No Country for Old Men
The Rise of Managerialism and the New Cultural Vacuum
Recalling my youth and then first professional trainings, from the 1950s to
the 1970s, I see now how I was primed and fuelled by an era of creative subversion, a kind of demotic philosophy.
Everywhere, old Orders were arraigned by bold, bright challenges: in literature, art, academia, music and fashion.
Amidst these cultural sparks I ignited my lifetime's interest in those primal questions of politics, social-care,
psychology and psychiatry:
Introduction and Summary
The NHS has been changed massively by refinement and expansions of complex, hierarchical, ‘cascading’ forms of management. These culminate in the standardised micromanagement of clinical care. Much of this derives from models from competitive corporate industry. While such intense and rigid management may eliminate some of the worst clinical practice, it may (unintentionally) prevent the best. This is most likely where flexibility, creativity and attuned imagination are required to enable growth and healing. New forms of Service Design and Economy (eg NHS Trusts and Commissioning) may work well with easily treated and clearly defined physical pathology, but are likely to be problematic, even harmful in other healthcare areas.
The psychology of practitioners is both cause and effect in relation to these changes; likewise the broader professional culture. Vignettes of contact with senior colleagues, over a thirty-five-year time-span, are used to illustrate some assumptive-worlds that lie behind these themes.
No Country for Old Men
My early apprenticeship in psychiatry, from the early 1970s, was blessed and guided by two older men, my supervising consultants. These fatherly mentors were models for compassionate and creative professional dialogue: head, heart and soul interwoven seamlessly into their many-faceted communications. Although young and otherwise restless, I valued the cultures and communities they ‘fathered’ and wished to prolong their influence on me. Between them, I stayed five years. Now, more than thirty years later, I evoke these mentors and memories with warmth, admiration and gratitude: sweet–sad clouds that guide me still.
Dr G was a South African Jewish man whose family had fled Nazi Germany. As a young adult he became increasingly troubled by his comfortably privileged status in the Apartheid State. The two types of authoritarianism confronted him with resemblances, if not equivalence. To live more amicably with his conscience, he shipped his young, burgeoning career and family to England: he would train as a psychiatrist here, in the Mother of Democracies.
Fifteen years later I joined him, to begin my own training. This apprenticeship was in a large, grandiose late-Victorian Asylum, more recently poor and provincial Mental Hospital. He had a soft green-eyed gaze; observant, enquiring, encompassing. A sharp intelligence was swathed in a softly reticent, self-deprecating courtesy and deft, gentle irony. The beginnings of a stooped posture reminded me of his many stoically carried burdens and his ancestral losses. On many occasions we sat together to make some kind of ‘assessment’ of an individual’s bruised and faltering struggle with, and against, their biological predicates and their existential tasks. He would listen with empathic detachment; his attention sometimes free-floating, sometimes sharply converged. Drawing together our ensuing discussion he would often say: ‘I suppose we could call that …’. His cautiously and ambivalently hued language was no accident: he well understood the inadequacy of our tools of language or science, in their assigned tasks of defining or changing complex human predicaments. When the psychiatric language seemed to offer some pragmatic guidance or clarity, he was transiently and conditionally grateful. We would talk of how easily an over-extension of our quasi-medical vocabulary would turn help into hegemony; compassionate containment into prescriptive control. We considered the seductive dangers of aggrandising our partial metaphors into didactic conclusions. I remember an especially fruitful dialogue, over coffee, exploring how the Lord of Language becomes The Definer. I thrived in the inviting and reflective space he created to initiate such discussion. In my youth and optimism, I did not anticipate how rare such sanctuaries would become.
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The next mentor I sought out worked in the very different setting of a large, (then) prestigious Teaching Hospital. Dr R had, I thought, similar qualities to Dr G, but in a High-Anglican form. Spawned from an old and respected ‘medical family’ in the Home Counties, his salubrious, educated background progressed with a kind of blessed and urbane inevitability, through Oxbridge to his medical training. World War II interrupted such euphony with discords of terrible violence. As a young army doctor he tended the battle-shattered and trauma-deranged in North Africa. Earlier, at a distance, he had inferred the Black-Hole of human destructiveness, growing up in the legacy of the previous war. Now he witnessed it directly. Thirty years later he talked to me of this awakening: how a tidal wave of experiences impressed on him, as no theory could, the complex, fragile interconnectedness of all: mind and body, friend and foe, libido and mortido. Garnering whatever could help men restore and heal, he began his life-task and scholarship; to offer a sensitive but pragmatic service of ‘Psychological Medicine’.
