drops that we have reached the limits of efficiency savings, we can expect the NHS to lurch towards its second and final solution – slash and burn. Traditionally budgets for improving health and for social care are the first to be cut – as they have been already. Next we can expect the NHS stop doing ‘non-lifethreatening’ procedures such as varicose veins and in vitro fertilisation. Eventually there will be no fat left. Perhaps only when once the knife is scraping on bare bone and trust board members are being asked to pay for their sandwiches at meetings, will the media and patients call foul!

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SOLUTIONS Saving the NHS

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Volume 13 Issue 3 Winter 2016

in the system and find ways of filling them through volunteer, voluntary and other organisations, social prescription will begin to support the communal fabric of health and wellbeing. In subtle ways it is helping general practices to make better use of their registered list to reframe themselves as hubs of local health development. By supporting the development of health-creating communities, social prescribing projects will begin to reduce demands on the NHS and its precious resources.

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The third solution…is to see the NHS as a co-operative, where people and communities are assets

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So what are my three solutions for saving what is undoubtedly the best health service in the world? The first and most obvious was Tony Blair’s chosen solution. After he was verbally assaulted outside St Thomas’ Hospital by a patient berating him over hospital waiting times, he simply put more money into the NHS. Is it really unthinkable that the UK should increase the percentage of GDP spent on the health service to the sort of levels that are already spent in France or Germany? This should surely be the focus of a national debate on the choices and consequences we face but without, hopefully, the sort of pre-election rhetoric that pretends we can reduce taxes and at the same time improve the health service. The second solution is to explore more opportunities for co-funding. Co-funding is seen by many as the devil incarnate and the end of NHS values. Yet it happens already. There are many examples – from patients paying for prescriptions, to paying for car parking or television sets in hospitals. Co-funding seems to me inevitable. The only question is where it begins and ends. Most agree that it should never be an issue in any life-threatening situation, but what about there being an element of co-payment for the many who could afford it in areas such as non-urgent and non-life-threatening hospital interventions, extended hours GP consultations or travel immunisation? The third solution – the third way – is my preferred one. It is the most radical of all. It is to change the paradigm that has been constantly reinforced by decades of empty political promises. It is to see the NHS not simply as a service but as a co-operative, where people and communities are assets with responsibilities every bit as much as rights. It is a new paradigm that asks all of us what we can offer as well as what we want. In a nation where 75% of us volunteer at least once a year, rather than commercialise and ramp up costs and demand as we are doing, we should now capitalise on the vast reserves of altruism and goodwill available. Having explained ‘the new story’, government should support its translation at local level allowing the Social Care Act to trump competition law, wherever local health service development is fuelled by voluntary effort or where it has wider implications in improving local health and wellbeing. To signal this changed paradigm, the government should introduce a system of litigation and redress more in keeping with a health service that is free at the point of delivery, rather than one that has been fitted to the needs of big business and the competitive market place. The NHS Litigation Authority has estimated the money needed to settle all medical negligence claims is £25–£30 billion – almost a third of the £115 billion NHS annual budget! As an example of a new model for bridging health and social care, another symbol of this changed paradigm is the very rapid development of social prescription in the past year. It aims to help motivate people to care better for themselves, care for others and make non-biomedical alternatives to costly health service interventions available. As social prescribers and their patients discover the gaps

There are enormous reservoirs of goodwill to be tapped. People like to help. In my village surgery, patients frequently insist on buying their own paracetamol and in the waiting room will often suggest that a patient who is more ill should go in before them. If we are to make the most of people’s wish to volunteer and serve others then we will have to overcome the ever-widening gulf that has opened up between ‘service-users’ and ‘professionals’. In parallel the NHS has become a profoundly risk-averse culture, where lawyers and sometimes clinicians have embedded distrust and demarcation as the system’s basic assumptions. The consequent over-medicalisation and professional protectionism has contributed greatly to making the NHS unsustainable. Some will say all this is unrealistic idealism. There is no shortage of examples of individuals – high and low – who will use foul means or fair to get what they want. But if greed is good, and the gap between rich and poor continues to widen, our sense of belonging to one society will be endangered. Then, if our sense of inter-dependence breaks down, the NHS will not survive. It was founded on, and must continue to be grounded in, solidarity and collective goodwill. It is now up to courageous politicians, committed clinicians and the people themselves to speak out about the choices we face and for us all to demand better of each other. The ‘third way’ I have described will require us to re-establish the values and vision of the NHS as one of the 20th century’s most wonderful social inventions. This won’t happen from the top down: morale and purpose have to be restored at every level. In practical terms it is the only way the NHS can be saved. All the other solutions – increased investment, increased efficiency, cutting out the unnecessary and co-payment – are first aid. They may all have a role but they are will not address the core issue of whether, as a people, we believe in society as a force for good, where the rule is not ‘every man for himself ’. The meaning of the NHS is inextricably bound up with our choices about what kind of society we want to live in.

TICKING BOXES

Death by documentation: The penalty for corporate non-compliance David Zigmond Recently retired small practice GP, Bermondsey, London

I have spent most of my long professional life in the same posts: hospital psychological medicine and a small general practice. With this stability I could anchor my practice in the sense I could make of personal experience and relationships – the art and heart, spirit and soul of medicine. But successive reforms to schematise, economise and streamline our services have often traded such ‘modernisation’ for our personal relationships, attachments and shared meanings. Corporation has replaced vocation. For many years I attempted to alert those around me to the cost of this. The following account is both a coda and a denouement.

Background

Our organisational efforts to assure fail-safety, uniformity and probity can easily – in excess – turn destructive beyond anyone’s wish or anticipation. This tale tells how such ‘mission creep’ happens and how it is sustained.

‘The more laws the less justice’ (German proverb)

In the last 20 years the ethos of our welfare services has changed exponentially: from colleagueial supportive trust to managerial litigious mistrust. In medical practice the erstwhile medical authorities mostly acted as supportive administrators to doctors’ more autonomous judgements and activities. Current management, by contrast, is increasingly about identifying ‘outliers’ and fault, and then exercising control or elimination. These changes are inimical to small general practices and their unrivalled opportunities for high-quality personal and family doctoring. To serve modern regulatory requirements GPs are now – almost entirely – corralled and managed in increasingly large and depersonalised practices. The coerced demise of a longestablished and previously well regarded exemplary small practice illustrates this process, and the price we pay.

February 2014 ‘That wasn’t too bad, was it? I rather liked them. I think they liked us, here, too. They certainly listened…’ Sara, the practice manager, closes the front

door behind the two exiting Care Quality Commission (CQC) inspectors. Her sigh is soft, tired and appreciative. I agree: for this first inspection we had been probed, questioned and examined with the best kind of professional intelligence: dialogic and sharp, yet always with a view to a greater whole – with good sense and sensibility. They dextrously sampled and witnessed the ethos of my small practice: engaging with patients and my staff, often sitting watchfully and unobtrusively to see our interactions. After that they perused and enquired about some procedural records. Seeming satisfied with these, the inspectors’ attention shifted to personal infrastructure: how did I manage and sustain all this? What were my definite priorities? What would I then compromise? What did this cost me, personally? Yes, I agreed with their questions’ implications: to keep long-term, good-quality personal healthcare is hard: it depends on well-nourished and well-perfused headspace and heartspace. So I described our endless choreography between the personal and institutional. And how, when it is impossible to do both, it must be the personal that takes precedence:

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TICKING BOXES Death by documentation: The penalty for corporate non-compliance

institutional requirements are then relegated or sometimes avoided altogether. I gave examples: judgements to bypass detailed data collection boxes, or contextually clumsy prescribed care pathways. The inspectors pressed me for my explanations of such judgements, my discernments. I drew a parallel with what they were doing with us, now: they could not sample or know everything by exhaustive procedure. So the skill is wise and pragmatic selection and compromise: from the accessible parts they would apply their imaginative intelligence to extrapolate a likely and meaningful whole, and then they would apply their best judgement. Yes, the inspectors agreed, there is no certainty in such human complexity; the skill is to construct and offer our best informed and shrewdest judgements. This is not easy – it requires nuance and delicacy: too direct an approach may destroy or disperse what we are trying to see. We are here like naturalist observers: often we must be stealthy, still, and part of the landscape – that way far more will come to us. The two inspectors resonated with this and talked around my metaphor. ‘Yes’, the older concluded. ‘Our approach has to be skilfully and subtly different on each occasion – we can then see much more of the important things that are going on, good and bad … If we don’t do that our better judgement will be blind.’ As Sara closes the front door, she turns to me and smiles. ‘Well, whatever their report I think they got a good sense of us’, I say. * The CQC report, publicly displayed for the next two years, glowed with positive acknowledgements. *

February 2016 A clinical commissioning group (CCG) meeting. The atmosphere is wearied and listless, acquiescent though fractious. The GPs forming its nucleus are obligated to attend by the Health and Social Care Act: theoretically they have an executive role but they feel more like political prisoners. This paradox is important – it illustrates how our institutions have massively misconceived the vocational psychology of healthcare: why and how we may wish to offer often difficult care for others. The result? An ever-increasing human and community waste and misunderstanding. Now we cannot contain, sometimes even survive, the effects of this. For years I have publicly and recurrently warned of this. I do so again today. I meet the usual kind of diplomatic avoidance and mollification. As the meeting limps dutifully to a close, Dr C, a veteran colleague, approaches me inquisitively. ‘Have you been CQCd yet?’ I am struck by how the noun of this institution has been turned into a verb, to which I now serve as a passive recipient. ‘No’, I say simply, but I know he has a message as well as a question.

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‘Well, you should be careful. They can be very nasty…’ ‘Oh, I think I’ll be alright. I found them helpful, intelligent and sensible last time…’ I am thankful but cheerfully disregard him. Dr C’s look is of irony laced faintly with pity. He gives a twitch of a shrug and turns away. *

July 2016 Sara spends much longer with the inspectors than we expected and she leaves them looking apprehensive. ‘They’re very different to those we had last time. They don’t really want to discuss anything – just check documents and endless certificates. Some of them – the more obscure ones – I couldn’t find…’ A contrite hand rises to console her mouth. It is now my turn. The inspectors enter my room. After necessary greetings and seatings, a rhetorical question: ‘Your presentation?’ ‘I’m sorry … what’s that?’ ‘It’s the preliminary part of what you should have prepared for this CQC inspection. We informed you of this in a detailed email. Don’t you read them all?’ ‘No, I don’t. Certainly not all. Not if I want to stay alive in this job…’ ‘What does that mean?’ their uneasy incomprehension already glares with disapproval. ‘Well, it’s an enormous problem. Everybody knows it, but we can’t tackle it. The ever-increasing electronic traffic numbs our brains, dumbs our speech and often displaces off-screen reality. Email encephalopathy is an enervating institutional disease. If I want to save my time, my mojo and my sanity then I must be selective … Anyway, I think my semi-deliberate lack of preparedness is better now for us all.’ They are both busy notekeeping, their questioning frowns seem mirrored. One of them asks: ‘How can not preparing something be better?’ ‘Well, I can explain. In my experience ‘presentations’ easily become feints of PR: careful conjurings, editings and polishings. Slick packages. Choreographed distractions and distortions to get the other person to see what we want them to see, and conceal or opacify all else. An inspection is wonderful host territory for all this. No, I don’t want to perpetuate this ‘spin culture’: I think it has replaced, often dangerously, more natural and authentic dialogue in our NHS. I don’t want to do that here, or anywhere. ‘So, let’s talk: a conversation. That way you’ll get a more real view of our struggling, flawed but wholesome little world here and my role in it: what I do well and happily; what I do not; the compromises I make; the rewards I get; how I hold it – and myself – together … I want to be candid: warts and all…’ I pause, to see if they are receptive. There is a jerk of the scribbling pen – a green flag to continue.

TICKING BOXES Death by documentation: The penalty for corporate non-compliance

I go on to talk of the complex challenges – and gratifications – of providing bespoke, personal continuity of good medical care in our inner city. My human results reflect what I believe is mostly good work: extremely high patient satisfaction rates since records began, no serious complaints (ie requiring a formal hearing), stable and enduring staff expressing affectionate loyalty, low staff sickness rates and no substantial accidents… ‘How do you achieve that, then?’ asks an inspector. ‘By assuring my priorities: personal contact and understanding – relationships. If they’re good, the rest usually follows: morale, co-operation, attentive intelligence … But what we have to secure first is headspace and heartspace: those are essential. Other things much less so.’ ‘What is less important?’ ‘Ah! That’s where we come to what I’m not so good at: what I selectively relegate or discard.’ ‘What are those things?’ ‘Oh, mostly formalities to demonstrate corporate compliance: contextually un-useful and irrelevant data-inputting, some health and safety meetings or trivial regulations, sticking rigidly to care pathways when I deem them counter-productive. All that tick-box stuff…’ My hand flips away. ‘Give us an example.’ ‘Well, I haven’t had a staff-minuted meeting about a muster station in case of fire. The premises are small, with four rooms, one straight corridor, a front door and a rear emergency door. It is quite clear what we should do: go to the exit away from the fire.’ ‘But there are more serious omissions. For example you have no evidence of child protection training…’ I sigh with encumbered irritation. ‘Well, I went for an afternoon course.’ ‘Well, where is your certificate?’ ‘Probably stuffed in a bag somewhere. I’m sorry. Look, that course was so useless for me it wasn’t worth certifying. I was in a hot room with about a hundred practitioners of very varied grades and experience. For three hours we were lectured and instructed by a specialist nurse and social worker. They said, basically: “Children are neglected and abused more than we realised. Obviously this is serious and often stealthily concealed. This happens more with struggling, conflicted or unstable families – but certainly not only. Be vigilant. Contact us.” ‘I know this well. I’ve been working thoughtfully with families for years. I don’t need to take half a day away from my work to be cropsprayed in this way. What I do need – and what has now vanished – is easy access to an experienced colleague who personally advises and sees things through, both with me and the patients…’ The silence has grown leaden and glowering. One of the inspectors, Dr S, a neatly suited and formally mannered man in his mid-50s, clears his throat. ‘We have found other areas of concern. In mental health. Your under-diagnosis of depression and dementia. This may indicate your lack of providing a good service to certain patients.’ 10

‘Oh, I don’t think so. Look, when someone contacts me, anguished, with, say, a broken love-bond, an inassimilable bereavement, a humiliating impasse at work, or a haunting from old traumas, I am not going to spend that delicate time with them filling in a formulaic – often clumsy – depression or risk factor analysis. If I do that I may gain points with the compliance system, but at the risk of losing the patient. So, to avoid all that, I code such people differently: ‘emotional problem’, ‘work stress’, ‘family/marital problem’, etc. In carefully using those kinds of discernments I believe I am then freer to provide better care. Inconveniently for our current systems, that involves trusting the practitioner with those many deviations … But we do have to trust to make those decisions.’ ‘So, you don’t see a place for the recommended diagnoses, templates and pathways?’ The inspector’s voice is dry. ‘Well, only sometimes. It’s complicated, of course. My skills must have the professional autonomy to decide about this patient, now: is organisational compliance here likely to be helpful, unnecessary, or even deleterious?’ ‘And your approach to dementia: is it similar?’ ‘Oh, yes! And for similar reasons…’ ‘Being?’ ‘Complexity and context. Failing cognition is only rarely decisively treatable by doctors. Yes, we can help with certain risk factors. We certainly should offer our most informed guided support and advice. But “dementia” becomes mostly a relational and social problem: does the declining person have robust, and intelligently affectionate, care from significant others? Who are they? Do they need guided support? and so on … It’s the same for all of us, when we decline with age… ‘These problems increase with our ageing population. As a frontline GP I have to rapidly identify and weave these myriad and delicate threads to create a personally meaningful, useful and accessible whole. But I can only do that well when I can use my human and technical skills freely – when I am the choreographer. An institutional template often obstructs all this…’ ‘So, again, you choose to depart from established procedure?’ ‘Yes, sometimes. It’s a tricky paradox. With these kinds of problems I can be a better doctor when I avoid doing what the institution might expect. I choose when and how to override institutional procedures…’ Dr S is looking at me with quizzical caution. ‘But I am very thoughtful about how I do so’, I quickly add, as an insulating caveat. ‘I’m sure. But nevertheless you do feel you have the right to “cherrypick”, when you choose?’ ‘Yes, that’s true’, I answer simply and softly, though I am already sensing a darker subtext to the question. ‘Thank you. I have no more questions.’ Dr S looks down at his notepad: his smile, to himself, seems consummate. This meeting has been difficult but I want an amiable farewell: I chat as we are disbanding.

