Planning, Reform and the need for Live, Human Sacrifices: Homogeny and Hegemony as Symbols of Progress
rigid attempts to get others to standardise or ‘modernise’ are often shrugged off as a kind of Zombie-Curse of
large organisations. But what are the hidden psychological and social currents that so burden and reduce us? How
does it start? Who is responsible?
I have spent most of my four decades in the NHS as a single-handed
GP and part-time Psychiatrist. I was always interested in the subtle shifts and balances required between opposites,
to make our better understandings and interventions. Central to these is the general truth of the species (‘Science’)
.v. the particular variation of the individual (‘Art’). As electronic technology makes mass management of
communications and information more efficient, I fear the loss of creative diversity to increasingly standardized,
anonymised procedures, professionals and premises. I fear the loss of Art in Medicine and Heart in Practice.
Inescapably, the world becomes more populous, and our lives longer
and more complex. Governments’ responses tend to increase goals and targets, directives and legislation. Official
policy turns easily to officious practice. There, any Holistic considerations are disregarded in favour of visible
submission to itemized edicts.
In Healthcare this can, paradoxically, be discouraging, even destructive
of best practice. Such requires conditions of flexibility, discrimination and personal investment. Institutions,
by their nature, require homogeny and hegemony. Inevitable tensions arise between the Institutional and the Interpersonal
whenever there are large-scale and complex human variables. Dextrous and imaginative care is needed to navigate
and balance between these. A current narrative of an anomalous NHS practice, and a brief sampling of other, darker
times, serve as metaphors to explore these themes. The descriptions, events and encounters are authentic. Usual
devices disguise the characters only.
‘Our sense of power is more vivid when we break a man’s spirit than when we win his heart’.
The Passionate State of Mind (1954)
wise become as the unwise in the enchanted chamber of Power whose lamps make every face of the same colour.'
Walter Savage Landor
Imaginary Conversations (1824-58)
When I sought sanctuary, twenty years ago, in a large, fadedly-handsome
and age-weary 1830 church I was equally amused and bemused by my fate. The previous lease for my General Medical
Practice had been terminated in rapid and unforeseen circumstances. Amidst my anxious and fevered searchings I
found this cavernous, deserted, forlorn space. Despite the superficial decrepitude of neglect, I immediately sensed
an august serenity, a rare comforting quiet in this ancient recess. As an agnostic Jew, I chuckled at my location
and fortune. I was in my fortieth year.
Those early omens foretold a fertile and appreciative relationship
between occupants and space. At the start of these two decades I resettled my practice and celebrated my feelings
for my occupational new home with a profusion of delights for the eye and comforts for the body: impressionist
and expressionist period prints, hand crafted and painted objects, plants, substantial and comfortable furniture,
warm and luminous background colours. All recorded and amplified a long and loving investment: the satisfactions
of the patient gardener.
This eccentric locus and mode of institutional healthcare has provoked
a steady stream of spontaneous comment. Most often people would speak, with surprised warmth and bright-eyed delight,
of the informal, inviting ambience, its oasis-like incongruities. Very rarely I was encountered by surly, malcontent
modernism: ‘What are you doing in an old building like this? Can’t the NHS afford anything better? ...’ These brief,
cold gusts were rare, but they chilled me: I somehow knew they were harbingers of a vigorous new culture, sharply
focused and uncompromisingly business-like. From the fragile peace of my oasis I glimpsed the approaching dust-clouds
of new orders and reform.
The NHS Surveyor’s report felt like a thud of both inevitability and
threat. Amongst the many alleged deficiencies or aberrations of ‘current acceptable standards’ stood an obelisk
of ‘lack of provision for the disabled, especially access and WC facilities.’ There is no counter-balancing comment
on the unusually aesthetic or comfortable environment and its great popularity among staff and patients (including
the disabled), which are much in evidence. To the uninitiated, the report conveys a picture of neglect, negligence,
hazard, drear of the premises and certain abject discomfort (and worse) of its occupants. This is not a place for
safe or viable contemporary medical practice. This is the view of an expert on premises with a narrow, executively
prescribed brief, who does not speak to its inhabitants.