By the time I joined him, his department embodied the sophisticated pluralism of his experiences and intent. Although a busy service, covering a large General Hospital, there developed through and around such tasks an informal University of ideas. Alongside psychiatrists, I was engaged and guided by open-minded psychoanalysts and refreshingly rethinking medical anthropologists. Fertile experimentation enlisted other groups: GPs exploring the unexplicit psychological subtext of their work, medical students taking on patients for psychodynamic psychotherapy (the results were remarkably good, and probably not just for the patients). Without any higher edict, plan or mandate, we were all studying the Psychology of Affliction. Remembered now, from a current perspective, it seems almost impossible that this fecund community of learning and healing blossomed independently of any centrally directed NHS management or plan.
Dr R was tall and imposing, though he chose not to impose. His considerable intelligence and knowledge were quietly flanked by a kindly wisdom. I remember us listening to a many-chaptered, harrowing account of a woman’s long and complex difficulties; how the medical and psychiatric organisations and mind-sets had habitually missed the personal meaning of her struggle. He looked up from the voluminous case-notes, weighing heavily on his lap. His blue eyes glinted both gentle humour and sorrowful recognition. ‘It may be the best this kind of psychiatry can do’, he had said. This was no condescending judgement, rather a stoic lament for how our complexity so often eludes our determined attempts to encage and understand ourselves.
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In that decade, rapid technological advance proceeded amidst swirling philosophical challenge. From the structured, scholarly enquiries of Medical Anthropology and Sociology, to the more poetic and maverick challenges of Szasz, Laing and Illich, the stolidly revered worlds of medicine and psychiatry were being deconstructed. Fundamental questions regarding the relationship of subjective to objective knowledge, and of these to language, power and agency – all of these became matters for public and professional debate. As in all genuine philosophy, it was the process of enquiry and dialogue that was enriching, not the (impossible) end of providing definitive answers. I did not, then, appreciate how robustly dialogic those times were. Remarkably, I cannot remember talking with Dr G or Dr R much, or even, explicitly, about the challenging scholars or the rebellious luminaries, but they had somehow distilled their spirit for private consumption. These Two Wise Men had developed a kind of potent humility, a demonstration of how wholesome (self) doubt could be harnessed to great therapeutic leverage. Philosophical curiosity need not be the reserved preserve of the leisured, or the academic.
* * * * * * *
More than three decades have passed. I am now older than either Dr G or Dr R when I apprenticed for them. My work in Medical and Psychiatric Practice is as near the end now, as it was in its beginnings, then. Despite, and because of, the passage of so many years and so many different experiences and influences, I value their values and modae operandae even more. But though my faith is solid, my optimism is not.
* * * * * * *
‘Manage or be managed!’ an executive young NHS consultant, Dr T, had exclaimed sharply to me in recent years when I lamented the loss of familiar forms of colleagial and cooperative dialogue. I was not sure if his remark was meant with any humour or irony, but I reflected later on how pithily it captured our changing world. Simultaneously it conveyed description, prescription, prophecy and ethos. This utterance came from a world far from my early influences of the Hippocratic Oath, or the gentle sagacious guidance of any Dr G or Dr R, or the better kinds of confederate socialism that had nourished and encouraged the NHS in its earlier years. This now is a world of corporate industrialism, large competing organisations, and the then inevitable hustling, hassling, spinning styles of authoritarian management.
* * * * * * *
More recently still, for the first time in many years, I am involved in disputed negotiation with, and between, NHS Trusts. The problematic area is one which used to be called ‘Psychosomatic Medicine’: substantial chronic physical disease, fuelled and exacerbated by the sufferer’s ongoing life-problems and conflicts. Such an association has to be discerned, not only by the experienced and imaginative practitioner, but increasingly by the (self) afflicted patient. It is an operational arena of interfaces, often paradoxical: Psyche–Soma, Subjective–Objective, Art–Science, Determinism–Choice, Procedure–Innovation, Individual consciousness–Generic biology. Unlike procedurally-based areas of medical practice, it relies on ‘induction’ quite as much as ‘instruction’, to help in the restoration and growth of resilience and health. Induction is the evocation and development of internal, personal resources; Instruction is the application of external, impersonal resources and notions. Generally then, induction is dialogic; instruction is didactic. Induction is (more) receptive; instruction propulsive. Applied with functional synchrony, they are two essential components of Holistic Care: like the pulsing heat; receptive in diastole, propulsive in systole.
Problems arise. The ‘systolic’, instructive, propulsive aspects of medical practice can be (relatively) easily measured, managed and standardised. The ‘diastolic’, inductive, receptive components cannot. Politicians, health-economists and planners, managers and clinical directors are likely to see the way to greater effectiveness and economy through increasing standardisation, mass-production, instructive management. The burgeoning plethora of audits, goals, targets, ‘treatment packages’, NICE guidelines, league tables, QUOF points – all are designed to supercharge the ‘systole’ of propelled, executively-managed care.
What then happens to the ‘diastolic’ functions of care? Diastole needs time and space for the heart to fill, for systolic thrust to be possible. Likewise, we need the time and space for the art of induction, the inter-subjective dance that makes the objective then possible. As with families, we need freedom-within-structure in order to function well, both individually and collectively.