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TICKING BOXES Death by documentation: The penalty for corporate non-compliance

I ask Dr S, ‘Are you still in practice?’ ‘Oh no. Not for three years now.’ ‘Why did you retire?’ ‘Well, I’d accumulated a very good pension, so I could leave easily!’, he beams. ‘I’m just doing this [CQC inspections] now.’ ‘From practitioner to judge’, I say: a serious banter. ‘Yes, I’m doing a university masters degree in CQC Inspections’, he answers, with enthusiasm. ‘Ah’, I respond simply, with rather less enthusiasm. ‘And what keeps you going, in your 40th year as a GP?’, he enquires, as if he cannot imagine. ‘It’s like a happy second family here, this small practice. Through all our joys and sorrows we get to know one another: patients, receptionists, clinicians. And amidst this, with my human and technical skills, I can sometimes be really helpful. At other times we can, at least, be a personal comfort, support and witness to life’s inexorable sorrows. We all here want to come to work in the morning. Where else could I get such satisfactions?’ Dr S registers his own simple ‘Oh’ and shoots me a brief smile that is bemused but not hostile. He is now standing at the door, about to leave. I offer my hand, to say farewell. His grasp seems reticent and ambivalent. * The coup de grace was co-ordinated with brilliant and shocking efficiency: a lightning strike worthy of Blitzkrieg. It came three days later, on a Friday night at 6pm. My receptionist received a call from a senior officer at the CQC notifying me of their intention to close my practice on the next working day, Monday morning. The charge is that my practice was found by inspectors to be massively and irremediably unsafe and must be closed immediately. This would be done by an emergency legal procedure, through a court order. At the time – until a few hours before the set hearing – I was on a brief holiday, in France. I was uncontactable and oblivious of these rapid and shocking (for me) developments. Tired from a very long train journey I was unprepared and disorientated by such overwhelming and draconian measures. I arrive flustered, hurried and alone to the court. The CQC has assembled massive and well-armed forces to encounter my unsupported and unbriefed solitary enfeeblement: a solicitor, a barrister, a CQC director, a CQC compliance officer and a medical expert (in what?). They all have hundreds of pages of meticulously prepared and filed ‘evidence’ against me. I cannot see how they could have assembled such thoroughly destructive documentation and slickly rehearsed choreography between them within three working days: there must have been much prior briefing and planning. I immediately ask the magistrates for an adjournment, but the barrister is adamant that this should not be granted: that my practice is so extremely hazardous that the public need immediate protection, by its closure.

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Public safety must here, exceptionally, take precedence over natural justice. The magistrates acknowledge they have never encountered this problem before and, bewilderedly, opt for safety. They rule in favour of the barrister: whatever complexities emerge, at least the public will now be protected. This court hearing will turn out to be extraordinarily long – eight hours. The chair of the magistrates will later describe what is (for them) unprecedented length and difficulty. Throughout the long day there are court adjournments for respite and procedure. Outside the courtroom I am expected to wait, seated, in a bare ante-room which I must share with my CQC prosecutors, my assailants. This is awkward and they understandably create maximum physical distance, avoid looking in my direction and mutter very discreetly among themselves. In another context I would think they looked amiable. To loosen the tension a little I say: ‘Look, we can see how difficult this is and I want to make it a bit easier, just for now. I can see you are all “just doing your job”, following procedure. Yes, that’s hard for me, but I shall argue my case and bear no personal animosity toward you. None of you know me, so I understand that – for you – it’s a technical and institutional matter.’ I notice two of them look at me briefly, signal a tentative smile and say a quiet ‘Thank you’. They seemed touchingly grateful for this: mercy from the condemned. * In this strangely cohabited space the ‘other side’ give me copies of the voluminous prosecution documents. I have time only to briefly peruse some of them: a thorough reading and response would take me days. Very soon I can see the professional profile they have constructed: reckless or feckless, casually or deliberately unsafe, uninsighted, disobedient and unreformable – in short a gross and intolerable liability to any public service. With ironic gloom I conjure cartoon scenarios. A uniformed senior policeman in front of TV cameras issuing a statement: ‘We have been warned of the great danger this man poses. Members of the public should not approach him directly, but instead immediately contact the authorities’. Or a shouting tabloid headline: ‘DANGEROUS DOC EXPOSED! Authorities find years of concealed danger to the public. How many have died?’ In my brief time for perusal I can merely identify some misattributions or inaccuracies. Maybe I will have the opportunity to designate them: many will go unchallenged. But my more substantial legal vulnerability lies elsewhere: I have already frequently acknowledged deliberate and thoughtful non-compliance. I will never deny this. My self-defence – however much I am allowed – will have to also address this. So, in the courtroom, I offer a few parries and corrections to (what I think are) documented errors. My main thrust, though, is an appeal to natural justice, as opposed to strict legality. Yes, I argue, all can easily see areas of non-compliance. I have long argued that this, selectively, must be done if

TICKING BOXES Death by documentation: The penalty for corporate non-compliance

we are to provide our best personal care for others and (importantly) ourselves: that over-regulation, paradoxically, is destructive to much of our best healthcare. I have vigorously argued the reasons for this, often, in public, and in many publications. The lawyers prompt my return to their combat arena of legalities – their many showcased items – but I am trying to break away, to view the bigger picture – the whole – the overall integrity of myself and my practice. Despite the lawyers’ stymies, the magistrates ensure some (if inadequate for me) time to do this. What is this bigger picture? Well, it’s much longer, too. I attempt a brief, well-documented profile: 39 years as a principal GP; never a formal complaint needing a hearing; excellent long-lasting and warmly appreciative staff and close colleagueial relationships; never – until now – any litigation; never on-premises serious accidents; far-above average patient experience feedback, consistently and for many years; robust good health and humour; highly regarded and well-known academic and journalistic output; similarly acclaimed teaching … the magistrates are attentive. I continue. With all this – for decades, and no sign (yet) of personal decline – what is the real life evidence that I am a serious risk, professionally or environmentally? Wouldn’t that now be long evident, and from many sources? No, the barrister argues, you are flagrantly unsafe. All the regulation and requests for documentation are there to assure safety. Therefore, if you do not comply fully you become unsafe. So, I reply, I am guilty (of unsafety) unless I submit to all your procedures and then get a certificate of compliance from you (the CQC) saying I am safe. Guilty unless proven innocent: innocent only by submission – a stark inversion of natural justice! Doesn’t this – the selfreferring system of proceduralism – eventually become a folly of officious abstraction? Isn’t that what is happening here? No, the barrister assures the court: such devices are there for our communal protection. I take a contiguous, but different, tack and then appeal to the bench: my exceptionally good real-life record (ie not the one abstracted recently by the CQC) has been possible only because I have created the professional autonomy to decide on priorities with my practice and patients. That is my skill and my ethos – to employ my good faith and judgement to make the best compromises. Our current error – as enacted by this CQC action – is to assume that every possible risk, problem and adverse situation can be prevented or solved by ever-increasing regulations of compliance, monitoring, management and penalties. The truth of this is very limited, but we (eg the CQC) are exerting this principle far beyond these limits. The resulting trespass is egregiously – though inadvertently – damaging of healthcarers’ vocational ethos, spirit and healthy colleagueiality. Hence our evidence of another kind throughout the NHS: collapse of staff morale, health, career longevity, satisfaction, recruitment

… .Overstrict parents rarely produce what they, or anyone else, say they want. This – increasingly for a decade – is what I have been trying to avoid. This is why – very selectively and conscientiously – I have openly chosen non-compliance. To serve as a good personal and family doctor I must sometimes compromise or discard my unworkably dense matrix of regulation. Real-life general practice – like so much of our lived (rather than abstracted) lives – is the art of the possible. Only rarely is it completable or perfectible. To suppose otherwise will teach us painful lessons: that is what we are struggling with, here and far beyond. I am relieved and grateful to the magistrates for allowing me the time to say all this. Even more so that they seemed genuinely interested and supportive, despite their professionally neutral demeanour. Not so, not surprisingly, the barrister. All this, he says, is beside the prosecution’s argument and evidence: that I have been knowingly disregarding – flouting even – of clear regulations. Other argument, explanation or mitigation is irrelevant. Within this narrow legal frame I can see he is right. I am guilty as charged. My heart sinks. I am wanting to say: ‘But the whole (evidence from life) is more than the sum of its parts (evidence from procedures). We must – whenever we can – pursue and grant precedence to the whole.’ I look around the court. After many hours I can see it is now wearied to a standstill. I do not think they can be further receptive to me. I decide to say nothing. The magistrates adjourn for their final, private conference. * Another 30 minutes. We are assembled for the summary and verdict. The senior magistrate delivers this: ‘In my 27 years on the bench I have never encountered a case of such length, interest and complexity. Yet at the end of the day we are all subject to the law, and this court’s task is to administer the law, not to express opinions about any such laws or regulations.’ She turns to look at me directly: ‘It is with reluctance, but necessarily for this reason, that we find for NHS England and against the doctor. To his credit the doctor has been open and honest – both verbally and in documents – about his failure of compliance to clear regulations, but this becomes indefensible in terms of his contract of employment. NHS England is thus legally entitled to immediately effect its remedial procedures.’ * After eight hours we all leave slowly, sagging with fatigue. 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

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TICKING BOXES Death by documentation: The penalty for corporate non-compliance

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.’ For the first time each individual holds my gaze. They each smile with a sweet-sad sincerity and say a lingering and deliberate ‘thank you’. At the end of all this very long procedure we have – only now and briefly – found and recognised our common humanity. I feel a tug of intense grief: it is mixed strangely with relief. * Notices are put up on the front door of my practice informing of its closure of services and where patients may now go. As I walk away from the front door Ronald approaches me. I knew him as a docile adolescent and he now approaches me as a thickset middle-aged man with a cumbersome gait and a habitual aura of trusting – but never really articulated – anxiety. This is evidently worse now. ‘I’ve heard, doctor … Can’t you be my doctor any more?’ ‘No. Not from now on. I’m really sorry. But I’m pleased I was able to offer a bit of help over the years…’ I am trying to buoy us both up, offer us both something positive. ‘But why is that? Don’t you want to go on?’ I think Ronald hopes that his question will bring a reversal. His eyes glisten with stemmed tears. ‘Oh, no. The authorities have decided I’m not modern enough. I’m not really what they want. There’s all sorts of regulations I have to follow…’ ‘Can’t you do that?’ His question sounds pleading. ‘Probably not. I’d exhaust myself and I wouldn’t be able to be the kind of doctor I believe in … how I’ve tried to be with you all those years.’ ‘So they think they know, better than you, how to be my doctor, do they?’ His voice is earnest and slow: this sounds like a real question, without guile or rancour. I respond in kind. ‘Yes, I think that’s right. You see, they pay the money, so they make the rules.’ I try to sound simple, neutral and benign. I exclude much else. * Later, outside the NHS city gates, my severed professional head will be displayed on a spike. It will not need much comment or explanation to spread the necessary message. Corporations can function only with hegemony, and hegemony necessarily must have compliance, and when have we ever achieved mass compliance without publicly displayed, draconian penalties? *

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‘Oh dear! That’s terrible news … I’m so sorry. How did it happen?’ Dr E, a young doctor now senior in my CCG, sounds genuine in his shock, kindness and commiseration. He is an intelligently humane man but stressed, I think, by the diplomatic strain and responsibility of shepherding very difficult schemes of governance that he (privately) does not believe in. With delicate and opaque skill he has signalled this to me previously, while always ensuring protective ambiguity. ‘I’m really sorry’, his voice lowers further with the repetition and sadness. ‘You know this is going to leave a massive gap for us. You’re going to be greatly missed…’ ‘How so?’ I am touched and a little perplexed: I have previously sensed his wish for me to be more silent, or even absent. ‘Well, you’re the one who always said the bold and challenging things other people want to, but never would. You’re older and you’ve had this honest – some would say tactless – courage. But these things needed to be said … now there won’t be anyone to say them…’ His voice fades into a faint desolation. ‘Why don’t you, E?’, I ask, trying to revive him. E is silent for several seconds before sidestepping: ‘Yes, but how are you David? Do you have enough support?’ He is sounding brighter and stronger. * As I enter my exile I await a formal CQC report: a pillory, a publicly displayed penalty for non-compliance. I am thinking that there are times in life when we must choose between personal integrity and survival. I am grateful that this – my most serious test – has been encountered so late in my career. I am thinking, too, of the elemental questions of all relationships and welfare: what do other people want and need? How do we (think we) know? Who decides, and how? Some eyes need spectacles to see things clearly and distinctly: but let not those that wear them therefore say that nobody can see clearly without them. John Locke, An Essay Concerning Human Understanding (1690)

The young man knows the rules: the old man knows the exceptions. Portuguese proverb

David Zigmond has recently won the 2016 Leadership Awards positive deviant leader category. Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com David Zigmond would be pleased to receive your feedback.

JU NIO R DOCTO R S’ SURVIVAL

Bring back joy in work – what junior doctors need to survive Olivia Jagger Masters Candidate, Harvard T.H Chan School of Public Health; GP, ACF Wessex

The practice of medicine is demanding and can be stressful. The gratification that comes from doing a good job is an important factor in keeping doctors resilient. But many junior doctors in the NHS face excessive workloads and increasing demands in an ever more challenging training environment. The recent contract dispute has left many feeling demoralised and undervalued and worried for their future. This article proposes a number of ways that may help junior doctors rediscover joy in their work, and by finding meaning, purpose and a stronger sense of appreciation, raise their morale and resilience.

I became a doctor at a time of significant change in the NHS. Excessive workloads and pressures on service provision created a challenging training environment. Working in the ‘thick of it’ ignited my passion to improve the systems I work in. Not only to improve patient care and experience, but importantly the working environment and experience of my colleagues. I completed the National Medical Director’s Clinical Fellow Scheme to understand the ‘bigger picture’ of NHS and how to influence the system from within. Building on this, I am combining training in general practice with research into resilience training for doctors.

Introduction Sadly, for many junior doctors working in the NHS, the joy has gone from their work. I deliberately talk about joy in work, not mere satisfaction Why? Doctors who feel joy in work feel happier and more secure, have greater job satisfaction and greater career fulfilment. As a knock-on effect, they deliver higher quality patient care, are more likely to remain in the workforce and more likely to engage in healthcare improvements (West 2013a). For the NHS to continue to deliver excellent healthcare, it needs to retain a happy, fulfilled and engaged workforce who are committed to delivering highquality care, even in stressful times. Bringing back joy in work is not only important for junior doctors’ survival, but is vital for the long-term survival of the NHS. One of the first people to speak about the concept of joy in work was the American engineer W. Edwards Deming. Deming promoted the idea that every employee should be able to achieve joy at work and that this joy would lead to improved quality and higher organisational performance. The Institute for Healthcare Improvement has led the way in applying this concept to healthcare, advocating joy in work as a

resource for excellence and a driver for improvement in healthcare. Unfortunately, many factors are diminishing joy in work for junior doctors. The working environment in the NHS is tough, with excessive workloads and increasing demands on service provision, which presents a challenging training environment. There is currently a highly conflictual atmosphere in the NHS and many in the workforce are demoralised. The recent contract dispute left junior doctors feeling distressed, undervalued and worried for their futures. Frequent healthcare and training reforms create uncertainty and make it challenging for junior doctors to imagine what their future practice might look like. As a consequence, many of these highly skilled future NHS workers are thinking with their feet and leaving the NHS. In 2015, 48% (over 3,400 junior doctors), did not continue to specialty training after successfully completing the foundation programme (UKFPO 2015). In the wake of the contract dispute, it is predicted that greater numbers of junior doctors intend to work abroad or leave a career in medicine entirely. For junior doctors to survive, there is a need to bring back joy in work.

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JUNIOR DOCTORS’ SURVIVAL Bring back joy in work – what junior doctors need to survive

Finding joy in work The best indicator for me that I feel joy in work is when I look forward to going to work in the morning. There are a few simple actions that can bring back joy in work, which most junior doctors will identify with, but it is an individual experience. Reflecting on different jobs that you have had, both positive and negative experiences, is an easy way to identify the factors to focus on that bring you the most joy in work.

Re-finding meaning and purpose A study by Deloitte highlighted the connection between joy and meaning in work: ‘Free food and ping-pong tables are fun perks, but companies that succeed in having highly engaged employees focus intently on driving meaning, purpose, and passion among workers’ (Deloitte 2016). Most doctors enter a career in medicine to help others and make a difference. Although prestige, money and academic stimulation may have a role, the opportunity to care for patients at their most vulnerable and share in intimate moments in their lives is the real privilege of being a doctor. We have all experienced joy in work, be it a memorable encounter with a patient or being part of a really good team who became your great friends. Unfortunately, what it is to be a doctor is changing and the opportunities for having the kind of moments that doctors find most professionally satisfying are diminishing, as patient encounters become briefer and team structures less stable. To feel joy in work, junior doctors need to appreciate meaning and purpose in work. It takes time or effort to experience moments that count but not all that much: I have found that making a conscious effort during busy on calls to get to know something personal about my patients lives can really turn a shift around.

Take back control and build resilience A study of doctors in Sweden found the three strongest predictors for work-related illness are high workload, lack of control and lack of social support at work (Wilhelmsson et al 2002). The working environment in the NHS can be tough and, with high patient volumes and long working hours, the job is undeniably pressured. Junior doctors don’t have much autonomy in their roles: we constantly move around, have little control over rotas and we often experience work/home conflicts. You need to have some choice and control over your work to feel joy in work. Simple things, such as more effectively managing your time and prioritising jobs, can allow you to take back some control and not feel overwhelmed at work. Importantly, to survive it is necessary for junior doctors to accept that we are not infallible. Doctors are high achievers and don’t respond well to failure, but medicine is complex and full of uncertainty, the workload is intense and the environment can be chaotic. The only thing guaranteed is that we will make mistakes. Having a supportive team to stand by

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you, buffer stress and help you learn from mistakes is important. These shifts in attitude and self-management are personal resilience skills that can help us thrive, not just survive, in this challenging working environment, and boost joy in work.

Play to your strengths and pursue your interests Playing sport does not make me happy. Sewing does not make me happy. Why? Because I am not very good at either of those activities. Cooking, on the other hand, makes me very happy (I like to think of myself as a semidecent cook!). We all enjoy things we are good at and that interest us. Having the opportunity to pursue, develop and use your strengths brings joy. In work, take account of the skills mix of your team and play to your strengths. Throughout your training make your area of clinical interest known to your team and seize opportunities to develop your skills or pursue an area of special interest. You will find this personally and professionally rewarding.

