Why have things gone so wrong? And what can we do about it?

David Zigmond, a member of DFNHS’s Executive Committee,  summarises his thoughts, drawing on five decades of experience as a frontline doctor


Only some politicians might dispute how damaged and dire is the state of NHS general practice. Is there a primal reason for this?

Yes: apart from the well-known funding issues, it is the successive reforms that modelled healthcareincreasingly on competitive manufacturing industries, rather than traditional vocational welfare networks.

How have the reforms been implemented?

The reforms have mandated three convergent streams:

  1. The 4Cs: Competitive commissioning, commercialisation and commodification. A marketised system.
  2. REMIC: remote management, inspection and compliance. This operates akin to an air traffic control centre, but directing people. A policed system.
  3. Gigantism: the coerced closure of smaller, more local units, then amalgamated to ever-larger,more remote ones.  A purblind juggernauted system.

Why do these make for such problems?

Because they all contribute to these lock-stepped changes: industrialisation, standardised compliance,managed proceduralisation and generic consultations.


So what gets lost?

So much! … Crucially personal continuity of care. So personal relationships, bonds and understanding. Then a sense of community with both colleagues and patients. We are then left with a no-one-knows-anyone-but-just-do-as-your-told- and-follow-the-algorithm service.


And then?

Then the job becomes progressively humanly deskilled, artless, heartless, lonely and joyless.


Because doctors lose the sense of personal context, connection, community and meaning in their work. How can they then skilfully guide, contain or comfort? Even if they can treat successfully, how can they heal?


These lost things made for the élan vital of our erstwhile much more stable and happy general practice … and many of our kindred welfare services. If we industrialise-out these essential components of healthcare, both doctors and patients become importantly impoverished and function less well.

So we have much to learn from the past?

Certainly, though learning does not necessarily mean copying exactly. So we should study and heed what used to work well and find how to grow contemporary equivalents.

In the main, what does that involve?

Utterly abolishing the NHS market. Drastically reducing and editing REMIC. Reversing much Gigantism.


So what would that look like?

More small and local practices securing partnerships and championing personal continuity of care. Leaner, more intelligently focused and inspection regimes; a reestablishment of professional trust and autonomy dependent more on a vocational ‘police presence’ than a micromanaging Police State…



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