What of the inhabitants of this alleged nest for potential mal-function:
myself, my many staff, my two-thousand patients. The human eco-system of perpetrators, victims, both?
The unheeded evidence is decisively and dramatically opposed.
In summary: Results from my patient-experience questionnaires have
been consistently and exceptionally good, and among the best on record. Most of my various staff (Nurses, Assistant
Doctors, Receptionists, Administrators etc) stay for many years, leave on good terms and have little sickness leave.
I, myself, continue blessed with good health and have never taken sickness leave or had a substantial complaint
made in twenty years. There has never been a significant accident. Disabled patients have cheerfully accepted help
with access (when needed), and our explanations and apologies regarding any difficulties (when needed). ‘It’s worth
it,’ they have said, ‘I prefer to come here …’
Holistically, this eco-system is working well in its anachronistic
If ‘bad’ premises are defined as those likely to lead to a ‘bad’ effect
on its occupants (surely the most meaningful definition), how can we best understand a ‘bad’ premises (as defined
by an expert surveyor) hosting remarkably ‘good’ results (as defined more Holistically by medical and personal
feedback)? When expected correlation breaks down (as in my practice) which set of data and concepts should be discarded,
and which retained and valued?
It occurs to me that much of this management difficulty arises from
a confusion between ‘correlation’ (a ‘sometimes’ relationship, which allows exception of many kinds) and ‘equation’
(an ‘always’ relationship, often causal, that allows no exceptions). At its best such confusion may lead to clumsy,
indiscriminate decision making. At its worst it is a major source of the most frightening and destructive human
acts. There is a spectrum from dogmatic over-inclusiveness, to fanaticism and elimination of the most horrific
Correlation mind-sets may lead to aspiration and guidance. Equation
mind-sets tend to intractable ideology and mandate.
I do not need persuading that disabled people and their needs (among
numerous groups) have been poorly understood and represented. I see clearly how improving awareness, dialogue and
facilities can help them with their predicaments.
I point out to my managers that I am a relatively small inner-city
practice in an area where patients have many practices to choose from. The disabled patients I have are all intelligent,
informed adults who understand my predicament (lovely old building, very difficult to radically transform etc)
and are well able to make their own choice. They choose to stay.
I also point out that with the cumulative growth of newer premises
designed with full disabled facilities, that the problem is bound to disappear. Older practitioners and their premises
will be naturally retired, to be replaced by more contemporaneous designs. With guidance and careful projected
planning, the provision for the needs of this group (and others) will grow solidly and surely. There is no need
for ideologically postured co-ercion, or destruction.
What, then, is the need for an urgent cull of the obsolescent?
In my frustrated dystopia I seek the counsel of two NHS Managers.
The first, Sam, a genial man, stooped-before-Andropause, with a passive,
damply-anxious hand-shake. He listens initially, I sense, with gratuitous fascination. Soon, he shrugs, a mixture
of apology and embarrassed dismissal. He looks away. ‘Look,’ he says, ‘I probably agree with you, but that’s got
nothing to do with it … I don’t make the rules … I’m just doing my job …’ As his voice fades away, my mind involuntarily
reels back some forty years to a black and white television image of a bespectacled, unremarkable looking man in
a glass armoured box in a court-room. Quiet, unassuming, clerically mannered and plausibly rational. Adolf Eichmann
on trial. I shock myself and shudder invisibly, grateful that my life is of this generation. I ponder how close
is imaginative intuition to paranoia.
The second, Paula, shakes my hand with a dry, sure, decisive grasp.
Her sympathy has a canny edge. I sense she has a well-ordered and well-filled stock of elegantly pre-packed answers.
She offers me one: ‘Yes, I understand, your points are very valid … Unfortunately, our hands are tied by current
legislation. We cannot allow any exceptions, as we have no power or right to exercise discrimination in these matters.’
This declaration is concise, courteous and consummate: an impeccable
wrapping of political correctness. I flounder with clumsy perplexity. Surely this cannot be true: ordinary policeman
arbitrate about whom to confront with (say) speeding or illicit drug use. This happens thousands of times daily.
And when were the laws on Blasphemy last applied consistently? A lather of protest foams from my mouth.
