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Balancing healthcare: Technical vs Personal. Local vs Systemic. Closures at Lewisham Hospital

Dear Joan Ruddock MP and Lord Ara Darzi

I heard your important but brief debate on BBC Radio 4 on 26 January. As expected, your arguments were cogent, though polarised. What was not explicated was the inescapable conundrae we now have in contemporary healthcare: that there are, increasingly, juxtaposed principles we must balance – these are technical
vs personal, objective vs (inter)subjective and science vs art. The conundrae arise most clearly when we cannot easily combine these, when they remain antithetical: then we need the wisdom of our best compromises. As you have demonstrated, finding the right balance is no easy task.

I am a long-serving, small-practice City GP with an attentive view of people and their relationships. I think we have a growing problem – paradoxically – from the indisputable success of the scientific/technical/objective in certain areas: because of these successes they have largely hegemonised our mindsets, budgets and plans in
all areas of healthcare. This has then led to an inadvertent neglect of the personal/(inter)subjective/art in healthcare: people! We have lost our balance and this is now manifest in our healthcare centres being often technology-rich but humanity-poor: shock headlines pillory the worst examples, but it is clear to me that this sinister new pattern has much to teach us.

Yes, of course it is important that we receive the best technical care, but we must attempt to do so in a humanly-scaled and responsive milieu, where people feel seen, heard, understood, connected and cared-for. These interactions are complex living processes which can only survive with the interpersonal equivalents of space, oxygen, nutrients and habitat. For these we need a ‘family’ environment, if we are to perform our ‘factory’ tasks with rooted and growing humanity.

Yes, larger regionalised Specialist Units may logistically provide better technical care, but how do we combine high volumes of technically exacting and urgently required work (that is needed for the procedures of
treatment) with a personal sense of connection and understanding (that is required for the care of healing)? For when we industrialise healthcare to treat more efficiently, the care often drains away. If we are not mindful of this, it becomes inevitable.

If we take the examples of Stroke, or Coronary Care, it may make good sense to centralise and specialise skills and expensive resources, and this is probably reflected in good results. But results will be better still if
personal connections and communications are regarded as an equal priority. This is even more so with chronic conditions. The required balance of centralised efficiency vs locality identifications needs careful thought: it may be very different for different people.

This is now a formidable task as the personally connected aspects of the NHS have suffered from inadvertent but parlous selective inattention. I now work in a health service where, increasingly, patients cannot name their GP or hospital consultant, doctors have little personal knowledge or understanding of their patients, colleagues do not know one another, Hospital Consultants do ward rounds with junior staff and nurses they do not know, seeing patients for a first and only time ... There are many more examples. What kind of therapeutic contacts, affections or care can develop in such a system? What happens to staff morale? Our shock-headlines provide a darker part of the answer.

The causes of such industrialised healthcare casualties are numerous, complex and sometimes obscure. The fact that very large organisations with rapid human throughput may have difficulty in positively bonding with and understanding complexly distressed individuals may be easy to discern and explain. Other decisions and events which alienate, depersonalise, dislocate and demoralise may be more obscure, but just as real. Examples? The dispersal of hospital nursing schools to Universities; the European Working Hours Directive; the amalgamation of smaller, identity-rich Medical Schools; the abolition of GP personal lists; the economic discouragement of small GP practices; the demise of the General Physician – all such have contributed to our ever more tightly managed, but anomic, healthcare.

How we reinfuse and re-enthuse our often misindustrialised healthcare with human heart and professional art, is an endless and difficult challenge, for the problems now have deep cultural roots. If we can discern our
excessive uses of industrialisation, informatics, systems management, competition, commodification and commercialisation, we may be able to act with more intelligent restraint. Those smaller, more fragile and imperilled, caring aspects of healthcare may then revive and, possibly, flourish.

Small and large, generic and bespoke, art and science, universal and vernacular, all address different aspects of our complex health needs. We need matching, complex, though pragmatic, responses. There are rarely (if ever) solutions, only our wisest compromises.

I have a distilled slogan for all of this: ‘Healthcare is a humanity guided by science’*

With best wishes

David Zigmond (GP)

PS It is probably self-evident that I write to encourage and provoke thought and discussion. I welcome contact about this and related matters. If you want to see what all this looks like on my NHS frontline I’d be happy to show you: I think you’d find much to interest you.

I have explored these themes widely in several articles, which are available online via http://www.marco-learningsystems.com/pages/david-zigmond/david-zigmond.htm

If you are interested, I suggest:

Continuity of Care: Of course, but whose? A Sleight of Slogans
Fallacies in Blunderland: Overschematic overmanagement: perverse healthcare 
From Family to Factory: The dying ethos of personal healthcare

Copyright © David Zigmond 1986, 2010

Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com

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Version: 27th February 2013

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