Wednesday, 28 September 2016

TRUMP - THE ULTIMATE SHOWMAN

28 SEPTEMBER 2016  - I watched the televised debate between Hillary Clinton and Donald Trump, broadcast on 26th September. 

Hillary Clinton was the consummate professional, as would be expected of a senior world politician who has occupied and bestrode the corridors of power for decades, and had her home in the White House as First Lady. If a wealthy casino and hotel owner such as Trump had sought a meeting with her as Secretary of State, I guess she would have met him - they are both major New York figures - but probably have kept him at arms length, and given him eight minutes, before her aides politely escorted him off the premises, pressing an autographed photo into his hand; and before she returned to serious national issues. States-person Hillary was on top form.  

It was the first time I had watched Trump in action, other than 30-second sound-bites on TV news. I was astonished to see that he is incapable of forming a coherent sentence; mixes syllables from different words to make new words with incomprehensible meanings; and blusters nonsensically through contorted body language, tortured smiles and grimaces, like a double glazing salesman suppressing acute indigestion. How on earth does he attract any support from anyone, irrespective of their education, politics or job? We have all, rich or poor, dealt with fumbling salesmen and seen through their shallow trumpery and promises. How does this man, with his ridiculous blonde toupee, seduce and command a large following of fellow Americans? 

The gestures that most struck me were his peculiar hand and finger movements which he employs to emphasise a point when he runs out of words and simply repeats whatever slogan enters his mind at that moment, while cricking his head sideways and grotesquely puckering his lips. When caught out in debate or challenged personally, Trump goes through these gyrations and responds very waspishly. At first it put me in mind of the Monty Python song - He's a Lumberjack and He's OK - but there was an older memory that was nudging through from the past - particularly when Donald turned his grimace into a lip-smacking winning smile for the cameras. In the 1950's my mother liked to watch Liberace on our little black & white TV and I sometimes watched that King (or Queen) of showbiz performers,draped in white furs, jewels and sequins, crooning and grinning at us from Behind the Candelabra. He was doing Liberace.

Donald was using the same nods, winks, frowns, soundbites and flummery, with similar hand gestures, to win adulation and applause from his fans. All that was  missing from the act was Dear Mother and Brother George. Donald has learned that words do not matter when communicating with the great American public. He writhes, he agonises, he weeps, he bullies, he gossips, he struts, he flounces, he flicks his peroxide wig, he flaunts his sparkly, shiny wealth, he stabs,  he needles, he spurns the establishment, he cries all the way to the bank, he preens, he twinkles and sympathises and empathises with the mute, impoverished, ignored masses. He seduces millions with his empty, meaningless banter and antics. 

Move over Liberace - prancing Donald has stolen all your gimmicks and your limelight - and America is entranced. The American Dream Has Come True. My mother would have loved his gigantic, self-serving showman's ego. And, at the end of his life, he will press the nuclear button and take us all with him, in a brilliant puff of light, over the rainbow, to Nirvana - Beyond The Casino Candelabra. 

More...  TRUMP - SANDERS - CORBYN - MIDAS

Tuesday, 20 September 2016

IF YOU WANT GOOD HEALTHCARE - SEE A VET


After 40 years of practice as a doctor in south London, aged 70, with no complaints from patients in those 40 years, following this excellent report by the NHS in June 2015, Dr Zigmond was dragged into a disciplinary hearing courtroom the day after he returned from a week's holiday; with no time to prepare, facing 8 hours of lawyers' questions and hundreds of pages of "evidence", was not allowed an adjournment or appeal - and had his office and surgery shut down without notice - with a closure notice on the door. Patients are distraught, the surgery team are in shock and Dr Zigmond is in despair. Buy his book and send a note of support.

The ousted doctor: 'My patients' souls matter most' - The Guardian

www.theguardian.com › Society › Health
Dr Zigmond at Amazon books

2 days ago - Dr David Zigmond had plenty of time for his patients – but not for bureaucracy. Now the plug has been pulled on his surgery. Angela Neustatter ...

What changed from the excellent 40 years record in June 2015 to September 2016? Dr Zigmond had a book published, chronicling his experience of de-humanising changes in the National Health Service over his lifetime, entitled:

"They" obviously didn't like his book and "they" shut him down; overnight, without notice, and barred his patients. This is his diary of the shocking event. 

My view: The doctor has been abused by vicious, poisonous "colleagues", intent on forcing people into "compliance" with their pen-pushing and computer report rules - or ruining them. It wholly illustrates the articles Dr Zigmond has been publishing for decades, mapping the takeover of caring medical services by zombie robots. This injustice needs an instant Judicial Review, before the medics and patients lose hope.