Value and appreciate one another Cows that have names and are treated as individuals produce 500 pints more milk a year. Junior doctors are no different! (Douglas, Rowlinson 2009) When doctors feel valued they are happier, work harder, deliver higher quality care and put in discretionary effort over and above their core responsibilities to improve the systems they work in (West 2013a). Sadly, many junior doctors do not feel valued, and this diminishes their joy in work. They are required to work erratic and frequent on-calls and have to rotate around large geographical areas with little regard for their family lives. Unlike other industries, there are few ‘perks’ to the job. The free parking, meals and housing junior doctors used to enjoy have long since gone. All these little things may seem inconsequential but make junior doctors feel less valued. Importantly, it is not about money. This was highlighted by the recent junior doctors contract dispute. Patient safety aside, the key issue was not that junior doctors were demanding more money but that they want to feel valued, to be fairly compensated for the work they do and to be treated equitably. Undeniably there is need for change at a national, organisational and local training level to ensure junior doctors feel valued in their work, training and personal lives. However, simply working in a mutually appreciative team, in which you feel valued, will increase your job satisfaction (West 2013b). It only takes a few moments to appreciate your colleagues by encouraging them and thanking them at work, but this can have a big impact.

Look after yourself and support each other I was amused the other day by a ‘tweet’ of a picture of Maslow’s hierarchy of needs with the addition of wifi at

JUNIOR DOCTORS’ SURVIVAL Bring back joy in work – what junior doctors need to survive

the base of the pyramid – a wry and apt reflection on modern life. Joking aside, Maslow’s hierarchy (Maslow 1943) is a concept that all doctors are familiar with yet all too often they overlook their own basic needs. To reach the higher levels and feel joy in work, you first need to feel safe, both physically and psychologically, and attend to your basic needs. Junior doctors often overlook the basics, not taking time to eat, drink, rest or go to the toilet during busy shifts. Taking care of the other areas of our lives such as exercise, nutrition, sleep and social connections is as important. Your job should not be the be all and end all. There are many other areas of your life in which you find joy and every junior doctor can benefit from learning some self-care strategies. Establishing security in your working environment is also important. We all derive joy from strong social networks. Collaborating with colleagues and experiencing camaraderie creates a safer, supportive and positive working environment. Taking a few minutes each day to talk with colleagues about their lives is an easy way to boost team morale and increase joy in work. To feel joy in work you need to: appreciate meaning and purpose; feel safe and have job security; have some choice and control over your time; experience camaraderie with colleagues; have career flexibility and opportunity to pursue interests; look after your personal wellbeing; feel valued as a trainee and clinician.

Be positive Times are tough for junior doctors and the challenges facing the NHS may seem insurmountable. In these times it can be easy to fall into the mode of learnt helplessness, but the power of thinking positively should not be underestimated. If you are optimistic and think positively you feel happier than people who are pessimistic or feel helpless. Walt Disney built his career on spreading joy. It is Disney company policy that you cannot pass a colleague in the corridor without greeting them with a smile (Lee 2004). The act of smiling itself makes you happy! A study found that when you ask people to place a pencil in between their teeth, which forces them to activate the facial muscles used to smile, they find cartoons funnier (Soussignan 2002). Even more powerfully, joy, like smiling and laughing, has a viral property – it can be cultivated and it is contagious. A study has shown that happiness spreads from person to person to person in a chain reaction through social networks (Fowler, Christakis 2008). Therefore, positive behaviors like smiling and being optimistic, which make you feel happy, pass from person to person and can create joyful working environments. The same is true of negative behaviors, if one person is having a bad day it can drag down the whole team. It is therefore important to take responsibility for your own happiness because it affects everyone around you. Can you imagine the ripple effect of spreading joy if Disney’s policy was adopted across the NHS?

Conclusion Many junior doctors currently feel that they are just hanging in and surviving. But bringing back joy in work can move you from merely surviving to thriving once again in your work. Joy in work is not just important to individual doctors. For the NHS to survive in the face of new challenges it needs a happy, fulfilled and engaged future workforce. Key to junior doctors surviving in the NHS is ensuring that they enjoy their work, that they feel valued again and that they take back some control over their work lives and future careers. We shouldn’t be passive in letting change happen to us. The junior doctor contract dispute united junior doctors and demonstrated that together we have a loud voice and can be powerful influencers. A positive outcome of the dispute would be for junior doctors to continue to engage in and influence debates about the future of the NHS, especially workforce issues and training issues, and to ensure the future NHS is one that we enjoy and want to continue working in. The wellbeing of junior doctors is the shared responsibility of individual doctors, training programme directors, healthcare organisations and the government. But there are many simple things we can do for ourselves and colleagues right now to bring back joy in our work. A junior doctor colleague shared her mantra with me: ‘gratitude is the new attitude’. If we can all be kinder to one another it can make the working day much more enjoyable. Emotions are catching. Be aware that how you feel is having a real impact on others, and you may be able to spread positive feelings that could lift the whole working environment. It all starts with a smile. Who you are matters! Deloitte Global Human Capital Trends 2016 report. Online. Available at: www.bersin.com/uploadedFiles/hc-trends-2016.pdf?aliId=76051297 (accessed 4 November 2016). Douglas C, Rowlinson P (2009) Exploring stock managers’ perceptions of the human-animal relationship on dairy farms and an association with milk production. Anthrozoos 22 (1) pp 59–69. Fowler J, Christakis N (2008) Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ 337 (2338) pp 1–9. Lee F (2004) If Disney ran your hospital: 9 1/2 things you would do differently. Bozeman, MT: Second River Healthcare Press. Maslow H (1943) A theory of human motivation. Psychological Review 50 (4) pp 370–396. Soussignan R (2002) Duchenne smile, emotional experience, and autonomic reactivity: a test of the facial feedback hypothesis. Emotion 2(1) pp 52–74. UK Foundation Programme Office (UKFPO). F2 Career Destination Report 2015. Online. Available at: file:///C:/Users/User/Downloads/F2_Career_Destination_Report_2015__FINAL.pdf (accessed 4 November 2016). West M (2013a) Promoting a culture of high quality care. Online. Available at: www.kingsfund.org.uk/leadership/promoting-culture-high-quality-care (accessed 4 November 2016). West M (2013b). Compassionate care means rooting out staff stress. Online. Available at: www.hsj.co.uk/comment/compassionate-care-means-root ingout-staff-stress/5065611.fullarticle (accessed 4 November 2016). Wilhelmsson S, Foldevi M, Akerlind T, Faresjou T (2002) Unfavourable working conditions for female GPs. A comparison between Swedish general practitioners and district nurses. Scandinavian Journal of Primary Health Care 20(2) pp 74–78.

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CLINIC AL LEADER SHIP

Clinical leadership – the aspirin for an ailing NHS? Daghni Rajasingam Head of Service for Obstetrics; Deputy Director for Post-Graduate Medical Education, Guys & St Thomas’ NHS Foundation Trust

Patients are the most under-used asset in the NHS. But staff are more accustomed to ‘doing to’ or ‘doing for’ patients, than they are to ‘doing with’ them. The culture and environment to facilitate this will require a significant shift in ideology and a transformation in leadership style: a fundamental shift in power away from top-down hierarchy and into partnership relationships based on a better understanding of systems thinking in the wider context of the NHS. A new VORTEX model helps make sense of the challenges we face in a patient-centred NHS where patients become partners.

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I am a consultant obstetrician in a large, urban tertiary hospital serving a diverse local population. I believe in social justice and advocating women’s rights through practising and disseminating women's health rights both in the UK and globally. I have an academic interest in leadership development and passionately believe that we need to build the resilience of the NHS workforce through understanding systems change and a hosting style of leadership.

The NHS Constitution ‘The NHS belongs to the people. It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives. It works at the limits of science – bringing the highest levels of human knowledge and skill to save lives and improve health. It touches our lives at times of basic human need, when care and compassion are what matter most.’

The modern NHS Within the last decade the NHS has prioritised the importance of safe care, together with high-quality service provision that improves the experience of patients. However, changing demographics of the population and constrained resources, both financial and human, means that services will need to be designed and delivered in radically different ways across traditional boundaries of care. The culture and environment to facilitate this will require a significant

Volume 13 Issue 3 Winter 2016

shift in ideology from one where the professional is the expert and the patient the recipient of this expertise, to one where there is a more equal partnership-based relationship, where providers, both from the acute and primary care sector, users and stakeholders share responsibility and work together to find sustainable solutions. Our NHS landscape has been deluged by a tsunami of reforms over the last 10 years, culminating in the Health and Social Care Act 2012, an unprecedented period of healthcare institutional failings (Mid-Staffordshire Hospital , Morecombe Bay Hospital and the Keogh 14) and a shrinking financial purse. With ‘clinical leadership’ emblazoned on every single signpost, we have had to reconsider what we mean by leadership and to challenge some of the traditional notions of leadership. Much of the published healthcare leadership discourse focuses on managerial concepts, meanings and framing of the term ‘clinical engagement in leadership’. The assumed passivity of the clinician is a common thread. And yet, most clinicians have the closest relationships with patients and are potentially the ones with the most influence and moral obligation to do their best.

CLINICAL LEADERSHIP Clinical leadership – the aspirin for an ailing NHS?

In 2013, Don Berwick was asked to review the NHS in the light of the Mid-Staffordshire Francis report (Francis 2013). Berwick, in his letter to clinicians, managers and all the staff of the NHS, talks of being impressed with the NHS workforce of ‘1.3 million people who are trying to make real a vision of a vital, universal healthcare system, accessible to all and free at the point of service’. In addition he was impressed with the UK’s commitment to healthcare as a human right and to healing as a shared social mission. Despite being clear in his letter that some standards should be rigorously enforced, he also acknowledged that real, sustainable and active improvement depends far more on learning and growth than on rules and regulations. He says that in an ‘all teach-all learn’ culture, ‘measurement is not a threat, it is a resource; ambition is not stressful, it is exciting; defects are seen as opportunities to learn; and curiosity abounds’. The four guiding principles he recommends are: • placing the quality and safety of patient care above all other aims for the NHS • engaging, empowering and hearing patients and carers throughout the entire system • fostering wholeheartedly the growth and development of all staff, especially with regard to their ability and opportunity to improve the processes within which they work • insisting on, and modeling in your own work, thorough and unequivocal transparency, in the service of accountability, trust and the growth of knowledge.

The NHS workforce are trying to make real a vision of a vital, universal healthcare system

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A clear understanding of ‘quality’ and systems thinking, co-production, quality improvement methodology and reflective team practice seem to be the bedrock of a sustainable, learning healthcare system.

Patients are the most under-used asset in the NHS For some time now, it has been recognised that patients are the most under-used asset within the NHS. In areas where their experience and expertise have been harnessed, service provision has been transformed with reduction in demand for clinician input. Traditional pathways and inappropriate skill mix are barriers to thinking innovatively about designing radically different ways of providing high-quality care. Co-production means delivering public services in an equal and reciprocal relationship between professionals, people who use

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Patients are the most under-used asset within the NHS

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An outsider’s perspective

services, their families and their neighbours. Where activities are co-produced in this way, both services and neighbourhoods become far more effective agents of change. By involving people in the delivery of their own services, co-production shifts the balance of power, responsibility and resources away from professionals and into the hands of individuals and communities. It recognises that ‘people are not merely repositories of need or recipients of services’, but the very resource that can turn public services around. Co-production also means unleashing a wave of innovation wherever services are designed and delivered. Though the NHS has tried to institutionalise co-production, in its essence co-production has to bring the actions of individuals in communities together with the people who have the authority to make decisions. Consequently this process of doing with, rather than doing to, or doing for, calls for a fundamental shift in power away from top-down hierarchy and into partnerships based on network relationships.

Clinical leadership styles Clinicians need to take ownership of the current challenges their services face. They have to demonstrate leadership by influencing their provision at all levels – from the frontline to the political sphere. How they choose to lead, though, may determine their success or failure. In the context of the NHS two different kind of leadership are needed. Transactional leaders focus on the task and targets and manage performance. They focus on the practicalities of the job and turn ideas into reality. The transformational leader, however, changes the way that people think about themselves, by focusing on new possibilities, and turning visions into ideas. Within the complex political framework of healthcare provision in the UK, coping with increasing numbers of policy and legislative documents relating to commissioning and provision of services, has given transactional management and leadership an important role. However, senior management is pulled in two directions: on the one hand they want us to practice in novel ways in order to make cost savings, but at the same time we are expected to improve the patient journey. But, understandably, given the structural turbulence of legislation, a certain kind of inward focusing has made the necessary new relationships with other organisations – which would be required in order to do more and better with fewer resources – even more difficult to build. Even though transformational leadership rhetoric is ever present in NHS leadership frameworks, the realities of structural and financial restraints generally stifle it. Nonetheless I believe that if we can develop a style of leadership based on ‘hosting’

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CLINICAL LEADERSHIP Clinical leadership – the aspirin for an ailing NHS?

Why clinical leadership

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Clinicians who occupy ‘hybrid’ roles have a challenging time bridging the gap between two cultures

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we might realise the powerful and positive asset base which our patient populations and NHS staff represent and, that this could potentially overcome the undeniable structural restraints we face.

There is evidence to suggest a strong link between medical leadership and organisational performance. forms of medical leadership need to be developed alongFor example, when the introduction of total quality side other strategies. Most importantly these leaders need management into the NHS was evaluated, there was an to be nurtured, supported and valued by strategic leaders intricate link between how well it was applied and how at all levels of the NHS. engaged doctors were. McNulty and Ferlie (2002) echo Can transformational leadership be encouraged, these findings in their report on business process developed and sustained? The complex external forces re-engineering in Leicester. The US literature found now operating on clinicians are seldom understood. similar results; for instance Watson and Kimberly (1997) Leadership, though it must come from within, also emphasised engagement of doctors as one of the key requires strategic nurturing early on in clinical careers and facilitators for successful reconfiguration. especially so during transitional periods between jobs. In Much of the discussion about engaging doctors in order to make this a reality, a non-negotiable assessment management has been based on a deficit model which of self-awareness, reflective practice, commitment to assumes there are identifiable managerial skills and areas quality improvement and resilience should be integrated of knowledge which doctors have not acquired. This overinto would-be medical leaders’ appraisal and revalidation looks the process of management as a social and political processes. The standards already proposed by the Faculty process, which many doctors may have an aptitude for of Medical Leadership and Management would go some and indeed experience of. There is an assumption that way towards ensuring this. doctors must ‘become’ managers, a position which some sceptical colleagues see as an expedient viewpoint constructed by managers. The question rarely posed Models of clinical leadership however is how it might be possible to have Having examined several different frameworks around organisations that are truly clinically led but with clinical leadership, I have found none that fully reflect the managerial enablement. complexity of leading individuals and teams that provide Tribalism is strongly ingrained in many healthcare patient-focused, quality care within the today’s turbulent professional groups. Clinicians who occupy ‘hybrid’ roles have a challenging time bridging the gap between • Values and variety two cultures. In addition, the • Organisational culture Edge of chaos Edge of chaos tendency of professional • Respect tribes to orientate towards • Turbulent tsunami effect • X-Factor stability rather than change Politics generates a host of Patient Value Maximisation problems. To overcome (PVM) = experience+safety+effectiveness Complex DH and NCB these inherent obstacles to outside innovation we need to move forces towards appointing large Clinical numbers of doctors to commissioning X-Factor groups leadership roles while • Reflection accepting that some of Commissioning support units • Situational these leaders will not require awareness formal positions in the Organisations • Resilience hierarchy. Instead the • Self-compassion emphasis should be on Professional Co-production collegial and horizontal bureaucracies control processes. Yet even Complex inner Mental models new forms of leadership forces WORKFORCE alone cannot deliver the transformational change the NHS is desperate to implement, so these new Vortex model of clinical engagement and leadership © Rajasingam 2009

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CLINICAL LEADERSHIP Clinical leadership – the aspirin for an ailing NHS?

environment of financial and time constraints. In most existing models deeper clinical perspectives are lacking. Based on my own action research into ‘what makes clinicians tick’ I have produced a modification of Senge’s systems-thinking framework with the aim of encouraging clinicians to understand systems thinking in the wider context of the NHS. To be effective as individual leaders and members of teams they have to grasp how they fit into this volatile landscape. My model incorporates maximal external forces and turbulence at the top of the ‘vortex’ with patients in the centre (the eye of the storm) and staff in close proximity at the base of the vortex, exerting complex inner forces (mental models and professional bureaucracies) and providing a relatively stable foundation for the vortex. A service delivery chain extends from the chaotic political environment at the top through regional commissioning groups to provider organisations and ultimately as far as the patient. If the sole aim is to maximise value for patients (patient value – PVM) then striving for a stable and unchanging environment is likely to be unsuccessful. Instead we will need to be self-aware, adaptable and flexible in order to thrive in the present climate and ‘save the NHS’.

Fundamentals of resilient organisations, patients and staff The ability of clinicians to best exert their ‘X-Factor’, enabling a coupling of external and internal forces, will depend on three factors: their resilience, their ability to reflect and their understanding of systems. Organisational resilience is defined by the British Standards Agency as ‘the ability of an organisation to anticipate, prepare for, and respond and adapt to incremental change and sudden disruptions in order to survive and prosper’. As individuals increase their self-awareness and resilience, the organisation will reflect this. Our healthcare system requires us as professionals, to act compassionately, but until we as a profession give self-compassion the credit it is due, and NHS organisations nurture and respect this quality, what is being demanded of our workforce will be neither fair nor deliverable. Only when we, as parts of the system, understand the crucial role of resilience, reflection and self-compassion as crucial moderators and mediators in the system, will we have it in our gift to ensure that our amazing healthcare system, the NHS, survives another generation. Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: TSO. McNulty T, Ferlie E (2002) Re-engineering health care: the complexities of organisational transformation. Oxford: Oxford University Press. Watson S, Kimberley J (1997) Re-engineering hospitals: evidence from the field. Hospital and Health Services Administration 42(2) pp 143–163.

