David Zigmond: The extinction of care by treatment—our healthcare’s heart failure

david_zigmond2At the end of last year, the media had a brief frisson over another dark story from our NHS: seven recent suicides and one homicide involving people who were acutely mentally ill. The transient newsworthiness came from the probability that the deaths were preventable: psychiatric beds were sought for these patients, but none were available. Typically, the media story has rapidly passed from view and memory, but the vast problems it signifies are still very much with us. What are these problems? How have they arisen and what can we do about them?

Forty years ago I was a young psychiatrist. I remember hearing hopeful talk about how more scientific forms of diagnosis and treatment would make longer term and residential care unnecessary: specialist delivered, focused treatments would make extended forms of human containment unnecessary. The benefits to mental healthcare would be similar to those achieved in surgery: speed, accuracy, efficiency, and economic savings. The closure of large mental hospitals became a celebrated symbol of this. My view, although youthful, was jaded: we were over-reaching our medically modelled treatments to complex human distress.

Most of these early doubts have proved dishearteningly accurate. As a now veteran inner city GP, I have seen the dismemberment, then disappearance, of our better forms of long term containment and care. It is not just that many psychiatric hospitals have closed, it is that the wider ethos of those places—compassionate containment—has become increasingly rare. I find it almost impossible now to find for my patients the kind of protective spaces and relationships that are essential for many kinds of healing and growth—the kinds of investment I could more easily make as a young practitioner.

How has this happened? How—amid our plethora of Royal Colleges, think tanks, specialist training, and massive resources (yes!)—have we departed so far from our better sense and sensibility?

I think our error has been a failure to heed the subtle differences, yet synergy, between treatment and care, and to then lose our capacity to craft our best therapy. What does this mean?

First, some subordinate notions: generally, care comes from ethos, while treatment comes from technology; care is about wholes and relationships, treatment is about parts and mechanisms; care springs from—then returns to—the intersubjective, treatment remains closely tethered to the objective. Treatment may fix, but it is care that heals. The best of our healthcare balances these with ceaseless sentience.

In recent times, we have lost the skills of blending these delicate amalgams. Paradoxically, this is owing to the many and dramatic successes of our technological treatments: we have then adopted such activities as the dominant and determining paradigm. So, increasingly we have replaced care by treatment; personal understandings by formulaic care pathways. Pastoral healthcare now suffers from a stark inverse relationship: the technologically complex sharpens and burgeons; the humanly complex is short circuited and neglected.

Such displacement of care by treatment is seductive, for treatment seems to bypass human vagaries and uncertainties and, instead, anchors us to what can be reliably manufactured, measured, and managed. But, like many seductions, this is specious: it obscures what we may lose: our unindustrializable humanity and the realms of relationship, imagination, and meaning.

The economic costs of our lack of human containment are hard to measure but probably vast. This is because much distress is pleomorphic: it takes on other forms and is then dealt with by other agencies: A&E departments, the police, social services, probation, courts, lawyers, prisons (a desperate asylum), other medical specialists . . . the list lengthens with investigation.

Such human and economic cost extends far beyond psychiatry. The submission of care to treatment has weakened the entire spectrum of pastoral healthcare. In a culture dominated by goals, targets, financially linked points, managed procedures, and care pathways there is, ineluctably, less and less head space and heart space to nourish human imagination and connection. What then?

To start, we become demoralised and alienated.

Morale and a sense of connection are crucial to human activities and welfare. Several decades of research has recurrently shown how important these are in the genesis and outcome of innumerable health and welfare problems. Parallel to this is evidence of NHS healthcarers’ increasing demoralisation and burnout: officially in statistics of sickness, early retirement, career abandonment, emigration, drug and alcohol abuse, and litigation.

More informally, this flows steadily in innumerable stories and descriptions of professional loss, alienation, and stress: how our convivial healthcare “family” has turned into a hostile network of siloed and fractious factories; personally infused acts of care become executively managed procedures; the quiet warmth of vocation becomes the staccato clamour of career. Such accounts have common undertones: bleak loneliness, dispirited ennui, and impotent anger.

By contrast, good quality care nourishes the giver as well as the recipient, for care—unlike treatment—is rooted in relationships. This is what we have jettisoned.

“Seven suicides and one homicide” was a deserving headline, yet it is merely the iceberg’s tip. Far beneath the surface, extending massively, lies the dying body of an ancient healthcare ethos.

How can we resuscitate a dying culture? What are the best conditions to foster experiences of meaning and connection in our work?

As with any living culture, we must first depend on a nurturing substrate. Yet the foundation of our NHS is now formulated in such a way that is becoming heedless of this vitalising principle. Healthcare is now governed by purchasers and providers; competitive markets; commissioning; commodification; and boundaried, autarkic trusts. In such a milieu our contacts and experiences become disinvested in human interest and relationships. This situation now confronts us with a very difficult dilemma, for to make a path back to a humanly nourishing and sustaining culture will require the demolition of many of our recent developments.

The stakes are high: contention will be fierce.

David Zigmond is a GP in London.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.

  • danny

    I bumped into your blog looking up the phrase ‘dispirited ennui’ a phrase which I sought to use in reply to a plan to update a back pain pathway. The emblematic discord between the rush to fix and gifting both the patient and carer space to allow for healing, found voice in the contrasting approach of neuro-surgeons to my gentler acceptance of how this difficult ‘self’ shattering condition can be. The challenge for me is that fixing is done in snapshots of lives and on parts of humans whereas healing is observed in the sharing of narrative over time. Something which remains for me as I disregard the clock in my gp practice starting all too many consultations with ‘thank you for your patience.’ Your sentiments are great to hear and resonate for many. I trust the seeds of reconnection with misplaced – not lost wisdom – are being sown. BMA conference quoted Carlo Levi “the future has and ancient heart” I agree.