She quietly listens to my foaming, looking down at a pen which she
revolves between her fingers. A gold-plated Rollerball; smooth hegemony. She then looks up at me, radiating a consoling,
winsome smile; patient, experienced, forbearing. I understand I am misunderstanding something fundamental.
‘Yes’ she says euphoniously, ‘but how is any of that going to help
you? Authorities won’t make that explicit. They talk only of official Policy: “x is the law: offenders are liable
to prosecution” ... Don’t you see?’
I do, but I don’t want to. My foam is difficult to swallow.
When Jed is addressing the media his voice has a tough, compact alacrity.
Now, at his kitchen table at the end of a long Westminster political day, he sounds wearily ironic.
He had earlier been humoured though harangued by my semi-parodic analogies
of contemporary politically fuelled NHS reforms with 1930’s Soviet Five Year Plans. We share a fascinated scholarship
of the follies, horrors and genius of the 20th Century.
‘I’m a happy Kulak’, I lampoon-protested. ‘I’m productive and settled
on my small allotment… I definitely don’t want to be forced onto a Collective Farm … I don’t even want to be shot
Jed knows that my jesting both expresses and conceals much fear, anger,
and anticipatory grief about my uncertain fate. Our shared laughter dies and the mood darkens. He rises and shuffles
slowly to a favourite old armchair, a trusted friend to contain and support his strong but work-enervated frame.
He well understands my relationship with the old church. He unbuttons the top of his shirt, a further loosening
of the bonds and demands of public service.
‘We politicians, planners and change-merchants often make almost impossible
tasks even more difficult … One of the things that happens is we lose the bigger picture, and with that much else
goes; flexibility, creativity … our imaginative humanity. But difficult change often needs a lot of effort and
resolve. So, we change-merchants, and our buyers, both need evidence of ‘progress’, to keep going (and keep our
jobs). This easily leads to the kind of deception and self-deception that, decades later, startle us with grandiose
ideology and then the eventual grotesque cruelty … The Communist Commissars developed such a strong belief in the
Collectivization Programme that they would go to any lengths to ensure recruitment and conformity. The human cost,
and even the clear evidence of tragically large production losses, became utterly eclipsed by the enormous ideological
bulk of “The Plan” …’
‘What’s often most frightening is how sincere, vocational and visionary
the agents of change can believe themselves to be. People often think of Nazi SS Officers or Stalin’s Communist
Commissars as being sadistic opportunists. The truth is more shockingly ordinary and paradoxical: they often truly
believed they were making the world a better place. ‘Doing what needed to be done.’ Many were sincere ideologues
who needed ‘evidence’ of their success.’
I consider my own current drama: massively small and benign, in comparison.
I think about the predicaments and modus operandae of my NHS Managers whose reputations, jobs, mortgages, maybe
even self-esteem may depend upon offering up (to their managers) visible tokens and totems of change. To leave
me be, in my benign and atavistic place, would be symbolic of their inertia and inactivity as agents of change.
Allowing natural evolution through retirement might feel and appear like managerial impotence. A live human sacrifice
‘How do we maintain vision, momentum, resolve and caution, flexibility, openness all at the same time?’ A rhetorical question, Jed knows. He groans, a
tiring acknowledgement of his insoluble dilemmas, the conundrae of power.
‘On reflection, I don’t think I’ll bother any more … I’ll just sit
here, where I have peace and quiet … ‘, he pats the arm of his old chair, his comforter and container. He darts
me a witty mischievous smile, a mock-surrender to my self-interested, insistent doubts and questions.
We sit in a restorative silence. Jed, I think, needs some respite
from clamour and challenge. I want time to assimilate this bigger picture to my own small story, so important to
As my mind recedes from its 20th century panorama and returns to my current preoccupations, I think again of how fortunate I am to be
living where and when I am.
In my fortieth year I chuckled insouciantly at my fortune. In my sixties
I am less mirthful, but more mindful. The consolations of ageing are hard-won and subtle.
‘Conformity is the ape of harmony’
– Ralph Waldo Emerson (1940), Journals
Copyright ©; Dr David Zigmond 2006
This has been published in Journal of Holistic Healthcare, Vol 9, Issue 3, Dec 2012
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
Version: 12th December 2013