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R ESILIENT O R GANISATIO NS

How to enable organisational resilience Ideas from a conversation at the Centre for Resilience Venetia Young Safeguarding adults lead GP, Cumbria CCG

In health and social care, we must deal continually with our own and our

I have worked in many settings in the NHS over 35 years as a GP and as a systemic therapist in adult mental health. My therapy training taught me to look for the places where there was manoeuvrability in families and systems. My GP self always looked for simple tools for 10-minute consultations. I have found so many ideas, tools and skills that work and produce lasting change. This is the passion that drives me – that remarkable change is possible even in the most complex of systems and the most dreadful of circumstances. in my new role as safeguarding adults lead GP I hope to enable organisations to become more curious and compassionate in the ways they care for vulnerable adults, including their staff.

patients’ vulnerability and limitations. Regulatory

Background

regimes are designed to

This article rose out of a conversation I had at a symposium for medical school teachers (held at the University of Westminster’s Centre for Resilience – Peters 2016) with a senior clinical manager of a London teaching hospital. She listened to the narrative of two ‘case’ examples where change had happened in simple ways and then began to expand the thoughts and ideas, evoked into thinking about her own hospital. The article is underpinned by the work of Michael West (2012) and his research into effective teamwork and the work of Frederic Laloux (2014) and his examples of self-motivating organisations. The advent of the critical culture full of regulators, rules and imposed organisational recipes for change, has left many workforces in the caring professions demoralised, demotivated and distressed. Negative beliefs about the length of time it takes to ‘turn around the ocean liner’ and the impossibility of implementing real change and compassion in complex

minimise avoidable failure but when clumsily applied they can make this already difficult work feel even more unsafe. The 2014 Care Act applies principles of empowerment, protection, prevention, proportionality, partnership, and accountability/ transparency to vulnerable adults. If we saw the NHS as a vulnerable organisation would these six principles apply?

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systems, do not help. Suppose that these limiting thoughts are removed and a thought emerges that change is simple. What will happen next? Where do you start to think about this? One sense is to start with the principles of the Care Act 2014, which deals with vulnerable adults. Maybe the NHS and care homes could be seen as ‘vulnerable adult organisations’. This means that applying the thinking of the six principles of the Care Act would involve thinking about empowerment, protection, prevention, proportionality, partnership, and accountability/ transparency. Here are three case histories.

A large healthcare organisation The staff survey at a hospital showed that there was a culture of bullying. A senior doctor had experienced bullying at the hand of two senior nurses. An admin worker refused to participate in the survey because she had experienced bullying and she thought the forms weren’t confidential. Other

RESILIENT ORGANISATIONS How to enable organisational resilience: Ideas from a conversation at the Centre for Resilience

organisations experienced the team as bullying in meetings. The overall ethos was ‘that will never change’. The Chair had emailed everyone to ask them to report their concerns to him. Only one person had come forward. A conversation with him produced some ideas. The bullying had structural elements in that line management responsibilities hadn’t been taken seriously. The appraisal form didn’t give an opportunity for staff to talk in a proactive way with their appraiser. Is the appraiser the same as the line manager? Do staff want supervision/ mentoring/coaching. Could a safer structure be created? How about changing the bullying and harassment policy into a dignity at work policy? This would provide more clarity about how people raise small concerns and get a proportional response. This would then empower the staff. Then there was the subtly undermining language used in bullying. What would be the effect of learning about non-violent communication? Marshall Rosenberg uses the principles of talking giraffe or talking hyena (Rosenberg 1998). He gives some graphic descriptions on YouTube of giraffe and hyena talk using glove puppets to show the different styles. This could be incorporated into a development day. Maybe there could be an experiment of an excessive politeness day which staff could then reflect on. Maybe there could be a deliberate rudeness day. Maybe there could be a ‘four compliments before criticism’ day. The idea that we all have choice can then be embedded (Kline 1999). This idea could be discussed at the staff development day.

A care home The staff had been demoralised by the death of a patient who had had three ambulance journeys to and from the hospital on the day she died. Her death was in hospital which was not what she had wanted. This had been taken seriously enough to have a practice review. The practice review became therapeutic when the home manager had a conversation with the safeguarding panel members. She needed to be empowered to regain her nursing professionalism. She didn’t have to report all concerns to CQC or safeguarding, only the ones that were serious. At review three months later, she was busy creating a safe working environment where staff raised concerns at once and were able to sort them out quickly to prevent escalation. She admitted honestly and transparently that at times the work was hard and she would have a meltdown. She then shut her usually open door until she had regained her composure. This modelled for staff the reality of the toughness of the job and also that staff can manage their own distress. Her availability created a psychologically safe environment in which staff could then begin to learn, be curious about their patients’ lives and illnesses and raise concerns (Garvin et al 2008). Going through the case report, it became abundantly clear that many people were accountable in the chain of the dying woman’s ambulance journeys. It wasn’t just the

care home’s fault though the care worker had felt unsupported. This non-blaming, seeking-to-understand approach relieved a lot of stress. The idea of the unsupported care worker then developed into discussions about who was out there to work in partnership with them on end-of-life care. The deciding right team and the local palliative care team were to develop sound relationships with the home to ease the burdens of care at the end of life. The process of relationship-building to support the care home will develop and improve over time. The simple question which opened up the conversation was ‘how can we help?’

A senior manager at a large hospital This manager had sought advice about where to begin with her tired, distressed and sad organisation. Having listened to the previous two cases, these are the points she took away to think about: • dignity at work policy • empowerment and support of key people • managers being visible and accessible • occupational health and HR fully playing their role in staff wellbeing • developing wellbeing champions in most teams • ‘nicking good practice’ from elsewhere, a culture of curiosity • options for staff like mindfulness training in a rebranded form that sounds less ‘fuzzy’ • valuing staff and the resources they have that aren’t tapped into, with simple questions ‘what are or have been your passions? how would you like to use them at work? a different form of curiosity. • creating a sense of belonging • creating buddying or co-mentoring partnerships to support each other • enabling staff to control more of what they do. It is interesting to reflect that one of the principles of solution-focused therapy describes how different solutions are from problems, and also how problems don’t even have to be clearly described to find the next steps forward. The ideas defined above all seem to point to relationshipbuilding as the way forward, supported by good language and positive thinking. Garvin D, Edmondson A, Gino F (2008) Is yours a learning organisation? Harvard Business Review (March). Kline N (1999) Time to think: listening to ignite the human mind. London: Cassell. Laloux. F (2014) Reinventing organisations: a guide to creating organisations inspired by the next stage of human consciousness. Millis, MA: Nelson Parker. Peters D (2016) Report on Tomorrow’s Doctors: a symposium of medical teachers. JHH 13 (2) pp 36–37. Rosenberg MB (1998) Non-Violent communication: a language of life. Encinitas, CA: Puddledancer Press. West MA (2012) Effective teamwork: practical lessons from organisational research. Hoboken, NJ: Wiley.

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EXPER IMENT S IN HOPE

Islands of hope Configuring for abundance: Bromleyby-Bow, NUKA and Fife SHINE William House Chair, BHMA

Providing a compassionate and caring service to the sick is hard. When faced with the difficulties and frustrations of working of the English National Health Service this hard job can become impossible. It is easy to become demoralised and negative, even burned out. So we all need hope. This article is about new and novel ways of caring for the sick while helping to keep people well in a holistic way. My own work as a GP for 30 years in the south west of England inspired me to look for better ways and to try them out. I and others are developing an experimental scheme amongst the people who were my patients and colleagues. Along the way I have been inspired by all three of the schemes described in this article. I hope you will be too.

This article showcases three innovative healthcare systems, each built on human relationships mediated by conversations between local residents and by integration with their particular communities. They each express this similarity in dissimilar ways because of the radical differences in their cultural and geographical contexts. They are underpinned by

In his farewell address in 1961 President Dwight D. Eisenhower offered the nation a warning about what he called ‘the military-industrial complex’ (MIC). This is an ‘informal alliance between a nation's military and the defense industry which supplies it, seen together as a vested interest which influences public policy’. It was not long (1969) before this form of alliance was recognised in healthcare: the ‘medical industrial complex’ (MIC). Similar warnings accompanied both movements: that military and healthcare policies would meet the needs of the respective supply industries at the expense of their prime purposes: to keep the nation safe and healthy respectively.

A crisis of scarcity

the values of the ordinary

Medical science has made such tremendous progress that there is hardly a health human left.

people, in contrast to the domination by big business

Aldous Huxley

and politics that characterises much mainstream healthcare in developed countries.

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The source of the energy driving both MICs is, of course, money. In a system driven by money it pays for a lot of people to desire something which seems to be scarce. We then barely notice things that are plentiful. The

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frustration, stress and fear of disappointment in your desire is bad for your health. If the desired object is healthcare, you then have (at least from the monetary viewpoint) a virtuous circle for the supplier and a vicious circle for the people. Everyone in the system becomes stressed. Some also make a lot of money. The recent junior doctors’ industrial action in the UK was an unprecedented expression of the stress and frustration of working in this system: insufficient nurses, and doctors avoiding specialities with frontline pressure, especially general practice and A&E. In response to this scarcity, we all demand more, and so it goes on. It is soul-destroying. Though we humans may get carried away by the wonder of our inventions, we can also step back and constructively re-examine our purposes. Of course, the British Holistic Medical Association (BHMA) emerged in 1983 with exactly this sort of informal reflective inquiry. More recently, there are others. In the early noughties, the preventing overdiagnosis (POD) movement began its questioning of the medicalisation of human suffering. About the same time (2001) the Scotland-based International Futures Forum (IFF)

EXPERIMENTS IN HOPE Islands of hope: Configuring for abundance: Bromley-by-Bow, NUKA and Fife SHINE

began its journey towards addressing ‘complex, messy, seemingly intractable issues’. Emerging from the restive atmosphere, coupled with reflective movements, experiments have appeared. Here I take three particularly interesting ones and tease out some common features. Their interest lies in their integration with the communities they serve.

Three islands of change You never change things by fighting the existing reality. To change something build a new model that makes the existing model obsolete. Buckmaster Fuller

Bromley by Bow Centre, East London, UK This now famous community centre began in 1984 with the arrival Andrew Mawson as minister of a small Church. It had only a handful of members and was heading for closure. Bromley by Bow was a deprived area even by East London standards. It is one of the world’s most racially diverse places with a majority professing the Muslim faith. Andrew and his wife, Susan, made a bold decision to gather a group of local older people and open the church for local projects. ‘The key driver was the assumption that people were the future and that you couldn’t sit around and wait for the State to provide the much-needed services in a poor community. This dynamic approach led to a number of new initiatives which were very much about backing people, their ideas and their passion.’ Their mission became one ‘to help create a cohesive, healthy, successful and vibrant community, and to remove the label ‘deprived’ from Bromley by Bow.’ Early in the development the growing team decided to build a new GP surgery adjoining the church. Having built it, they then advertised for general practitioners to join the team and grow a practice in line with the ethos of the Centre. This proactive and entrepreneurial community spirit has fueled remarkable growth. The centre today is about enabling the people to reach their full potential. ‘The end result is achieving changes in their lives and circumstances that they never dreamed were possible when they first arrived.’ The centre’s ‘active values’ are: ‘Be compassionate, be a friend, have fun, assume it’s possible.’ Their ‘ten top tips’ (really a set of priorities) starts with: ‘The quality of the human relationships’ All of these are made possible by conversations. Without conversations, none of them can happen. These are encouraged in many ways at the centre, for instance, having no signage so that you have to ask someone – have a conversation. Though much depends on the quality of the conversations, even asking the way can be the beginning. 24

The team now describes the centre as a ‘community department store’ making use of the footfall, not to make money, but to build the vibrancy that we know creates health. So it is the active values and not the money that drives the organisation. It is now an independent charity with around 150 staff on 25 sites and many spin-off businesses. Whether growing to such scale is a good thing is a separate question.

NUKA – Southcentral Foundation, Alaska, USA This story started in 1979 with the appointment of Dr Kevin Gottlieb as the first dentist in a new dental clinic opened by the Cook Inlet Native Association. Having worked in the local hospital (operated from the US federal government 5,000 miles away) and witnessed the very poor care delivered to native peoples, he understood the value of local native management. When the recently formed nonprofit organisation (social enterprise) Southcentral took over the clinic and a few other primary healthcare services in 1985, the fundamental values of NUKA were clear in Gottlieb’s mind: a welcoming environment, personal relationships, ease of access and continuity of care. ‘NUKA’ is an Alaskan Native name given to ‘strong, giant structures and living things’. So the healthcare system becomes a ‘living thing’. Initially, Southcentral ran only services tailored specifically to the priority needs in the community, in particular mental health and substance abuse, offering treatment and prevention using behavioural programmes long before they began elsewhere. Finally, in 1992 the US federal government agreed to devolve to Southcentral the budget for all primary, community and mental health services, with freedom to innovate as necessary. They grabbed this chance with both hands and redesigned the entire system in line with the NUKA concept and traditional values (Hannah 2013). The first two years were spent listening to the community, basing the system design on what they heard. Over 20 years it has transformed local healthcare from a very poor, costly and unpopular service to one where families and communities have taken ownership of their own wellness and recovery, with reduced costs and some of the best health results in the world. (Betz 2015) They have planned and developed the transformation in thoughtful and ingenious ways which honour the indigenous values. For instance, they empower the users of the system in many ways, such as calling patients ‘customer-owners’; designing workspaces that are nonhierarchical; calling clinical rooms ‘talking rooms’ (reflecting the importance of conversations); and providing uniform size and design of chairs. Regarding their vision, mission, goals and concepts, these are woven through all systems and processes. For instance, by presenting them as acrostics, such as the ‘operating principles’ spelling out: R–E–L–A–T–I–O–N–S–H–I–P–S

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EXPERIMENTS IN HOPE Islands of hope: Configuring for abundance: Bromley-by-Bow, NUKA and Fife SHINE

The first two letters represent ‘Relationships between the customer-owner, the family, and provider must be fostered and supported’; and ‘Emphasis on wellness of the whole person, family and community including physical, mental, emotional, spiritual wellness’. In line with this, all their resources are focused on the generalist model, bringing in specialists only when essential. In 2003 they introduced a ‘Data-Mall’ – a sophisticated data-gathering and display system. This has nothing to do with targets or financial incentives (there are none of these), but is rather a form of action learning – from each other. Regarding continuity of primary care, each GP works within a small team providing the key skills needed for the population and every registered customer-owner is encouraged to stay with one team. The Foundation now provides services for about 55,000 Alaskan Native and American Indian people in the Anchorage area of Alaska, and about 10,000 people in 55 remote villages accessible only by plane

Fife SHINE Project – Scotland This project is much younger than the other two and emerged in part from the NUKA transformation. Fife SHINE started with a conversation in 2009 about winter planning for NHS Fife. The particular concern was delayed discharge of older people because of inadequate support at home – a common problem throughout the UK. Through further conversations with the International Futures Forum (IFF) it was clear that the solution required a radical shift in culture (Leicester 2016, pp 22, 39). Parallels were seen between this problem and aspects of the NUKA project and exchange visits were organised with members of NUKA. This led to a specific focus on conversations and how these could enable people to thrive at home despite difficult circumstances. Similarities then emerged with Asset Based Community Development and with social prescribing with the possibility of a shift in community culture towards more self-reliance and caring for others. The Fife SHINE project got underway in 2011 with a grant from The Health Foundation. It involved training for NHS and social care staff in having ‘good’ (enabling and empowering) conversations with older people so they can identify what changes would help them to thrive. This is not a healthcare conversation about ‘what is the matter with you?’, but rather a conversation about ‘what matters to you?’ This is combined with largely voluntary community support in helping vulnerable people to make the changes the vulnerable person identifies. Ultimately, they may be able to support others to thrive in their turn. By early 2016 at least 15,000 people had experienced a ‘good’ conversation, with numbers increasing steeply. In her inspiring book, Humanising Healthcare – Patterns of Hope for a System under Strain (Hannah 2014), Margaret Hannah – one of the small group behind Fife SHINE – writes about her frustrations and the vision and values that drive that project. You can also watch her speak at the book launch (https://vimeo.com/119180069).

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It is too early to judge the transformative potential of this project, but it is included to show firstly, how one set of conversations leads to another which may lead to radical change. Both Bromley by Bow and NUKA will have passed through this phase of uncertainty. The other message from this is that projects in very different places with very different populations and challenges can be inspirations for one another. Using ideas is not a matter of copying, it’s rather translating into the ‘language’ of a different place. There is no best practice, any more than there is a best marriage!

Conclusions Never doubt that a small group of concerned citizens can change the world. Indeed, it is the only thing that ever has. Margaret Mead

It is clear to me that the energy driving the work and direction in all three of these examples comes from the people using and providing the services. Money takes a secondary role. I included the story of the genesis of each project to emphasise this and as a reminder of the ordinariness of the circumstances at the beginning. In many ways, the individuals driving the change were ordinary too. They saw that their situation was not good and had the courage to do something about it. But as we can see clearly in the Fife SHINE it takes conversations to change things. It cannot be done by one person acting alone. The intriguing thing about this example is that the conversation is both the proposed solution and the means of achieving it. The nature of the conversation matters. It needs to be a ‘dialogue’. This entails listening in an open way – suspending judgment. IFF call a group of people having this sort of conversation a ‘creative integrity’ (Leicester 2016, chapter 4). There is a certain ordinariness in the values that underpin and drive each example. If there is anything extraordinary, it was their insistence on keeping those values at the forefront of what they are doing, but the people with the values are ordinary people. This is surely an empowering thought about abundance. In the UK we live in a world of celebrity. This is disempowering! We invest in others our own hopes and fears and thereby lose control of them and feel vulnerable. In fact, making changes involves moving from control to participation. We can all do this. We can feel vulnerable together and that is the source of strength. The energy and capacity for changing the world exists in every one of us. It is called love. Betz A (2015) The future of our NHS and the power of community JHH 12(2) pp21). Hannah M (2014) Humanising healthcare – patterns of hope for a system under strain. Axminster: Triarchy Press. Hannah M (2013) Compassion in public health. JHH 10 (3) pp23. Leicester G (2016) Transformative innovation. Axminster: Triarchy Press, pp 22,39).