Intelligent Monitoring Report Dr David Zigmond (St James Church Surgery) St James Church (North Aisle) Thurland Road London SE16 4AA June 2015
****
EXCELLENT - 59.2% - 86.2% - 91.4% - 89.8% - 92.00% - 91.5% - 97.9% - 72.3% 

GPPS004: The percentage of respondents to the GP patient survey who stated that they always or almost always see or speak to the GP they prefer. (01/01/14 to 30/09/14) 59.2% 

 -GPPS014: The percentage of respondents to the GP patient survey who stated that the last time they saw or spoke to a GP, the GP was good or very good at involving them in decisions about their care (01/01/14 to 30/09/14) 86.2% 
 GPPS015: The percentage of respondents to the GP patient survey who stated that the last time they saw or spoke to a GP, the GP was good or very good at treating them with care and concern. (01/01/14 to 30/09/14) 91.4%
 GPPS020: The percentage of respondents to the GP patient survey who stated that the last time they saw or spoke to a nurse, the nurse was good or very good at involving them in decisions about their care (01/01/14 to 30/09/14) 89.8%

 GPPS021: The percentage of respondents to the GP patient survey who stated that the last time they saw or spoke to a nurse, the nurse was good or very good at treating them with care and concern. (01/01/14 to 30/09/14) 92.0% 

 Dr David Zigmond 1-495556335 Domain ID: Indicator description (time period) Observed Average Numerator Denominator Z-score Z-score range Intelligent Monitoring Report June 2015 GPIM V102 Page 9 of 9 Caring 

GPPS025: The percentage of respondents to the GP patient survey who described the overall experience of their GP surgery as fairly good or very good. (01/01/14 to 30/09/14) 91.5%

 GPPS001: The percentage of respondents to the GP patient survey who gave a positive answer to 'Generally, how easy is it to get through to someone at your GP surgery on the phone?'. (01/01/14 to 30/09/14) 97.9%

GPPS023: The percentage of respondents to the GP patient survey who were 'Very satisfied' or 'Fairly satisfied' with their GP practice opening hours. (01/01/14 to 30/09/14) 72.3% 


*******

 September 2016
Death by Documentation:
The penalty for corporate non-compliance


David Zigmond
© 2016
  
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

Background
In the last twenty 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 long-established 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: 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 required 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.

‘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 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 note-keeping, 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.

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, cooperation, 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 unuseful 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 crop-sprayed 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-fifties, 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.’

‘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-taking 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 “cherry pick”, 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.

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 fortieth 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 coordinated 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 Magistrates 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 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. 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 amongst 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 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: thirty-nine years as a Principal GP; never a formal complaint needing a hearing; excellent long-lasting and warmly appreciated 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 self-referring 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 thirty minutes. We are assembled for the summary and verdict.

The senior Magistrate delivers this: ‘In my twenty-seven 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 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?

*

‘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 side-stepping: ‘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?

-----0-----

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


Interested? 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

Monday, 12 September 2016

THE PLANNER - LONDON'S FUTURE?

https://www.amazon.co.uk/Planner-Tom-Campbell-ebook/dp/B00KT57Y82

I rarely read contemporary novels set in London, or any city society; usually plucking a science-fiction or even science-fact paperback off the airport or rail-station book-stand. But, leafing through Tom Campbell's novel The Planner, initially captured by a memorable, striking snake-like shape on its cover, I was immediately caught-up in the author's most alien (to me), exotic and strange society, set in a London landscape that I find is entirely familiar. 

It was an alien abduction - not by little green men from Mars, but by what my fading and failing aged generation used to call Yuppies -  young upwardly-mobile professionals. These now not-so-young creatures, brilliantly portrayed and observed in all their haunts and habits, incidentally consume limitless amounts of sex, alcohol, drugs and partners, while holding down good jobs and playing out complex relationships.

They commune in central London, north and south of the twisting-shape that I had immediately recognised - the snake-like tidal River Thames flowing under Tower Bridge, by the City of London to the north, and by Southwark to the south; being the iconic focus of every map of that famous built landscape. In an earlier age, before these fascinating yuppies were conceived, I worked with Southwark developers of wharves and Technology Parks, and latterly on sea-level-rise at Tower Bridge. Tom Campbell's laconic hero, James, is a London Borough of Southwark Planner. Here we met, despite the age gap. 

We, my grey-power, post-war 1950's baby boomers and I, did not have "carnal knowledge", or drugs, could not afford alcohol, and married our childhood sweethearts for seventy-years of faithful conjugal bliss. The book's characters, who, like modern "customers", only need first names, break all our rules, without even knowing there once were rules. They casually indulge in Sinful Acts that would make the banned and scandalous Lady Chatterley blush and would once have condemned and damned us all to Eternity in Hellfire, after a short Earthly life punished and plagued by incurable STDs: (if you have ask - you are not a yuppie alien). 

But our heroic James navigates this intriguing moral, urban and civil landscape with relative ease. He mingles with powerful developers and financiers, attends tedious planning-meetings, debates with academics, falls in and out of love, snorts cocaine and parties through the night; and effortlessly embraces the e-revolution; determined all the while to do his bit to transform The London Plan. 

