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The tragic legacy of our serial GP reforms



Why and how are we caring so ineptly for the services that must care for others? The current plight of general practice has much to teach us.

A long view, from personal experience, may help here.

When I first worked in general practice, in the 1970s, the standards were far more variable, but the profession mostly had higher morale and sustainability. This wasn’t due to better pay or working hours: they weren’t. Our greater work satisfaction came from now-vanishing personal relationships, understanding and trust. GPs have rarely had the glamour, drama or heroism of specialties such as cardiac or neuro-surgery: the more humble but subtle rewards came from being family doctors: from long tenures in smaller practices, we got to know not just individuals, but their families, their stories, their localities.

We could then better perceive less obvious patterns, meanings and experiences to enrich our understanding. Thence came the art of practice: our offers of attuned comfort, containment and guidance. These professionally-boundaried intimacies were not just good healing encounters for patients – they also provided the human warmth and interest to motivate and nourish the doctors.

The term ‘family doctor’ could also be understood from the doctor’s experience. We then felt part of a professional family that functioned largely from a basis of trust and understanding. Like biological families, there was variation – sometimes hazardously so – but the practitioners and patients were mostly happier with this. Recruitment was fertile, rancour much rarer, retirement usually delayed and reluctant. The service was clearly accessible and sustainable.

Yet amidst all this, our serial reforms have achieved a remarkable synthesis that many might have thought impossible

The accelerated reforms, such as Lansley’s Health and Social Care Act (2012) have destroyed these family-like tendencies in favour of factory-like control and uniformity. The thinking behind this presumes that these measures will bring greater reliability, safety and efficiency by eliminating human vagary, error and caprice. So modernising reforms have increasingly emulated competitive manufacturing industries and the ethos of neoliberalism.

This family-to-factory march has relied on three synergistic principles of management:

  • The 4Cs: Competition, commercialised commissioning and computerised commodification. A marketised system
  • REMIC: Remote management, inspection and compliance. This is akin to proceduralised surveillance and instruction from a control tower. A policed system
  • Gigantism: Scaling-up wherever possible to facilitate REMIC management for presumed greater compliance and efficiencies. ‘Get big or get out’

These three elements of ‘modernising’ reforms have brought us our current nature of practice. Micromanagement has replaced trust; data has replaced personal understanding; procedures trounce relationships; compliance dismisses professional discrimination or judgement … and vocation perishes as corporation flourishes.

This is what we have now: a system whose insistence on uniformity, fail-safety and compliance is so great that it has extinguished the profession’s motivating human heart and spirit.

More than 40 years ago, I enrolled as a family doctor and didn’t have children. I would, then, have encouraged any young person wishing to craft together medical science with social and intimate humanity to follow. Now my children have grown and I’m decommissioned as a ‘primary care service provider’, I have no such optimism.

More worrying for me is my own future: when I become very frail and vulnerable, who will look out for me and personally understand my decline? It’s unlikely to be a GP who knows me, or knows the importance of this to me.

Yet amidst all this, our serial reforms have achieved a remarkable synthesis that many might have thought impossible: we have devised a system that manages to combine the most venal, careless, opportunistic, divisive and unsustainable aspects of market capitalism with the insentiently monolithic, paranoid and fearful stupefication of centralised Soviet Communism.

In our quest to care for others, that is quite an achievement.

Dr David Zigmond is a retired GP in London, also trained in psychiatry