ST U DENT ESSAY

Diagnosis: Are we medicalising human experience? A radical review Alice Redfern Final year medical student

This year’s BHMA student essay competition had for its title: Diagnosis: Are we medicalising human experience? A radical review. This was a challenging title at undergraduate level, but the entrants streamed in from across the UK and the standard was remarkably high. Judges were looking for a well-researched essay that set a balance of scholarship and humanity, and covered all the key issues relevant to the title. Alice Redfern, whose essay is printed here, was highly commended.

I have a long-standing interest in all the social aspects of healthcare, from inequalities in access to care to the social aspects of the patient–doctor interaction. I’m also a fan of taking time out of my medical degree to study around the subject and see healthcare and research in different parts of the world. The rest of the time you’ll find me pretending I know how to play squash or binge-watching Grey’s Anatomy.

Medicalisation is the process by which human conditions and problems come to be defined and treated as medical conditions. The act of diagnosis can be described in almost identical terms – a process by which a person comes to understand, with the help of a doctor, a set of human experiences as symptoms and defines them under the label of a known illness. Across medical practice, research and policy, increasing focus has been placed on the study of medicalisation and more specifically over-medicalisation and attempts have been made to shift practitioners away from over-diagnosis and over-treatment (in particular overmedication). However, arguably the call for these changes has yet to take hold in practice. Mental health conditions, and in particular depression, have long been at the forefront of the debate surrounding medicalisation. With the new DSM-V criteria, announced in 2013, came controversy in the form of a redefinition of major depressive disorder to no longer exclude those who had recently experienced bereavement from the diagnostic criteria. In spite of the justification that we might otherwise be missing

diagnoses and therefore depriving patients of the appropriate treatment (American Psychiatric Association 2013), this has triggered concerns that we are treating what would previously have been considered as a normal human experience of sadness (Dowrick, Frances 2013). An increasing body of evidence suggests that mild depression is over-diagnosed and over-treated. A meta-analysis of patients in primary care showed that depression was more often wrongly diagnosed than missed or correctly diagnosed (Mitchell et al 2009). Another showed that only 38% of adults with identified depression met the diagnostic criteria over the previous year using validated structured measures (Mojtabai 2013). Prevalence of depression appears to be stable and yet prescriptions of antidepressants increased 10% each year between 1998 and 2010 in England (Ilyas, Moncrieff 2012). While in part these numbers can be explained by changes in prescription patterns, there does appear to be a trend to diagnose depression where patients do not meet the full criteria. Furthermore, while the NICE guidelines suggest that drugs should

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STUDENT ESSAY Diagnosis: Are we medicalising human experience? A radical review

not be the first line of treatment and should not be a treatment at all in mild depression unless resistant (NICE 2016), prescribing in these cases still frequently occurs.

Medicalising the human experience: What’s the harm? I recently witnessed a consultation in general practice that for me perfectly exemplified the current tendency towards over-diagnosis. A 75-year-old presented with dizziness, but on questioning had no specific symptoms leading to a clear differential. When asked about her social life she became emotional over the recent loss of a very close friend. She left the consultation with a diagnosis of depression and a prescription for antidepressants. Overall the consultation felt successful and by the end, the patient left gratified and, I believe, felt cared for. However, the shift from the patient’s expectations from an inner ear problem to depression was dramatic and the prescription of drug treatment felt premature. I was left reflecting on the progression of the following days for this patient. Whatever the condition, the implications of a diagnosis on a person’s life can be far-reaching. In the immediate aftermath of a diagnosis patients grapple with coming to a personal understanding of their illness through internet searches, reading information packs and talking to friends and family. The process of disclosure may raise innumerable questions; who should I tell? What should I say? How will they react? Will it change our relationship? Will it affect my work? Many illnesses expose the patient to stigma, which has been shown to impact on their self-esteem and their resilience (Corrigan et al 2006). Soon after diagnosis comes any behavioural change associated with the condition, often large lifestyle changes are recommended possibly going against habits of a lifetime. They may have to adjust to the burden of taking daily medication, learning how to deal with any side-effects and developing strategies to remember to take their pills. With the diagnosis of a long-term illness, expectations for the future may need to be considerably readjusted. All, some or none of these experiences, along with countless others not mentioned here, can occur and the response is unique to the individual. When a diagnosis is given for what could otherwise be defined as a normal human experience we expose the patient to all these downstream effects. The aim of a diagnosis is to enable access to the appropriate course of treatment, but even with this good intention patients are often exposed to more harm than good. Beyond the immediate psychological and social impact of the diagnosis, where a person is overtreated they are exposed to side-effects that may again expose them to undue risk. Antidepressants, for example, among a whole range of side-effects have been shown to be a major contributor towards falls in the elderly (Coupland et al 2011). Beyond the personal impact of a diagnosis and treatment come the wider implications to health systems. Concerns have

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been raised about the impact of medicalisation on allocation of resources; with more resources being used for milder disease, those with severe conditions may be deprived. The side-effects of treatments also come with their own costs, since falls in the elderly form a major component of the NHS budget (Scuffham et al 2003).

Towards an explanation for medicalisation? While many articles have been published pointing out the prevalence of medicalisation there seems to be considerably less research into understanding exactly why and how it happens in practice. A doctor’s consultation is an extremely complex and intricate social interaction that can be led in a thousand different directions at any point. Many contributing factors come together to cause a tendency to diagnose where it perhaps may not be necessary. The role of fear: One explanation for the phenomenon of over-diagnosis was eloquently worded by Davies in his discussion of the topic: ‘the fear of both the patient and the doctor can sometimes override the best knowledge, research and information known to man’ (Davies 2013). For both doctor and patient the fear of a missed diagnosis may be greater than that of an unnecessary diagnosis (Heath 2014). The role of habit: Through years of medical school the focus of lectures is on diagnosis and management: identifying the problem and fixing it. A disproportionately small amount of time is spent on how to approach patients with sub-clinical problems, undiagnosed impairments and those with difficult to manage conditions. As such, when faced with a patient, out of learned habit, all our efforts may subconsciously be made to fit the patient into the first category. The role of empathy: Empathy forms the cornerstone of a successful medical consultation (Bellet et al 1991), but with empathy for someone’s pain comes a desire to solve it with whatever tools you have at hand. Along with habit this may lead to a desire to diagnose and treat wherever possible. The role of time pressures: Trying to address all of a person’s expressed problems, expand that to a full history, order any investigations, make and explain any diagnosis and similarly make and explain any management plan over the course of 10 minutes is no small feat. It takes a long time to learn enough about a person’s experiences to define the subtle line between sadness and depression. With all those time pressures in mind, it is far easier to end the consultation with a diagnosis and a prescription than a broad conversation covering lifestyle changes and possible self-help techniques. The role of patient understanding: The vast majority of doctors are under no illusions about the efficacy of antidepressants and are well aware of the lack of evidence for their use in mild depression. However a patient from a non-scientific background has no reason to doubt that the

STUDENT ESSAY Diagnosis: Are we medicalising human experience? A radical review

drugs on offer work. Without explaining this in detail, which there is rarely time to do, even when offered a decision about drug treatment it cannot be truly informed. All of the above factors and more come together to a varying degree in general practice to create the perfect setting for diagnosis of a normal human experience as depression.

Conclusion The moment at which a person receives a diagnosis part of their human experience becomes medicalised. In the majority of cases this achieves its aim; placing people on the correct treatment course to improve their overall experience. However there is a current tendency in medical practice to diagnose conditions more frequently than may be necessary, thereby over-medicalising individuals. This exposes them to many potential risks as a consequence of the diagnosis and the overtreatment that may follow. By reflecting on the many psychological and social factors that contribute to this over diagnosis, individual doctors can adapt their practice to try to minimise these harms. American Psychiatric Association (2013) Online. Available at: www.dsm5.org/Documents/Bereavement%20Exclusion%20Fact%20 Sheet.pdf (accessed 15 March 2016)

Bellet PS, Maloney MJ (1991) The importance of empathy as an interviewing skill in medicine. JAMA 266(13) pp 1831–1832. Corrigan PW, Watson AC, Barr L (2006) The self-stigma of mental illness: Implications for self-esteem and self-efficacy. Journal of social and clinical psychology 25(8) pp 875–884. Coupland C, Dhiman P, Morriss R, Arthur A, Barton G, Hippisley-Cox J (2011) Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 343 d4551. Davies E (2013) Overdiagnosis – what are we so afraid of? BMJ Online. Available at: http://blogs.bmj.com/bmj/2013/09/12/edward-davies-overdiagnosis-what-are-we-so-afraid-of/ (accessed 15 March 2016). Dowrick C, Frances A (2013). Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit. BMJ 347(7) f7140. Heath I (2014) Role of fear in overdiagnosis and overtreatment – an essay by Iona Heath. BMJ g6123. Ilyas S, Moncrieff J (2012) Trends in prescriptions and costs of drugs for mental disorders in England, 1998–2010. Br J Psychiatry 200 pp 393–8. Mitchell AJ, Vaze A, Rao S (2009) Clinical diagnosis of depression in primary care: a meta-analysis. The Lancet 374, pp 609–19. Mojtabai R (2013) Clinician-identified depression in community settings: concordance with structured-interview diagnoses. Psychother Psychosom 82, pp 161–9. NICE (2016) Online. Available at: www.nice.org.uk/guidance/cg90 (accessed 15 March 2016). Scuffham P, Chaplin S, Legood R (2003) Incidence and costs of unintentional falls in older people in the United Kingdom. Journal of epidemiology and community health 57(9) pp 740–744.

Open Clinical Day from the Portland Centre for Integrative Medicine, Bristol

BUILDING RESILIENCE FOR THE HEALTHY HEART Saturday January 28th 2017 Venue: Penny Brohn UK, Pill, Bristol

This education day is part of the first of a series of three-day face-to-face intensives as part of the new diploma delivered by the Portland Centre for Integrative Medicine. These open clinical days are designed for health care professionals and CAM therapists with an interest in integrative medicine.

For more information about this clinical day or the Diploma in Integrative Medicine contact education@portlandcentrehealthcare.co.uk and check out our website www.portlandcentrehealthcare.co.uk

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LIFE AFTER T HE Q O F

Healthcare system transformation coupled with optimising individual and population health and wellbeing An opinion from a busy GP Campbell Murdoch GP

Doctors can make humans

My role as a GP has, over the last three years, been one of enthusiasm and energy – truly! Having studied medicine in the late 1990s the ‘evidence-based medicine triad’ and the ‘bio-psycho-social model of health’ became firmly tattooed onto my conscious mind. Later I undertook postgraduate studies in teaching, organisational behaviour, leadership and also sports and exercise medicine. This has provided me with a perspective and toolkit to use with my fascination of understanding what it is to be human, and how in our complex and resource-limited world human health and wellbeing can be optimised in the most effective way.

fit the linear medical model only if medicine narrows its primarily biological. But this biological focus is likely to divert our attention from other significant aspects of health and wellbeing. Intangible factors and health-risks which lack biomarkers may become invisible, especially in a pressured healthcare environment. The Human Five is a model designed to refocus primary care on things that really make a difference.

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Humans are diverse, multifaceted beings living in an ever-changing world. A dynamic adaptive approach to healthcare is what we need in order to interact effectively with such complex dynamic interdependent systems. The linear medical model, which can be very effective in some acute medical scenarios, is often inadequate or ineffective for the many individuals who present with more complex and chronic health and wellbeing needs. The GP remit has shifted over the last few decades from mainly providing solutions or interventions to acute conditions, towards also managing chronic diseases and disease prevention. This transformation is driving a fundamental shift of focus towards whole person and whole population healthcare. If it can be shown that this new approach is more effective and efficient than the narrower focus on biomarkers alone, then optimisation of individual and population health and wellbeing could be achievable even within current resource constraints.

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However, up until now we have transitioned the old linear fix-it medical model into arenas for which it was not designed. There are many reasons for this: an innate desire for simple solutions, reductionist thinking, market-driven healthcare, and the usual human tendency to stick with the things we are used to. Even though we have become very good at targeting some culprit disease biomarkers, our interventions will be ineffective at best and could at worst be harmful if the targets are the wrong ones.

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The GP remit has shifted over the last few decades towards also managing chronic diseases and disease prevention

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focus to see humans as

LIFE AFTER THE QOF Healthcare system transformation coupled with optimising individual and population health and wellbeing

I believe that we are about to experience a re-humanising of the healthcare system. There are strong drivers for this shift, not least the need for a more financially sustainable system. But behind it too are personal human drivers: the declining morale of many who work in healthcare services and their general desire to do good for their fellow humans. Could it be that a simple, flexible shared paradigm of health and wellbeing, acceptable to most users, could bring about solutions in all three areas? Might it be possible in one fell swoop not only to make far better use of our limited resources, but at the same time support more humane practice and meet today’s complex needs?

Some primary care history: the QOF The UK Quality and Outcomes Framework (QOF) was first rolled out in 2004. With the desire to drive up universal standards of care – and enabled by the mass adoption of electronic medical records – GPs were rewarded for hitting certain quality targets. The QOF definition of prevention was for the most part confined to testing for certain biomarkers – for instance blood pressure, cholesterol, blood glucose – and prescribing appropriate drugs to control them. Unfortunately, in practical terms, there are still relatively few biological factors we can meaningfully measure and record. And so, in the drive to practice ‘preventative medicine’, and even though impelled by the new GP contract, ‘the best available evidence’ for producing useful quality markers for prevention fell short of what was really needed to make the QOF fit for purpose . Yet over the next decade, the focus on QOF-driven primary care shifted general practitioners’ focus away from doing what they might formerly have felt was best for the individual in front of them, because they had been incentivised to prioritise doing things intended to be good for whole populations. Although, QOF helped standardise medical practice and may even have driven up efficiency, I believe it unwittingly reduced the effectiveness of care provision. A prime example of how immense resources can be efficiently applied but be relatively ineffective in achieving true health benefits is the use of statins. With the laudable aim of preventing future cardiovascular disease, GPs were financial incentivised to focus on total blood cholesterol levels, and the imperative to reduce them with medication.

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In practical terms, there are still relatively few biological factors we can meaningfully measure and record

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This QOF target leveraged huge resources for a healthcare intervention of questionable benefit, since the evidence for statins at population level is neither clear nor universally agreed upon [see box 1]. In this particular case, targeting a single biomarker misapplied the linear medical model of acute medicine to a complex multidimensional condition, because the likelihood that a statin will benefit an individual – even someone who has cardiovascular disease – is in fact rather small, as can be inferred from the numbers needed to treat statistics in Box 1.

Box 1 Evidence of benefits of statins One review looked at trials involving people who took a statin for five years because they had known heart disease or a history of stroke. • • • • •

1 1 1 1 1

in in in in in

83 were helped (life saved) 39 were helped (preventing non-fatal heart attack) 125 were helped (preventing stroke) 100 were harmed (develop diabetes) 10 were harmed (muscle damage)

If one million people were to take them roughly 45,000 people would benefit, while another 6,000 might be harmed. www.thennt.com/nnt/statins-for-heart-disease-prevention-with-knownheart-disease/

Another looked at those who took a statin for five years who did not have heart disease or a history of stroke. • • • • •

None were helped (life saved) 1 in 104 were helped (preventing heart attack) 1 in 154 were helped (preventing stroke) 1 in 100 were harmed (develop diabetes) 1 in 10 were harmed (muscle damage)

www.thennt.com/nnt/statins-for-heart-disease-prevention-withoutprior-heart-disease/

The next step in the evolution of healthcare In Somerset in 2013, just under a decade after QOF’s advent, there was a growing awareness that the healthcare system was not meeting people’s needs. There were many reasons for this, among them an ageing population, and a net reduction in the healthcare workforce. It was becoming clear that if the healthcare system was going to evolve into something more effective and viable, primary care would need the freedom to divert resources into areas where it could have real impact. But only by unshackling it from the QOF would primary care be able to innovate and adapt. In fact if individuals’ health and wellbeing needs were ever going to be met the entire health and social care system would have to engage in new models and paradigms of working with Somerset’s population. Discussions between NHS England, the Somerset Clinical Commissioning Group and the primary care workforce produced an agreement for GP practices to opt out of the national QOF and into an alternative scheme named

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LIFE AFTER THE QOF Healthcare system transformation coupled with optimising individual and population health and wellbeing

Somerset Practice Quality Scheme (SPQS). What we were looking for was an environment that could enable organisational and system transformation. Through the design and various mechanisms of SPQS (which are not discussed in this article) primary care can start this journey. The destination will be a mature, collaborative primary care system, functioning as a high quality learning organisation able to better align its resources to Somerset’s needs. Evidence-based medicine was originally meant to take into account not only the best available research evidence but also the person’s wishes (and expertise) and the professional’s skills and knowledge. If SPQS helps us achieve this transition it will have been a revolutionary success. But already, on a personal level moving from QOF to SPQS has been truly transformational. Instead of existing in a constrained and inflexible system I found I could use my energy to make primary care more effective and efficient. Whereas the QOF had put my purpose and my passion for medicine at odds with my need for an income (by incentivising me, for example, to chase cholesterol reduction with drugs in an 85-year-old while pushing me to ignore her loneliness) I was now able to focus on what makes me want to get up in the morning, go to work with integrity and strive to optimise individual and population health and wellbeing.