I have learned much about the next generation, and enjoyed the book's mastery of its subject and language; that I would have missed had I automatically picked up another sci-fi book displaying alien suns, moons and planets, urging me to "Boldly Go". It sometimes pays to be thoroughly Earthed and explore the alien but accessible world of top topical authors. Its a good read.

https://www.amazon.co.uk/Planner-Tom-Campbell-ebook/dp/B00KT57Y82

Thursday, 25 August 2016

GOD GIVEN RIGHT TO FIDDLE THE BOOKS

So, within a week of EU and UK threats to jail crooked accountants and lawyers, here come the legions who are hell bent on defending the inalienable God Given rights of bent accountants to continue to fiddle the books with "complex" (i.e. fraudulent) transactions. There will be multitudes of these folk rising from the sewers - who are embedded in the political, administrative, justice, business and society systems.

If only, if only, we could all send ourselves invoices, from our offshore companies, made up after the real transactions are known, to wipe out all our taxable income - what a wonderful, fairyland world it would be. If only we could all disguise our incomes, down to zero, with ENRON & Arthur Andersen bookkeeping entries.

Riding to the rescue of Crooks Against Communism - against those evil social forces who want individuals and companies to pay the taxes we all pay, that keep our nations functional for business - comes Jack Lew, US Treasury Secretary, waving his mighty cavalry Sword of Truth. 

With tax-unpaid $32 trillion hidden offshore, he will find many allies, from every corrupt corner of the world, to join his gang, "For they are Legion". Jack Lew wrongly states that taxing multinational US companies will take money from US taxpayers' pockets. But, it will not, as all the major companies are holding their massive cash reserves off-shore, legally free from US taxes, until and unless they bring the cash home to invest in the US, and end US austerity.

My letter to The Guardian 31 Aug 2016:
The USA, Ireland, UK and all Crown Territories tax-havens fully support Apple’s divine right to cut its EU tax bills by $13 billion – by sending itself no-fixed-abode cyberspace invoices to wipe out £150 billion of profits (Guardian headline 30 Aug 2016). All our businesses and citizens surely have the same legitimate rights. To ensure a “level-playing-field” and promote “small-government”, I trust you agree that we should all send ourselves fantasy E-invoices to wipe out all taxable income and thus zero our tax-bills.

Noel Hodson - Director
Tax Reconciliations, Oxford UK,
Tel +44 1865 (0)760994 Mobile 07713 681216




Previous article - last week:

And here are today's reports, as the forces of darkness summon their demons, to condemn ordinary people to continued austerity and, in impoverished regions, to collapse into chaos.

US threatens to retaliate over EU crackdown on corporate tax deals

https://www.pressreader.com/uk/the-guardian/20160825/281874412825979
5 hours ago - US threatens to retaliate over EU crackdown on corporate tax deals ... Cook has called the tax investigation 'political crap' and vowed to ...

Trans-Atlantic Spat Looms Over EU Crackdown on Corporate Tax ...

www.wsj.com/.../trans-atlantic-spat-looms-over-eu-crackdown-on-corporate-tax-deals-1...
6 days ago - The U.S. and the EU are far from seeing eye-to-eye over the bloc's ... Trans-Atlantic Spat Looms Over EU Crackdown on Corporate Tax Deals ... tax measures by the U.S. and threatens to undermine broader U.S. and EU ...

US in last-ditch effort to quash Brussels tax demand on Apple - FT.com

www.ft.com › World › Europe › Brussels

14 hours ago - The US has launched a stinging attack on the European Commission in a ... into an alleged sweetheart tax deal that Ireland granted to Apple, the biggest single case in a crackdown on corporate tax avoidance across the EU. ... the US touched on sensitivities over Brussels' accountability by suggesting that ...

Trans-Atlantic Spat Looms Over EU Crackdown on Corporate Tax Deals

www.universiteitleiden.nl/.../trans-atlantic-spat-looms-over-eu-crackdown-on-corpora...

23 hours ago - There is a growing conflict between the US and the EU about the investigation by the Commission under the EU State aid rules into so called ...

US warns Europe over $19bn tax crackdown on Apple - International ...

www.ibtimes.co.uk/us-warns-europe-over-19bn-tax-crackdown-apple-1577899

4 hours ago - US warns Europe over $19bn tax crackdown on Apple ... The US has warned it will be forced to retaliate if the European Union (EU) goes ahead with plans to demand billions of euros in unpaid taxes from Apple. ... "We are concerned that the European Commission's state aid investigations threaten to ...

Pfizer's merger collapse prompts speculation it will seek new takeover ...

www.theguardian.com › Business › Pfizer
6 Apr 2016 - Pfizer's deal with Allergan is the second major deal it has attempted to ... immediate speculation on Wednesday that the US drugs company would turn its ... The US president described global tax avoidance on Tuesday as a ... Shire is now itself in the throes of taking over the Illinois-based .... Eu tax havens.

USA at war with EU: US warns Europe over plan to demand MILLIONS ...

www.hotapplenews.com/.../usa-at-war-with-eu-us-warns-europe-over-plan-to-demand...

4 hours ago - US warns Europe over $19bn tax crackdown on Apple · uk.finance.yahoo.com / about 3 hours ago. The US has warned it will be forced to retaliate if the European ... with plans to demand billions of euros in unpaid taxes from Apple. ... US companies over tax deals ahead of a ruling on tech giant Apple.