Section G - Contention with NHS England and the Care Quality Commission
Letters and articles challenging our excessive micromanagement and commodification within healthcare
Key points: seminal questions
If you give me six lines written by the hand of the most honest of men, I will find something in them which will hang him.
– Cardinal Richelieu (1585-1642)
· When we get very different accounts of complex situations what do we believe? How do we decide? When do we need official arbitration?
· The mission of NHS England (NHSE) and the Care Quality Commission (CQC) – to provide competence, safety, kindness and probity (CSKP) in healthcare excites little debate. In contrast, their methods – in defining priorities, rules and truth – are sometimes much more problematic and disputed. This is especially true where important anomalies arise.
· The following detailed accounts and correspondence revolve around one anomalous and then contended example.
· The CQC has developed an increasingly precise and extensive regime of compliance requirements and inspection rules assumed to perfectly equate with CSKP. Yet CSKP is often inseparable from nuance and vagary that cannot readily be prescribed or formulated. So this strict regime frequently confers unhelpful rigidity and the trappings of specious ‘certainty’.
· This means that despite other claims and intent, these reports are often, in fact, accurate only in assessing compliance to their own requirements. These may, or may not, accurately reflect desired practice qualities of CSKP. Even frequent correlation is not an equation.
· In this particular practice, CSKP was rated egregiously poor by the CQC, but was excellent according to all other real-life sources. An important anomaly, surely?
· In science this kind of anomaly is always taken seriously. It invalidates, or seriously weakens, any hypothesis based on only one source. Evasion of this principle leads to ‘cherry picking’ – an inexcusable offence in science.
· Yet rather than explore this gross anomaly, the CQC ignores the evidence and then destroys its source (the practice).
· Such inspections are like many medical screening procedures: false-positives (attributing non-existent pathology) and false-negatives (missing important problems) are inevitable.
· The following example is akin to a false-positive screening automatically mandating major, then fatal, surgery.
· Such errors are most likely when a system becomes hermetic and thus closed to other incongruous (usually inconvenient) evidence. Draconian defensive procedures follow, and frequently backfire.
· How may NHSE and the CQC better understand such major anomalies, rather than expediently dismiss them?
· How do we best understand the many forms of practitioner CSKP that thrive outside rigid and prescribed regimes? And how may we better identify, then understand, the gap that often opens up between strict institutional compliance and actual CSKP?
· Our best CSKP in healthcare rarely comes from rules and regulations, or rewards and punishments. How do we now reacquaint ourselves with, and intelligently trust, our more natural human connections, sense and sensibility?
· Avoiding these questions, paradoxically, causes much damage to the very things the CQC and NHSE are briefed to protect.
The latter part of 2016 brought a personal coda: the coerced closure of my practice due to my conscientious non-compliance to ever more NHS regulations. This was, paradoxically, both a debacle and an endorsement – for it also served as a dire demonstration of my many years writing about our increasingly ratcheted and managed healthcare and its dangers. In particular, I recurrently urged caution regarding the ever-greater procedural squeezing and corralling of its professionals. The following selection of writings describes the drama of this denouement and then the questions and analysis I offered to the relevant authorities.
These writings derive also from my earlier long-term tracking and documentation of the evolving and extensive – if unintentional – damage. My prophesies of where this would lead have proved mostly accurate: any personal gratification from this instructive wreckage is grim and saddened.
Crucial to all this is how we have jettisoned certain principles of professional trust and autonomy. For these are essential if we are to sustain the kind of healthy professional identity and integrity that lead – mostly – to our better care and judgements: all these depend on individuals’ experience, informed intelligence and vocational conscience. Trust is a professional cornerstone, but now increasingly mistrusted and so driven out. Unless we are very careful, institutional power and professional integrity can become inversely related. This is now happening frequently, and with debilitating consequences.
I am not suggesting that we should abandon ever-present vigilance and thus discriminating mistrust. But the wisdom and workability of our professions lies in the balance (and thus style) we find for ourselves – or command in others – of trust v mistrust; of nourishing diversities of competence v punishing deviants for non-compliance.
The balance is crucial, yet subtle and delicate. It is not easy.
Recent management and economic policies have made small GP practices almost extinct. Those few that remain are now, almost always, heroically and perilously vulnerable. This hostile environment, together with my age, bodes ill for any lengthy Appeal process. How could I possibly, even eventually, recover and rehabilitate my practice? Even legal redress could not enable me to continue my work.
So, my submission and abdication are coerced, but my thinking and contention remain free. This freedom has aroused fraternalism. For beyond my own story and predicament many professionals throughout our welfare services have communicated to me how my plight and story are redolent of their own working experiences and predicaments.
Clearly the issues raised here are important to many, and widespread.
No written replies were ever received from NHS England. I made several further informal attempts at contact. Eventually a senior officer said this to me: ‘Look, a lot of us at NHS England agree with most of what you say. We hope you keep writing… This is strictly off the record, you understand…’ The voice was wearied, stoic and apologetic.
The CQC avoided all invitations for informal discussion. Eventually two warily courteous and lengthily defensive letters were received. These merely reiterated the content and method of the original CQC report. My fundamental questions and arguments were never answered.
Sections ix and x contain these last exchanges.
i Death by Documentation & Introduction (Articles 73, 74)
ii The Family Doctor and the Grid (Section E)
iii General Practice is the Art of the Possible (Article 75)
iv CQC Inspection and Closure of my NHS General Practice (Article 76)
v The Proof of the Pudding is in the Eating (Article 77)
vi When is Compliance Necessary for Public Safety? (Article 81)
vii When is Change Progress? (Article 84)
viii Should All Doctors Be Resuscitators? (Article 86)
ix wrong, wrong, WRONG … OUT! (Article 89)
x One Small Altercation: a Massive Residuum (Article 95)
Version: 19th October 2017