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The Human Five is helping to provide a number of solutions in primary care

The Human Five – a universal health and wellbeing model SPQS allows me to focus a dynamic approach on complex dynamic situations. I no longer have to be blinkered and see people as simply diseases, I am free to see myself and each person I meet as a unique human being. This may sound rather subtle, but I can tell you that the difference it makes is extremely powerful! Given this new freedom to innovate and adapt, we developed an idea that is now helping shape the way we provide healthcare: a simple universal health and wellbeing paradigm called The Human Five. The Human Five is helping to provide a number of solutions in primary care. It is based on a paradigm that enables people – doctors, health coaches, social care workers and others in the community – to work together, by encompassing as it does the spectrum of individuals’ health and wellbeing needs. It also provides a framework for thinking about population health. The assessment/ consultation tool itself, which can easily be integrated into everyday primary care work, may be used explicitly when working with a patient or just kept in mind as a loose framework for shaping better consultation. (The

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assessment/consultation tool can be found on page 31 and I hope practitioners will find it useful.)

Case scenario: QOF consultation vs SPQS consultation I have written this vignette to reflect a real-life GP scenario. I hope it illustrates the profound effect of changing the primary care consultation paradigm and environment. It is intended to highlight the contrast between QOF-oriented practice and the kind of primary care consultation made possible by SPQS. It is 7.30 in the evening when Mrs Evelyn Jones arrives for her appointment. You don’t know her but can see from her notes that she is 78 years old and recently had her annual hypertension review with the nurse. Her blood pressure was 155/80. Her blood tests from the review have arrived back. You also see from the notes that she had a bereavement a month earlier.

Scenario 1: A QOF consultation After a quick scan of Mrs Jones’ medical record you call her in, welcome her and ask why she has come. She tells you: ‘The nurse told me my blood pressure was too high’. You reassure her that ‘Yes it’s higher than ideal, as it’s best kept below 150 for the top number’. Mrs Jones asks, ‘Is it at a dangerous level doctor?’ You explain, ‘There is no immediate danger, but high blood pressure can raise your risk of having a heart attack or stroke. So we aim for the top number to be less than 150 for most people’. You ask her, ‘How are you getting on with your current medication?’ She is on two medications to lower her blood pressure.’Fine I think.’ she replies. You are not dreadfully keen to add a third antihypertensive. You suggest to Mrs Jones that you recheck her blood pressure now. As it’s a cold evening Mrs Jones is wrapped up in a number of layers. She stands up to take off her long coat, and as she does so you notice she’s probably got some arthritic joints in her legs. After a few minutes of layer removal there is upper arm skin exposed ready for the blood pressure cuff. You take her blood pressure – the first reading is 158/86, and the second reading a minute later is 153/78. Mrs Jones asks, ‘What’s it like now?’ You advise her its a little better, but not quite at target. Mrs Jones looks at you impassively. You are nearing the end of the consultation time. You have a nagging awareness that the QOF end of year is not far off. If you don’t ensure Mrs Jones’ blood pressure is recorded at being below 150/80 by the end of March you could lose QOF points (and thereby personal income). So you decide you had better add a third blood pressure tablet now so there will be time for Mrs Jones to get back in a couple of weeks and have the nurse repeat her blood pressure: hopefully it will be under 150/80 by then. You prescribe Mrs Jones amlodipine 5mg. ‘This should help lower your blood pressure some more.’ Mrs Jones looks a little sad. ‘Does this tablet cause any side-effects?’.

LIFE AFTER THE QOF Healthcare system transformation coupled with optimising individual and population health and wellbeing

You tell her, ‘The commonest is swollen ankles’. Mrs Jones looks down at her ankles which you can see are already are a bit swollen. ‘They normally get puffy by the end of the day already.’ You ask, ‘Do they go down overnight?’ She replies, ‘Yes they’re fine first thing.’ You have another fatigue-fuzzed internal debate – QOF targets, income, lower blood pressure, swollen ankles, dependent oedema or heart failure? Maybe amlodipine is not such a good idea after all…. You are now overrunning by five minutes. So with this in mind and needing to get to a resolution you decide. ‘Well you might well be fine with 5mg of amlodipine, give it a go, we’ll review it and we can always stop it again.’ You start to prescribe the amlodipine and remember that her blood tests are back (renal function, HbA1c, and blood lipids including her total cholesterol level which is 5.2). You see that she currently takes simvastatin 10mg. You are now rushing, but QOF is on your mind, the total cholesterol target for QOF is <5. You know that using total cholesterol levels as a marker of risk of future illhealth is not reliable, but you also know you could probably get Mrs Jones’ total cholesterol level below 5 if you increased her statin to 20mg. You say: ‘Your cholesterol level is up as well. I’m going to increase your dose of simvastatin’, as you hurriedly print out a prescription for amlodipine and the higher dose of simvastatin without making eye contact with Mrs Jones. You hand the prescription over along with a slip to give to the receptionist. ‘Here you go, take this to the receptionist who will book you for another blood test and blood pressure check in a few weeks. Do let me know if you have any problems.’ Mrs Jones thanks you and gets up unsteadily from her chair. You help her on with her long coat and guide her out of your consulting room. You dash back to your desk to quickly type up the consultation notes in her medical record. In your fogged and fatigued mind you quietly question what benefit that consultation did for Mrs Jones’ health and wellbeing. No social issues were raised by Mrs Jones; in some ways you are relieved as the consultation took too long anyway. You briefly wonder what her recent bereavement was all about. But the thought is a fleeting one and as you call the next patient in 10 minutes late and thank them for waiting, it soon fades from your mind.

Scenario 2: SPQS consultation Quick scan of Mrs Jones’ medical record. You call in Mrs Jones and welcome her into your room. ‘I’m Campbell Murdoch, I don’t think we’ve met before but it’s good to meet you. What is it we are doing this evening?’ Mrs Jones says the nurse had suggested she comes in to discuss her blood pressure which was apparently a bit high at her annual review. You have a glance at her records and respond, ‘Okay, well it’s a little higher than your normal but blood pressure can go up and down very quickly, within seconds or minutes, it can also increase when life changes happen.

And the good news is your blood pressure is certainly not causing any immediate dangers.’ You recall the ‘bereavement’ code in the problem list in her medical record and ask, ‘How are you in yourself at the moment?’ Mrs Jones looks at you and says, ‘Life’s been difficult, my husband died a month ago, do you remember him, you came to see him a couple of years ago?’ You don’t recall meeting her husband but are saddened by the news and the likely impact on Mrs Jones. You say, ‘I’m very sorry to hear that. How are you?’ Mrs Jones replies, ‘I’m doing okay. My daughters have been good but they’ve had to go back now, they live away and have their own families and work to deal with.’ You acknowledge Mrs Jones’ comments and feel you should close the blood pressure issue so that it is not a nagging concern. You say to her, ‘That sounds pretty tough for you. It certainly would explain why your blood pressure was up a little, and that’s okay, blood pressure is supposed to do that. What are your next few weeks at home looking like?’ Mrs Jones looks sad but is maintaining eye contact with you and states, ‘Well, my daughters are coming down at the weekend again to see me. They’re worried I’m lonely, I would have been married to Bill for 60 years next week and we did everything together. They’re going to take me out for a meal.’ You are pleased to hear that Mrs Jones has daughters who care about her and are in touch, even if they don’t live locally. You perceive that Mrs Jones’ social situation will change significantly over the coming weeks, months and years. You say to Mrs Jones, ‘Well, enjoy you meal with your daughters this weekend. Do let me know if we can do anything here at the health centre to help. We have some extra staff here now who can give you some support if you would like it. Vicky, a health coach, would be very keen to meet with you if you would like. There are lots of support groups in the community too, which she could help you get involved with if you’d like. Just call the practice and ask for Vicky. Either way you are very welcome to come back and see me over the coming weeks if you want. And at some point in the next few months we can check your blood pressure again, but it doesn’t need to bother you at the moment.’ Mrs Jones replies, ‘Thanks doctor, I’ll do that’. You quickly glance at her medical record again and scan her blood test results. Your eye is drawn to her blood lipid results. You feel deeply relieved that you now do not have to wrestle with conflicted thoughts of whether you should increase Mrs Jones’ statin dose to lower her total cholesterol level. You help Mrs Jones on with her coat and guide her out of the consulting room with a smile. You dash back to your desk and quickly write the consultation notes in her medical record. Even though you’re tired from your busy day you have a sense that you may have just improved Mrs Jones’ wellbeing. You call in your next patient five minutes late and thank them for waiting.

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LIFE AFTER THE QOF Healthcare system transformation coupled with optimising individual and population health and wellbeing

The Human Five …your health and wellbeing… Please score yourself out of 5 in each of the areas below (see the second page of this sheet for more information)

/5 Mind

Nutrition

Movement

The Human Five

Work

Body

What is most important to you at the moment?

Are there any of the above scores you would like to improve? Have you any thoughts about how you could improve the score and what might help?

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Volume 13 Issue 3 Winter 2016

LIFE AFTER THE QOF Healthcare system transformation coupled with optimising individual and population health and wellbeing

The Human Five …a universal health and wellbeing model… Mind

Nutrition

Movement

The Human Five

Work

Body

Your Mind

Making the most of your mind every day, and trying to deal with the challengers your mind encounters. Also your knowledge about your health and your feelings, emotions, beliefs, values and your knowledge about your health.

Your Movement

Your body is designed to move to interact with your world (functional ability). There can also be great benefits from physical activity.

Your Nutrition

What you eat and drink can be of great benefit to you, but it can also cause of a lot of problems.

Your World

A huge and broad range of topics covering everything to do with you and your world including, for example, your relationships and your environment.

Your Body

This includes your body parts and how they work. Each of these five areas is linked to all of the other areas.

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Volume 13 Issue 3 Winter 2016

R ELATIO NAL C AR E

Triumph of the relational Michael Taylor GP

A residential home that is truly part of the community must be the ideal way to create a centre where the elderly can be truly cared for and look after. A genuine community home for elders should not be apart from the community it serves. This article describes what the author learned when he visited a small care home in Scotland; about how, with the right leadership and proper planning, personal interconnectedness, enthusiasm, impetus, and stamina it is possible to make a place where a community’s frail elderly can live a happy and contented life.

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I have several pious friends who are ostentatiously humble. This behaviour I find irritating. Why am I telling you this? It’s because I am fearful that this short essay may be a sign that I am morphing into that self-same personality type. For years I have banged the drum ‘the people with the diseases rather than the diseases people have’. I am certain that I have bored stiff anyone remotely connected with the care industry foolish enough to walk slowly by. No one has yet run screaming from my lingering handshake, but I worried that it was on a matter of time. Such worries are now firmly in the past as a result of my Damascene revelation, described below.

For 21 years, my wife ran a home for the elderly; sometimes it was a care home, sometimes a nursing home, the title depending more upon the fashionable whims of the regulatory authorities than on the needs of the residents. I visited regularly, routinely on Wednesdays from midday ‘til whenever, and at other times when necessary. Together, with other members of our team I took pride that our ‘home’ was the best around. The home seldom had a spare bed available: the beds of course determining the number of residents. All except the very occasional resident was paid for by the local authority, so with the downward pressure on support prices and the upward pressure on service provision it was only a matter of time before we were unable to continue. I have many memories of that those 21 years but there are two that took me completely by surprise, so they are, I think, worth retelling.

usual. What astonished me, and what I didn’t fully understand for years afterwards, was how pernickety each resident’s idea was about exactly how they wanted their cup of tea. Though there were but three variables – tea, milk, sugar – no two were the same, so my head was reeling with the variety of instructions and permutations. My second story is about the time I had to call in the residents’ families to explain that due to finance, or rather the lack of it, we were having to close. I had expected a very difficult evening, but frankly I was shocked by their understanding; their sympathy for our predicament and their good wishes for our future. I’m sure readers of this journal will be able to tell me that the tea party was more an expression of individuality than just a way of having liquid refreshment. And that the families’ trust and sympathy was rooted in the long-running relationships we had with them.

Tea and sympathy

How my eyes were opened

Once, and once only, I gave tea to all the residents, most of whom I had known as my patients long before. We were in one of the two large lounges and there would have been 11 or so, mainly women there, all too frail to look after themselves. The matter was simple, it was to be a cup of tea and a couple of biscuits at 11am as was

Volume 13 Issue 3 Winter 2016

The point I’m making is that respect for individuality and relationship are profoundly important in the context of elders’ care. And I thought we had done pretty well in this regard and that with respect to homes for the elderly, I had been there, done that, got the T-shirt and there was nothing

RELATIONAL CARES Triumph of the relational

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Respect for individuality and relationship are profoundly important in the context of elders’ care

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I soon realised that despite seeing myself as a champion of holism, my understanding of care of the elderly and infirm lacked a real appreciation of relational continuity. However, their words and my desktop research into related matters led me on a fascinating journey. So rather than simply acquiesce that I was wrong, I determined to stick with the challenge and see where it would lead me. Around this time I was absorbing what people at the forefront of nursing like Tom Kitwood (1993) Dawn Brooker (2007) and Mike Nolan (Lundh and Nolan 1996) had to say about ageing and dementia care. I wrote: ‘Their descriptions of personal care and relational care made me realise that the homes of which I was aware were not delivering the care which was described. The bedrock to their framework is relationships: between staff and residents, home and care home, family and the outside world. Some village communities in the UK, especially those in undisturbed populations for example

Main Street, Killin. The community home for the elderly is the large building on the right of the foreground. It is in prime position on the main street; the annex on the front allows the residents to have the best of views of Main Street activity.

in the Highlands of Scotland, run their own homes for the elderly, with paid staff from the local population.’

Discovering relational care As I wrote these words it was the village of Killin, a community I had known for many years, which I had in mind. I knew of the stable population and of the delight people took in each other’s company; of the bonds of friendship and music, duty, participation, which bound the community together. I knew of the home where a relative, Jane, was a trustee. I arranged to visit the morning of Saturday 10 September. We – me with Jane and Jimmy, the chair of the trustees – entered together. I knew my first task was an olfactory one; I was pleased that there was none of the odour so common in homes for the elderly. Jimmy led us to the lounge where there were five comfortable chairs, a moderately large flatscreen TV, an electronic organ plus an electronic piano. The room, like the building, was substantial middle class and Victorian, warm and with photos and a carpet of the sort that the elderly often have in their own homes, with clean paint on woodwork and walls. It was in short, a home where most middle-aged people would feel physically and visually perfectly comfortable.

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My understanding of care of the elderly and infirm lacked a real appreciation of relational continuity

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anyone could tell me I didn’t already know. Or so I thought, until two new friends confronted my self-righteous certainty about providing personal care with the challenge that I should write a short essay about a single patient I remembered well. As a reward, one of them would buy me dinner.

From my recent research and my own past experience, I had come to understand many of the difficulties homes face. I had my questions in my head but first over tea and sponge cake I let my hosts guide me in what they wanted to tell before asking my own questions of Jane and Jimmy. The home, they told me, was 12 years old. The then chair of the community council for Killin and surrounding farms was the late John MacPherson. I had passed his photo portrait in the hallway. He was ‘from the North’ and ‘had been a policeman in Edinburgh’ before settling into a transport business in the village. He was a member of the Scottish Free Presbyterian Church – a ‘Wee Free’. Examples were given of his strict observance of the Sabbath: the respect he commanded was obvious from the reverential tone of Jimmy’s description. Formerly, the home had been a hotel but when its previous owner put it on the market John had been keen to establish the community home. As a well-respected local, he had been able to call on certain people in the village and to recruit them to his task. Jimmy for his part, had been recruited for his business acumen and Jane for her organising abilities. Industry, involvement and community interest

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RELATIONAL CARE Triumph of the relational

were taken as read and freely given. Then, when John died, Jimmy had been left in charge. Trustees faced three main difficulties: in order of importance, relationship with the council in Stirling, difficulties in staffing, and finance. As example of the first Jimmy spoke with passion and ire about the recent admission of a couple, who representatives of the council wanted to split, leaving the more able one at home and the frailer to be admitted. Jimmy, however, had insisted that having spent 60 years of their life together, they should be admitted together. Faced with his intransigence on the matter the council had sensibly acquiesced. Another example was the choice of the carpet. A high-quality Axminster was used throughout most of the communal areas – hall, stairs, lounge and dining room. It was dark blue with a recurring detailed pattern, and had been chosen by the residents. It looked expensive. An inspector had commented on its unsuitability because ‘plain light-coloured carpets were superior’. As some wag put it, ‘there’s safety in umbers’.

Pride and participation With its 10 residents this was a truly a small home where economies of scale were not possible, so finance was critical. There was no waiting list; residents were admitted according to local priorities of need; eight of the ten had lived in the village and the remaining two well within 20 miles and with family in Killin. Seldom was there less than 100% room occupancy, indeed a break of six weeks put a strain on finances. The home ran with a financial reserve of three months and on average broke even, with an annual loss or surplus of no more than £20,000. The acumen gained running a successful business close to the village was both necessary and sufficient. Of the 14 members of staff, almost all were from the village; each staff member no more than one degree removed from knowledge of every resident or their family. A recent rise in pay for the least trained to the living wage of £8.25p and the need to preserve the differentials of pay for those with additional training and responsibility had increased the wage bill by £350 a year.