The structure we can engineer, mass-produce, manage. The freedom we cannot. We must instead assure a respectful space, a skilled conservationism.
* * * * * * *
I attend this meeting of managers because my long-running ‘Psychosomatic’ service has been terminated by two mistrustfully allied executive NHS Trusts. This happened by oblivious default, without consultation with those most affected: the patients, referring clinicians or myself. Protests from all were parried by the kinds of skills, ‘correct’ avoidance and ellipse that large organisations use so frequently as a first line of defence. The new Trusts, and their employees, are now part of a corporate quasi-industrial world. This confers a new, but continuing, Darwinian struggle for survival of the fittest, with all the evolutionary feints, deceptions and traps – the behaviours of threat and fear. There necessarily follow changes to our mental life; our priorities, then our values: our individual thought-process, then our collective culture.
The psychosomatic work I do may have been valued by patients and clinicians for many years, but it has not been executively planned and is thus not a contractual obligation of any Trust. Occupying a territory of interfaces, it does not feature in the thrall of official goals or targets, or the threat of complaints or litigation. For the survival of the Trusts, it confers no evolutionary advantage. Ipso facto, there is no problem and no need.
* * * * * * *
As I listen to the guarded forays, assertions and retorts of these Corporate Managers and Managing Clinicians, I am struck by their acquired sureness of style and resolve of language. In this new world of competitive commissioning, expressions of doubt, ambiguity or respectful hesitation are likely to be seen as hazardous indecision, implied submission. To survive, an aura of potency, resolve and business must be maintained. These Commissioning Officers, who are now paid to commodify and trade in areas of outstanding natural complexity (human suffering), become powerfully and subtly changed by this new kind of market economy. Trusts’ negotiations and spokespersons must now appear, like senior politicians or multinational corporate bosses; authoritative, confident, decisive. The product marketed must appear definite, clear and assured. ‘Confidence’, as with the banks, becomes less an internal state of real assets, more of a hypnotic strategy, illusion, even deceit.
* * * * * * *
The economy determines the language.
‘Providers’ now spawn ‘treatment packages’. Fascinatingly kaleidoscopic forms of difficulty and distress are speedily designated to ‘Mental Illnesses’ or ‘Disorders’, and hence streamed to the ‘appropriate intervention’. There is no language (or time) here for the ambiguous, the nascent, the naturally evolving; the semiotics of symptoms, the creative possibilities of uncertainty. The language is systolic.
* * * * * * *
And then the language determines the thinking.
The monoculture language, intended to expedite the functions of system and symptom management, does not merely provide utilitarian thoroughfare. Like tarmac roads, such prevailing or exclusive language destroys other forms of intellectual life or thought. An unmitigated use of psychiatric or organisational language will, for example, lead to reification; an unwittingly obstructive consequence of language. Mental illness becomes a ‘thing’, akin to a Cataract or Inguinal Hernia. Sometimes this is unrivalled in effectiveness as a guiding metaphor, a procedural template. At other times, other kinds of language and understanding will yield more: the symptom as lever, language, sacrifice, catalyst or code; the sufferer as messenger or conduit; ‘illness’ as encoded social or personal construct or contract. The development, and discriminating use, of a wide repertoire of such ‘modae cognitiae’, constitutes the bedrock of any ‘Art’ we may bring to our Medicine or Psychiatry. The heart of this art must have Diastole and Systole in constantly changing, but functional synchrony. When this does not occur, the interpersonal or clinical disturbance represents a kind of dysrythmia.
* * * * * * *
And then the thinking determines the (inter) action.
‘There’s only one way to manage this kind of psychotic patient…’ avers Dr T in a way that seemed to impute to any attempt at discussion, qualities of incompetence, ignorance or insolence. In fact, both the patient and situation were rich with possibilities of understanding and encounter. The man’s psychotic difficulties turned out to be a minor part of what responded to a more holistic and personal approach. But Dr T’s utterance reflects far more than his particular nature, or his response to this scenario. It exemplifies the problems of excessive government, management and executive control in matters that are also personal, protean and delicate. The highly structured, proactive ‘bullish’ vocabulary and style is endemic amongst Corporate Captains. It now risks becoming epidemic in areas of complex human care, where it can do real harm.
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In my many youthful years of apprenticeship to Dr G and Dr R, I never heard such sharply prescriptive or didactically summary communications. These recollections are not only about departed individuals, their sterling and subtle qualities and my long-enduring admiration. They are also about changed times and cultures, and about the loss of values that could flourish in organisations that were more collaborative, colleagial and cooperative; when doctors were more vocational and less careerist; when managers did more to facilitate and less to control.
How would Dr G and Dr R have fared in this current world, to which Dr T is so much better adapted? To my consternation, my imagination deserts me.
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