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Of the 14 members of staff, almost all were from the village

Each resident had a formal care plan which included their activities and interests. This was complete and up to date yet the knowledge and relationships within the home meant it rarely had to be consulted. Families, who were encouraged to visit and get involved, would bring in the life of the village, which the residents knew and understood. There were good links with the Kirk and with other

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community activities. The nearby junior school and nursery organised fortnightly visits – the children and their families were of course known – and the fitter of the residents would sometimes visit the nursery. Visitors would often bring pets, especially dogs, though not a single dog hair was in sight. A musician visited each month plus there were ad hoc visits from the community choir and other musicians. Parties and social evenings were part of this pattern too, when ‘the ladies might have a wee dram, themselves’. Most of the residents, as they sat in chairs positioned to observe the comings and goings on Main Street, looked engaged and cheerful. Fitter residents would be accompanied down Main Street to visit the shops they knew so well or the newly opened Tea Pot cafe.

Small and beautiful Michelle, a woman in her 20s with a two-year-old daughter, talked enthusiastically about the active participation of families and friends. She said it made her work easier and more fulfilling. She spoke too of the pride she and her workmates felt when they told people where they worked. I was very curious about the home’s relationship with the community. Almost as an aside Jane mentioned something important: that this involvement was growing, because many families, having become supportive and involved, surprisingly (to me at least) continued to join in even after the death of their elderly family member. Community involvement continues to grow. Yet the council proposes to build a ‘dementia village’ where much of the dementia care in the county would be centralised. Though Sterling University has a national reputation for excellence in the study of dementia care (and it’s where home staff do their training) I share Jimmy’s concern: bigger is unlikely to be better than what I witnessed here in the heart of Killin. Of course in villages where community spirit is still alive it will be easier to look after the elderly in a residential home that is truly part of the community rather than separate from it. I saw for myself that a small community has the personal interconnectedness, enthusiasm, impetus, and stamina to support a genuinely community home for elders. In Killin I learned that with leadership and proper planning it is possible for frail elderly people to live a happy and contented life as an integral part of a community. End note: I bought my friends a curry dinner. And the meek shall inherit the Earth…if that’s okay with you. Brooker DJ, Woolley RJ (2007) Enriching opportunities for people living with dementia: the development of a blueprint for a sustainable activity-based model. Aging Ment Health 11(4) pp 371–83. Kitwood T (1993)Towards a theory of dementia care: the interpersonal process. Ageing and Society 13 (1) pp 51–67. Lundh U, Nolan M (1996) Aging and quality of life. 1: Towards a better understanding. Br J Nurs 5(20) pp1248–51.

SO CIAL PR ESCR IBING

Social prescribing – movement of the people? Marie Polley Co-Chair, Social Prescribing Network; Senior Lecturer in Health Sciences and Research, University of Westminster

Can the NHS slim down

I am a senior lecturer in health Sciences and research in the Department of Life Sciences, University of Westminster. After gaining my biomedical sciences degree, I trained as an Usui Reiki practitioner, becoming Reiki Master three years later. At the same time I was researching for my PhD in molecular carcinogenesis. I have spent the subsequent 15 years bringing all of these experiences under one roof, championing, researching and promoting integrated health approaches which address and empower the needs of people/patients. I co-chair the National Social Prescribing Network and chair the British Society for Integrative Health.

and yet remain patientfocused? GPs spend much time seeing people with non-medical needs, and in managing an ageing population with long-term conditions. In the absence of other options, there will be pressure to ‘medicalise’ psycho-social needs, ‘overdiagnose’, and prescribe medication. Social prescribing, by contrast, involves a link worker who can co-design a social prescription to improve a patient’s health and wellbeing. The national Social Prescribing Network co-ordinates this growing movement.

Introduction We live in interesting times. Providing medication to patients, without empowering them to take responsibility for their health, has led to a seemingly unstoppable rise in long-term conditions, many of which are underpinned by diets lacking in nutrients and high in sugar and unhealthy fats. Couple this with low levels of physical activity and you have a recipe for our shockingly high levels of obesity, cancer, diabetes, heart disease and mental health issues (Vos 2016). That’s not all; we have had a massive shift in how ‘community’ is perceived. The extreme development of technology has led to the paradox of being able to connect with anyone almost anywhere in the world instantly, while at the same time social isolation and loneliness are rife in our society. Then add in the austerity measures, the consequences of which are being felt now, particularly in the voluntary and community sector. Finally combine these developments with the worst levels of burnout and disenchantment in the medical profession in modern times. There is a huge cost to this situation – the cost of caring for an ageing population with long-term

health needs, the cost to the community and voluntary groups that can no longer get funding, the cost to the health of our healthcare professionals and the organisations that are finding it more difficult to attract the necessary workforce. If you need any more convincing, it is estimated that the amount of time a GP spends seeing people with nonmedical needs is equivalent to £394 million a year (CAB 2015). I could go on…. If someone developed a drug to cure these ‘societal ills’ the drug companies would bite your hand off to produce it. But this article is about exactly the opposite – what we can do when drugs may not be answer. Many have watched the policy changes in the health sector with baited breath. As William House wrote about the introduction of the Health and Social Care Act (DoH 2012), ‘it has this been a cleverly constructed story about localism, decisions nearer to people and a new culture of social enterprise, all disguising the real plan for a gradual hollowing out of the NHS... or will the NHS be slimmer, fitter, more patient-focused yet keeping the collaborative ethos, the commitment to shared responsibility, social solidarity and the common

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SOCIAL PRESCRIBING Social prescribing – movement of the people?

Social prescribing Social prescribing has existed below the radar for many years as discrete projects, not just in England, but in the UK, the Republic of Ireland, and in the Netherlands too. In 2015, with the support of the Wellcome Trust and College of Medicine, I led the project to set up the Social Prescribing Network, based at the University of Westminster.* We officially formed in January 2016 when we convened the first UK conference for people active in social prescribing. Until that point, there had been no way of knowing who was already innovating new approaches to people care, and therefore no way to of sharing experience and best practice and understanding the collective knowledge. When we began approaching people through word of mouth, we hoped for 60 people at the conference. What happened was amazing – 100 people attended the conference, demand was so high we ran a waiting list, and the buzz in the room on the day was fantastic. The conference was attended by as many stakeholder groups as we could identify, bringing healthcare practitioners together with social care, public health, CCG representatives, citizens, voluntary groups, academics and local authorities. A summary of discussions and priorities can be found in our report which was launched at the Houses of Parliament in March 2016 (Social Prescribing Network 2016). We had lifted the cover off an active underground social movement of the people and hopefully started to build a home for them. One year on, we have 500 members and are rolling out 7 regional network groups; from little acorns, big oak trees grow. There have been many definitions of social prescribing, which are often associated with an area of health eg mental health, or with the arts. At the conference, we debated this issue of a definition and then proposed the following short one. ‘Enabling healthcare

professionals to refer patients to a link worker, to codesign a non-clinical social prescription to improve their health and wellbeing’ (Social Prescribing Network, 2016).

Social prescribing in the NHS Despite social prescribing often being referred to as the common-sense approach, making social prescribing a reality in the current structures of the NHS is an interesting and, I would say, (as a pragmatist and an optimist) an ultimately achievable challenge, if the collective will is there. This article will now explore how it is possible for social prescribing to reshape healthcare provision.

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One principle…is to ensure all meetings and events are attended by as many stakeholder groups as possible

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good?’ (House 2013). William House’s words resonate with me, as over the last couple of years there has been the most unprecedented realisation, arguably at all levels, that something radically different needs to happen with healthcare provision, if the latter version of the NHS is to be realised. Hence the Five Year Forward View and GP forward view documents setting out the ambitions of how the NHS wants to change (NHS England 2014; 2016 respectively). It would only be right and proper to point out that the voluntary and community sector realised this a long time ago. This article is about the many people who are already working outside their comfort zone, doing something radically different. It’s about the vision of unlocking a person’s potential irrespective of their situation, to provide humane healthcare and to empower a person to live their life with meaning, purpose and fulfilment. It’s about the growing movement of people who are coming together and whose collective voice is getting louder.

First, this needs to be underpinned by a shared vision of an NHS which is ‘more patient-focused yet keeping the collaborative ethos’. A challenge here is about communication – communication between just one or two stakeholder groups is an unacceptable way of working. So often people are in their silos, working away completely unaware that knowledge and expertise exists in a different silo; this is a ridiculous waste of time and knowledge (and therefore money). One principle underpinning the Social Prescribing Network is to ensure all meetings and events are attended by as many stakeholder groups as possible. This is not how the NHS generally works, and I would argue that it is only the situation of extreme austerity which is forcing commissioners, healthcare professionals, local authorities, public health and the voluntary and community sectors to talk to each other. It takes some courageous champions in every sector to start these cross-sector conversations and we cannot expect ‘top down’ change to bring it about; this bit needs organic, bottom up activism. We explored what our social prescribing members (n=180) thought the key ingredients to a successful social prescribing project were. Communication, relationships and feedback loops were three of the themes we identified – which won’t surprise those already employing holistic approaches to promote whole person care. There is a desperate need for a patient/person to be heard, to tell their story without being stopped after seven minutes, to be able to unpack the complexities in their life and then be given the opportunity to choose a positive way forward. This is the role of the link worker. The link worker is the term we currently use to describe the community navigators, health trainers, health champions,

* The Social Prescribing Network is free to join and is open to all. Email socialprescribing@outlook.com to join. © Journal of holistic healthcare

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SOCIAL PRESCRIBING Social prescribing – movement of the people?

health advisors of this world, who listen to a person and match them with the appropriate community/voluntary groups or health resources that they need. It’s a very special form of communication and it is in the liminal space they provide that new paths can be revealed. So, is it possible to engender working practice whereby each stakeholder has equal voice and respect? Absolutely, it is already happening in half the CCGs in England on some scale.

What is the model? One frequently asked question is ‘what model should we use if we want to commission a social prescribing project?’ This question also exemplifies another unacceptable approach to patient care – the one-size-fits-all approach. There is no one model of social prescribing, which is fortunate as we are not all cloned from one person. Social prescribing projects are commonly set up to build on existing assets. This is often referred to as the ABCD – Asset Based Community Development – approach. What is there that already exists, what expertise is available, what community and voluntary groups exist, what buildings can be used? This means the focus needs to be on the underpinning values. It’s also about building in flexibility in a service to allow for varying needs of a person. Some people are recommended to go to a group, yet lack the confidence to go on their own. So they are accompanied for the first couple of visits. A person who has a lot going on may need many link worker sessions before they are standing on their own two feet again, but that’s OK as there are others who only need a couple of sessions. Flexibility must allow for such varying demands to be managed as its ebbs and flows.

Good commissioning If we come back to understanding how healthcare can be reshaped by social prescribing, then the commissioning of services is an essential element to sustaining this movement. It is crucial for commissioners to commission services that exist locally, and which already have established relationships with people, where possible. Crucial because this supports the local voluntary and community groups, who already have the relationships with people. Crucial because if there are established relationships in the community, local needs are more likely to be recognised and met. Crucial because without the local voluntary and community sector, the NHS would be even worse off than it is now. There is a real danger that commissioners will only look at the bottom line and fail to appreciate the value of commissioning existing assets. We therefore need to take shared responsibility for educating commissioners on what to look for in a good social prescribing project. That is not all, as we are often asked by commissioners about the evidence – is there enough evidence for social prescribing and what is the return on investment? To answer these two very pertinent questions, many pieces of

evaluation have been done on social prescribing projects, and we have been analysing 60 evaluations, as well as some RCTs and qualitative work. This is an emerging field, so there is certainly room for more research, however similar results are being reported around the country and in Europe. Predominantly it’s reported that the demand for GP time reduces, as the frequent attenders find new people to connect with. We also see that A&E attendance often falls in areas where social prescribing schemes have been introduced. Furthermore, healthcare professionals say they like to have more appropriate routes to refer patients to. We have seen many reports where social isolation, for example, is reduced, people are empowered, some people start to volunteer their time, those who felt forgotten find a way to live the life that they want to live. In some cases, people get back into work or set up their own enterprises. We are still analysing the full range of benefits and outcomes, however these benefits match what is needed in our society now to address those societal ills. Furthermore, most if not all the benefits we are identifying have some financial value, hence the potential for saving money and bringing about a ‘slimmer, fitter and more patient-focused NHS’. This is the beginning of a transformation of the healthcare system. Social prescribing is not the panacea for all ills, but it will make a sizeable contribution to reshaping the healthcare system. We have a unique opportunity right now, and in the Social Prescribing Network we are working hard to link people, share the knowledge and research, provide evidence and influence the ‘great and good’. It is our hope that by bringing many voices together, and by creating the spaces for us to listen to each other, a shared understanding will be revealed and great change will occur. We are an ever-growing number of people and I hope that social prescribing will be seen in future years as a true Movement of the People. Citizen Advice Bureau (2015) A very general practice: How much time do GPs spend on issues other than health? Online. Available at: www.citizensadvice.org.uk/Global/CitizensAdvice/Public%20services%20 publications/CitizensAdvice_AVeryGeneralPractice_May2015.pdf (accessed 21 October 2016). Department of Health (2012) The Health and Social Care Act. Available at: www.legislation.gov.uk/ukpga/2012/7/pdfs/ukpga_ 20120007_en.pdf (accessed 20 October 2016). House W (2013). Sealed with a prayer. Is the NHS up for sale? JHH 10 (1) pp44. NHS England (2016) General practice forward view. Available at www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf (accessed 20 October 2016). NHS England (2014) Five year forward view. Available at: www.england.nhs.uk/wpcontent/uploads/2014/10/5yfv-web.pdf (accessed 20 May 2016). The Social Prescribing Network (2016) Report of the Annual Social Prescribing Network Conference. Online. Available at: www.westminster.ac.uk/patient-outcomes-in-health-research-group/ projects/social-prescribing-network (accessed 17 October 2016). Vos T et al (2016) Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet 338 pp 1545–602.

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The family doctor and the grid William House Chair, BHMA

This article aims to make sense of the CQC’s enforced emergency closure of Dr David Zigmond’s small and much loved GP practice. This unprecedented event is examined from several viewpoints. It includes a critical appraisal of the approach and values of the Chief Inspector of General Practice and his new inspection regime; a discussion about the heritage of bureaucratic control in contrast to the family model of maintaining social order; the theory and evidence of cerebral hemisphere dominance to explain the radical differences between Zigmond’s and Field’s perceptions of reality; and a comparison of Zigmond’s approach to that of the creative artist.

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About halfway through my 30 years as a GP I realised that in the minds of bureaucrats, scientists and some leaders of our profession, we needed to be told what to do and how to do it; we could not be trusted. I knew this was wrong; that much of what we did was not about algorithms, or calculations but about judgement; that it is too holistic to be replaced by rule books or controlled by anyone outside that crucial doctor–patient relationship. I have spent much time studying this and making the case for the inherent ambiguities and uncertainties of health and illness; making the case for trust. The painful experience of Dr David Zigmond described here brings much of this to life.

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.

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The doctor: the character of the accused The best things in life hide from the full glare of focused attention. They refuse our will. Iain McGilchrist

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

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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. African proverb

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. Friedrich Jacobi

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

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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):

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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

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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.

Selective inattention We are prisoners of expectation Iain McGilchrist

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.

The artist 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

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Picture: Jorg R. Dubin http://jorgdubin.com

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.

Hope 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

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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.marcolearningsystems.com/pages/david-zigmond/n14.8.14_From_Family.pdf (accessed 12 November 2016).

Groupthink – do you dare to be different? William House Retired GP; Chair of the BHMA

In late 2007 I travelled to London to contribute to Lord Darzi’s Next Stage Review about making improvements to the NHS. I had been a GP for 26 years and had never been asked to contribute at this level before. I sought out the ugly building on the south bank of the Thames, opposite Tate Britain. After the coffee and pastries about 100 of us sat in a very large room at tables of six including a facilitator. I was uneasy about the obvious expense of the occasion. Still, ever hoping for real reform I was eager to say my bit! We were handed sheets with questions. To my dismay, none of the questions seemed even slightly relevant to the serious systemic problems obvious to me. I tried to be positive as we chatted around the table and the facilitator wrote things down. Later, at a plenary session, questions were invited from the floor. The panel included Lord Darzi with the NHS Chief Executive, David Nicholson, and some other bigwigs. I took my chance and asked why it is that GPs’ professional development received no state funding. I reminded them that, whatever the claims otherwise, the default drug company sponsorship was biased in favour of medicalisation and this is unsustainable. It is part of the problem. Nicholson briskly invited another question and no attempt was made to answer mine. It was as if I had not spoken. No one said anything, even over the tea and cakes afterwards. On the way home I pondered on the silence, the failure to challenge the system. It’s either stupidity or groupthink! They are not stupid people, so it’s groupthink. I don’t mean the bigwigs: I’m sure they are fully aware, but they are in Big Pharma’s bubble, so no change there. It’s the 100 silent and docile people in the room. That is the problem. So what is groupthink? The word was invented by research psychologist Irving Janis in 1972 to represent a common tendency for doubting individuals to stay quiet when most others in a group seem to agree with a proposal or course of action. This might be fear of being the odd one out or of retribution for stepping out of line or some other upset in the harmony of the group, but whichever way, it leads to persisting with flawed practices, or making bad decisions, sometimes disastrously so. Indulging in collective rationalisation of the events follows on. Linked to this is blame. The group closes ranks and points at someone else, often stereotyping and penalising vulnerable others for daring to be different (see articles

about David Zigmond in this issue). In that very large room in 2007 it was really the 100 people who were groupthinking their way to the deteriorating situation we now find ourselves in. If you can control information, you can control people. Tom Clancy There are several reasons why groupthink is common in the health service, but the principal ones are stress and the narrowing of knowledge. The latter is interesting. Among the storm of reporting on the recent Trump and Clinton campaigns was an article in The Guardian by historian Timothy Garten Ash (Garton Ash 2016). One of his points is the polarisation of the press and other media. Supporters of each candidate can easily spend all day every day reading or watching news and comment that reinforces their own particular inclinations. Effectively, both candidates had their own media outlets – their ‘bubbles’. Voters read copy that reinforced their own viewpoint. Balanced reporting was very hard to find. The result: groupthink. Much the same has happened in the NHS, but for different reasons. The volume of publications relevant to medicine is breathtaking. In 2010 there were 25,400 journals in science, technology and medicine In 2009 they published 1.5 million articles. A very substantial number of these are relevant to healthcare. Another huge number of articles and books in the humanities are potentially relevant to medics who try to take a broader view, especially GPs. Busy clinicians have no hope of keeping up in their own field, less still to read more broadly. Gods don’t like people not doing much work. People who aren’t busy all the time might start to think. Terry Pratchett For most the solution is to rely on summaries and guidelines provided by others. These ‘others’ have their own agendas and live in different bubbles – someone else’s bubble. Without broadening your knowledge and dipping into very different worlds, groupthink becomes almost inevitable. You shrink into your small space and feel threatened by the unfamiliar; and nothing changes. Garton Ash T (2016) Do you live in a Trump bubble, or a Clinton bubble? The Guardian, 29 September. Available at: www.theguardian.com/commentisfree/2016/sep/29/trump-clintonmedia-left-right-democracy (accessed 16 November 2016).

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Research summaries Tapping for depression? During a typical EFT session, the person will focus on a specific emotional issue while tapping a particular series of acupuncture points. This meta-analysis of the little available evidence base used 20 studies where clinical EFT had been used as a treatment for depression. The individual studies were small, only 461 subjects in the 8 outcome studies and a total of 398 in the 12 RCTs. Generally EFT has been dismissed by mainstream psychologists as a mish-mash of ideas gathered from acupuncture, NLP, energy medicine, and thought field therapy, and at best as an effective placebo-generator. Nevertheless in the meta-analysis of randomised controlled trials the effect size of clinical EFT was equal or superior to active treatment controls (diaphragmatic breathing, supportive interviews or sleep hygiene education) whether delivered in groups or to individuals, and participants maintained their gains over time. In fact the post-test effect size was larger than that measured in meta-analyses of anti-depressant drug trials and psychotherapy studies. Unlikely and pseudoscientific though this treatment might seem, larger trials, if positive, would oblige psychologist to broaden their horizons. Nelms JA, Castel L (2016) A systematic review and meta-analysis of randomized and nonrandomized trials of clinical emotional freedom techniques (EFT) for the treatment of depression. Explore, Aug 18. www.ncbi.nlm.nih.gov/pubmed/27843054

Integrating acupuncture 1 For various reasons more women now choose to delay pregnancy until they are 30 or older. Consequently subfertility is a growing problem and for many IVF is often a last resort. Yet despite advances in the technology, IVF success remains low, especially for older women, many of whom need several cycles of IVF and are faced with unprecedented anxiety and frustration. Reviews of the available acupuncture research disagree about its value. However, a new study from Homerton University Hospital in London adds to the evidence that acupuncture can indeed boost the chances of successful implantation. The Homerton levels of success were twice as high in women who had four sessions of acupuncture during their IVF cycle. A year on, 46.2% had become pregnant. In the no-acupuncture group pregnancy rates were only 21.7%. Was this remarkable benefit due the acupuncture or to expectancy and relaxation? It is well known that ‘placebo’ acupuncture has a powerful effect. To the happy couples it won’t matter of course! But the finding, repeated in so many acupuncture RCTs, that putting needles

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randomly into a person so consistently reduces pain and switches on self-healing responses surely tells us something of enormous significance about the ‘human effect’. More research is needed into the extraordinary potential of something too often dismissed as mere placebo. www.telegraph.co.uk/news/2016/07/04/acupuncture-doubles-chanceof-having-a-baby-with-ivf-study-sugge/

Integrating acupuncture 2 Multiple drug mixes are commonly needed to regulate blood pressure but these agents are often ineffective and can cause severe side-effects. In this study of a group of patients on antihypertensive medication, acupuncture reduced both their blood pressure and rate of side-effects. The research looked at the effects of acupuncture treatment on hypertensive patients who had been using 1 to 3 anti-hypertensive drugs for at least 24 months (mainly ACE inhibitors, diuretics, and beta blockers). In this group the common adverse effects of the drugs included fatigue, dizziness, weakness, headache, joint pain, sleeping problems, cold hands and feet, edema and depression. In the study, which was a small one, 24 male and 10 female patients were given acupuncture every 2 days for a total of 15 sessions. They showed clinically significant reductions in systolic and diastolic blood pressures. The value of combining conventional and traditional treatments (as in the IVF study above) will have to be confirmed in larger controlled studies. The prospect of developing integrated medicine in this way will be of interest to all holists. Cevik C, I eri SO (2013). The effect of acupuncture on high blood pressure of patients using antihypertensive drugs. Acupunct Electrother Res. 38(1-2):1–15. www.ncbi.nlm.nih.gov/pubmed/23724695

Sins of the fathers (and mothers) It has long been recognised that a history of poor parenting impacts on offspring health. A new longitudinal cohort study of 1964 community-dwelling adults aged 65–79 years suggests it affects offspring mortality too. More of the participants who tested for having experienced the poorest parenting style died earlier than those with an optimal parenting style score. Maternal and paternal parenting styles were individually associated with mortality. Demakakos P et al (2016). Parenting style in childhood and mortality risk at older ages: A longitudinal cohort study. The British Journal of Psychiatry 209(2): 135–141. http://bjp.rcpsych.org/content/early/2016/02/19/bjp.bp.115.163543

Reviews The evolution of medicine Dr James Maskell Knew Publishing, 2016 ISBN 9781619615090 ‘ It is more important to know what sort of person has a disease than to know what sort of disease a person has. Hippocrates

Introduction The world of medicine – and primary care in particular – is facing an unprecedented demand on services. With funding cuts commonplace and reversible chronic diseases crippling primary care services, we are all trying to look for solutions…fast. Job satisfaction is low, burnout is almost expected and there is naturally a recruitment crisis across the country. Through his unique and thought-provoking book, James Maskell shines a light on a leading healthcare movement in America – functional medicine. The Evolution of Medicine gives us an insight into this exciting new model for delivering personalised healthcare to curb the epidemic with which we are faced. Maskell provides his observations and suggestions as a health economics graduate and founder of the community e-commerce platform ‘Evolution of Medicine’. Maskell takes us on a journey of discovery through his book. The Evolution of Medicine gives us not only an introduction into the concept of functional medicine but also a suggested approach to setting up one’s own practice. There is an honest acknowledgement of the difficulties which functional medicine practitioners have been faced with. Functional medicine has at times been met with hostility from established medical bodies and thought of as quackery, built on unsubstantiated claims. The new generation of functional medicine practitioners are now facilitating systematic, scientific and reproducible change.

Message – themes and concepts There are several core themes and concepts which Maskell refers to throughout his book. To a reader not versed in the core fundamentals of functional medicine, I found these to be both interesting and thought-provoking. One of the primary themes is to develop root cause resolution medicine by shifting away from ‘production-line’ reactive medicine to moving upstream and addressing individualised predisposing and modifiable risk factors. Similar to the four Pillars of Good Health by Dr Rangan Chatterjee (eat well, move well, relax well, sleep well), Maskell refers to the four Ps of functional medicine; predictive, preventative, personalised and participatory. With a shift in focus from managing the masses to providing personalised lifestyle medicine. Furthermore, the value and importance of community is emphasised throughout. This is highlighted by the concept of ‘blue zones’ which are explored. These refer to the five rural

populations in the world where centenarians are commonplace and chronic diseases rates are significantly low. The only link between each of these isolated rural populations was a strong sense of belonging and community. Access to medical care was limited, diets were varied and there was no formal exercise outside the activities of normal living. The functional medicine movement in the US is steadily creating their own blue zones, where there is a focus on community health and shared values and services. The data suggests that rates and impacts of chronic illness are falling at steady rates due to a shared value in creating health on both an individualised and collective level. ‘ Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.’ Margaret Mead

Challenges in the UK There are, however, some challenges which Maskell outlines in his book. There are many barriers to change here in the UK when looking at the core themes and concepts outlined in the book. There are some similarities between healthcare in the UK and the US. These include an increasing burden on primary care resources on preventable and often reversible chronic diseases, and a workforce which finds itself increasingly dissatisfied with practising reactive medicine. Some of the differences include a patient base which is used to paying for services in the US with a heavy influence from insurance companies on healthcare provision. Maskell addresses these similarities and differences and suggests simple measures which can be taken to make the first steps in practising functional medicine. These can include patient focus groups and patient support groups from within the practice. The option of expanding past the walls of the practice are explored and include developing ties with local groups to identify health goals and needs and can range from crossfit groups to cafés. This approach can attract the low-hanging fruit of eager and enthusiastic patients while missing out on other high-risk patients who may benefit from the functional medicine approach. The emphasis which Maskell focuses on is to begin slowly with a ‘build it and they will come’ approach. There are services within practices already in the UK, where doctors practice functional medicine either within or alongside existing clinics. Although this approach can lead to positive patient participation and cause resolution medicine, it is doctorheavy and limited to the one-to-one model. Maskell’s vision is for a micropractice where there is a community of patient participatory groups, which create health and in theory make the job of the GP obsolete from a chronic disease viewpoint. Undoubtedly the biggest barriers to incorporating these concepts are a perceived lack of time, fear of deviating from the status quo and the loss of clinic time to a new model, which requires time to see results. Baby steps are required, but the book opens the door to this new and interesting concept of approaching the chronic disease burden from a different angle.

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REVIEWS

‘ You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.’ Roger Buckminster Fuller, former Mensa president and eminent scientist

The future and signposting The Evolution of Medicine offers a unique insight into the world of functional medicine. Not only does Maskell give an in-depth insight into the core themes and concepts of this new movement, he also provides practical and realistic advice on how established GPs can integrate these core themes either into or alongside current practice. For more information, inspiration and insight into this exciting new development, we are signposted to several online resources: • functionalforum.com – online community of functional medicine practitioners and enthusiasts, where ideas, research and experiences are shared • meetup.functionalforum.com – local community to share, inspire and collaborate – develop local services • youtube.com/user/functionalforum – free online video sharing channel including monthly forum lectures • www.youtube.com/watch?v=sgTjCpBOeCU – ‘Building healthcare from scratch’ James Maskell TEDx 2015 • drchatterjee.co.uk – arguably the UK’s most recognisable functional medicine advocate, a practicing GP in Oldham and also from BBCs Doctor in the House series. Dr Peter Foley GP Registrar and Sports and Exercise Medicine MSc student

The snake in the clinic: psychotherapy’s role in medicine and healing Guy Dargert Karnac Books, 2016 ISBN 9781782203742 This short book beckons with a handsome cover festooned with eulogistic endorsements. I started it with effervescent anticipation, but finished it feeling unexpectedly flat, burdened and tired. Why? Dargert’s book is admirably intentioned, but I found it leadenly executed. He writes as a veteran, liberally spirited psychotherapist about the subtle role his craft may take in the relief of suffering. His views are wide-ranging and his ethos will be welcome to most readers of this journal. Some better, briefer lines capture this:

Or That of which we are unconscious we are destined to enact. Alas, such pithy depth is too occasional. The commendable mission of the book deserves wide support, but is often compromised by writing that becomes earnestly prolix and religiose. If as healing professionals and as psychotherapists we can see beyond the presenting symptom; if we can recognise the archetypal forces (or gods) that underlie them, then maybe we can help to open a channel through which they make their way into conscious life and then, through the individual, into the world at large … We act as midwives to the soul and serve the gods. We value and welcome pathology knowing that the energy that lies within it potentially enables wholing or healing … (This goes on considerably longer.) For a small book there are a remarkable number of such long passages. While reading them I felt like a trapped congregant having to listen to a very long sermon from a sincerely insistent, yet avuncular vicar. Much of the book is suffused with this kind of high-minded guidance. Ideas are conflated with ideals, and thence become idealised. Amidst this I hungered for sharpminded philosophical enquiry and more real, messy, human-odoured human description or dialogue. Dargert’s benign abstractions are often fuelled by lumpily detailed accounts of ancient and Eastern healing practices, classical myths and the historic and fictional ghosts that Dargert believes still live on in the inhabitants of his beloved Cornwall. He is clearly indebted and fascinated. To my mind all of these should have been relegated, if anywhere, to brief footnotes. As if this is not enough, Dargert seeks to convince us with scientific explanations and evidence. There are long forays littered, for example, with technical words for brain structures and neurotransmitters. He even managed to recruit a psychoneuroimmunoendocrinologist (yes, really!). What is achieved? This is, to my mind, scientism but not holism. The Snake in the Clinic is a conscientious creation from a scholar with evidently humane values. Dargert has clearly read widely and offers himself as a committed and devout emissary. But his message is now perennially familiar and axiomatic for many of us. The problem is importantly instructive for us: it is that holism can all too easily be abstracted, then venerated, as a religious or philosophical text. Our greater and more cardinal challenge is to apply all this in situations that are often stressed, conflicted and unreceptive: the dilemmas of NHS practitioners is a current and massive example. For this we need a different kind of language and discourse. To engage interest and exert leverage, we now need literature of wit and grit, more than piety and idealisation. Current and spark are necessarily related, but they are not the same. David Zigmond, retired GP

We forget that healing is about ‘wholing’ – the bringing together of disconnected parts of a whole with the hope and expectation that this will help to harmonise and lessen the dis-ease between them.

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Guidelines for Contributors About the journal The Journal of Holistic Healthcare is a UK-based journal focusing on evidence-based holistic practice and the practical implications of holistic health and social care. Our target audience is everyone concerned with developing integrated, humane healthcare services. Our aim is to be useful to anyone who is interested in creative change in the way we think about health, and the way healthcare is practised and organised. Our basic assumption is that holism can improve healthcare outcomes and will often point to costeffective ways of improving health. Holistic healthcare can be understood as a response to our turbulent times, and medicine’s crisis of vision and values; an evolutionary impulse driving individuals and organisation to innovate. But when complex and creative adaptations do occur, these ideas, experiences and social inventions don’t always take root. Though they might be the butterfly wingbeats that could fan the winds of change, even crucial seeds of change may fail to germinate when isolated, unnoticed and lacking the oxygen of publicity or vital political support. Some of these ideas and social inventions have to be rediscovered or reinvented, and thrive once the culture becomes more receptive – or more desperate for solutions. The JHH sees holism as one such idea, a nest of notions whose time has come. So we want the journal to be a channel for publishing ideas and experiences that don’t fit easily into more conventional mainstream journals, because by making them visible, their energy for change becomes available to the system. The journal’s themes include the theory and practice of mind-body medicine; every aspect of whole person care – but especially examples of it in the NHS; patients’ participation in their own healing; inter-professional care and education; integration of CAM and other promising new approaches into mainstream medicine; health worker wellbeing; creating and sustaining good health – at every level from the genome to the ozone layer; environment health and the health politics of the environment; diversity and creativity in healthcare delivery, as well as holistic development in organisations and their management: a necessarily broad remit!

Writing for the journal We intend the journal to be intensely practical; displaying not only research, but also stories about holism in action. Personal viewpoint and theoretical articles are welcome too, providing they can be illuminated by examples of their application. The Journal of Holistic Healthcare is a vehicle for injecting

inspiration into the system: ideas and research that might enable positive change. We realise that there is nothing as practical as a good theory, and we encourage authors to foreground what they have done and their experiences, as well as what they know. Though we don’t always need or want extensive references, we ask authors to refer to research and writing that supports, debates or contextualises the work they are describing, wherever appropriate. We like further reading and website URLs wherever possible. And we like authors to suggest images, photos, quotes, poems, illustrations or cartoons that enrich what they have written about. Because the JHH aims to include both authors’ ideas and their experience we invite authors to submit case studies and examples of successful holistic practice and services, research findings providing evidence for effective holistic practice, debate about new methodologies and commentaries on holistic policy and service developments. Our aim is to be a source of high-quality information about all aspects of holistic practice for anyone interested in holistic health, including policy-makers, practitioners and ‘the public’. We aim to link theory to practice and to be a forum for sharing experiences and the insights of reflective practice. Articles should be accessible and readable, but also challenging. Key articles will link theory and research to practice and policy development. Contributions from the whole spectrum of healthcare disciplines are welcome. The journal is particularly concerned to highlight ways of embedding holistic thinking and practice into health care structures, including primary care organisations, networks and collaborative initiatives.

Original research JHH is a platform for holistic ideas, authentic experiences, and original research. We estimate our regular (and growing) circulation of 700 copies is read by as many as 2000. And, though we don’t yet attract researchers seeking RAE points, we are free to be a voice for the kind of ideas, reports, experiences and social inventions that wouldn’t fit easily into more conventional mainstream journals: small studies, pilots, local reports, surveys and audits, accounts of action research, narratives, dissertation findings (otherwise hidden in the grey literature), pragmatic and qualitative studies and practice evaluations. By publishing them in the JHH, important seeds for change become available to people who need to grow them on. Another advantage of submitting to JHH is the peer feedback to authors, some of which we may include as commentaries on a published paper.

If you would like to submit an article please contact either editor-in chief David Peters on petersd@westminster.ac.uk or editor Edwina Rowling on edwina.rowling@gmail.com. For our full contributors guidelines see www.bhma.org.

Editorial Board Peter Donebauer Ian Henghes Dr William House (Chair) Professor David Peters Dr Thuli Whitehouse Dr Antonia Wrigley

British Holistic Medical Association West Barn Chewton Keynsham BRISTOL BS31 2SR Email: contactbhma@aol.co.uk www.bhma.org

PROMOTING HOLISTIC PRACTICE IN UK HEALTHC ARE