David Zigmond

St James Church
(Home to the author’s NHS surgery for three decades:
a now vanished island of community – of personal continuity of care)

Photo by Ruskin Kyle

Why do humans suffer?
What do we want and need with, from, and for one another?
Who decides?
And how?

Short introduction for perusers

This is a ‘literary’ website. It is not one in which you will find quick opinions, ready and easy facts, contact links, ‘how to’s’, or handy hints. Instead it offers a kind of accessible philosophy: exploring questions of meaning and what we may all-too-easily overlook of certain important aspects of our experience and understanding.

So if this is not what you want, swipe, prod or look away now…

Longer introduction for readers: How to use this website: some navigational aids

So, welcome to this Archive site, which has grown over many years to offer a large amount of material. Although the site’s scope was initially anchored to a wide range of healthcare and Welfare questions, you will find much now that ventures far beyond. From the atavism of our sexuality, to the vilification of human relics. From Putin’s power, to when is deviation harmful perversion?

What follows here are several decades of articles, together with more recent open letters, interviews and brief videos. All of this is arranged like a very large traditional library, so you’ll need some explanation, a guiding map and signage.

The following suggestions may help you find what most interests you more quickly and easily. If you choose and click on the Table of Contents (black box on the left) it will link you to your choice.

Sections A to G provide professional and historical background and testimonials to the many writings and dialogues that follow.

Section G collects together articles and letters pertaining to the sudden ending of my forty years as a family doctor – why and how this happened and what it (accurately) predicted of the fate for future services.

Sections H, I and J are self-explanatory.

Section K is devoted to letters. These are generally short and more polemical. They are listed similarly to the articles, with dates and themed titles. The few longer letters are indicated by the number of pages.

Section L contains the articles: these are generally longer pieces, with more human description and discursive analysis. They are chronologically listed with the year of writing, together with a brief synopsis. Some have designated icons (see below).

Transcripted interviews are grouped in Section M.

The length of articles, interviews and longer letters is indicated to help match readers’ choice, stamina and appetite.

Icons are used to indicate some more specific trends:

• Reviews of books and films are symbolised by   Review and Review.
• Most of the articles are evidently ‘holistic’ in intent, eg they attempt larger views to include often overlooked patterns of ecology and individual and social psychology. However, some articles have mental health and hidden psychology as a central focus. They are indicated by   Mental Health and Hidden Psychology. 
• Those taking holism as an explicit and central focus are designated by  Holism
• Some articles detail and thematise the history of changes witnessed by the author, as shown in the human (rather than technical) aspects of our healthcare. These are symbolised by   Time Traveller
• Those articles illustrated by both historical and more recent personal vignettes are tagged by Then and Now 
• Many letters directly dispute the balance of healthcare governance shifting so much towards mistrustful micro-management, corporatised gigantism and commercialised industrialisation. Those changes are usually to the detriment of social and personal relationships and understandings. As you will see, in the last two decades the consequences of this shift have become ever-more evident and crucial. The longer and many articles that centralise these themes most strongly are symbolised by   Balance of Governance

Section N is a monograph summarising much of this. It is also published by the Centre for Welfare Reform.

Some articles may have particular interest for readers because of explored historical analogies or other enquiries. These are iconed by Particular Interest and are also listed in the separate green box, under the Table of Contents (found to the left of the screen).

Some of the contents of this Home Page can also be found on other publications’ websites, eg the Centre for Welfare Reform, Open Democracy, International Times, British Medical Journal, British Journal of General Practice, Journal of Holistic Healthcare, Doctors for the NHS, national newspapers and YouTube.

L. Articles, chronologised

[1] The Medical Model – its Limitations and Alternatives. (1976)
What it says in the title! Uses the example of an ailing, elderly man struggling with later-life changes. The biomechanical can only take us so far: after that we need a certain kind of imagination. What is that?
(11 pp).   Particular Interest

[2] Suicide and Attempted Suicide: Its Origin and Course. (1977)
Serious kinds of mental illness and self-harm are most easily designated. But what about more subtle forms of self-damage and self-sabotage? What are they?
(10 pp).  Mental Health and Hidden Psychology    Particular Interest

[3] Out of Sight But Not Out of Mind. (1977)
Those who professionally care for others are often much harsher with themselves. Overall, doctors have higher suicide risks than their patients. Why?
(10 pp). Mental Health and Hidden Psychology

[4] Scientific Psychiatry: Progress or Regress? (1977)
Medicine and Psychiatry operate from a premise of taking responsibility and defining reality for others. What are the implications for those who need to reclaim these capacities, for themselves?
(9 pp). Mental Health and Hidden Psychology

[5] Illness as Strategy and Communication. (1977)
Illness is often best understood and approached beyond the biomechanical. Experiences or conflicts not otherwise manageable can find a refuge and conduit in illness. How and why?
(10 pp). Mental Health and Hidden Psychology

[6] Adjustment or change? Radical issues in psychiatry. (1978)
Often mental distress is designated in a way that further ‘pathologises’ and stigmatises the sufferer. How may we, rather, reframe our problems in ways that are self-realising and empowering?
(15 pp). Mental Health and Hidden Psychology

[7] The Elements of Psychotherapy. (1981)
A short survey written for Doctors. How may thinking and talking with another person help the harmony of body, mind and relationships? How to start and when to stop?
(15 pp).  Mental Health and Hidden Psychology

[8] Transactional Analysis in Medical Practice: Part 1. (1981)
A clear and flexible model helping us understand the different parts of ourselves and others. How are these related to our unique stories, and then our patterns of concord or discord?
(11 pp). Mental Health and Hidden Psychology

[9] Transactional Analysis in Medical Practice: Part 2. (1982)
A continuation of Part I. How are so many repetitive unhelpful patterns set up in childhood, to last a lifetime? If we can understand, when is this helpful in redirection?
(9 pp). Mental Health and Hidden Psychology

[10] A Psychosomatic Approach. (1982)
How, by expanding the biomechanical approach into a more multifaceted holism, can we broaden and deepen understanding and engagement with individuals?
(15 pp).    Particular Interest  Mental Health and Hidden Psychology

[11] The Psychosomatic Mosaic. (1982)
A further coaxing of the biomechanical into a broader holism. How can individual illnesses be encountered and understood in family systems?
(17 pp).    Particular Interest  Mental Health and Hidden Psychology

[12] Mother, Magic or Medicine? The Psychology of the Placebo. (1984)
Placebos are fascinating phenomena of induced interpersonal healing, sometimes by accident! How does this happen? What are the developmental and transactional psychological theories that can explain?
(16 pp). Mental Health and Hidden Psychology    Particular Interest

[13] Physician Heal Thyself: The Paradox of the Wounded Healer. (1984)
What are the personal vulnerabilities of doctors? How are these related not only to individual wounds, but to idealised roles and depersonalised trainings?
(18pp). Mental Health and Hidden Psychology     Particular Interest

[14] Babel or Bible?Order, Chaos and Creativity in Psychotherapy. (1986)
Theories of mind are only ever ‘good-enough’, for now. What happens when psychotherapists (and others) elevate their theories to a realm of Immaculate Truth?
(13 pp). Mental Health and Hidden Psychology

[15] Three Types of Encounter in the Healing Arts: Dialogue, Dialectic and Didacticism. (1987)
Knowledge, language and understanding are all human activities and constructions. What are the different types when we encounter others? How do we then ‘pack’ or ‘unpack’ the experience of these others? How, when and why does it matter?
(19 pp). Mental Health and Hidden Psychology

[16] The Psychoecology of Gladys Parlett. (1988)
Distressed people often want skilful, if ritualised, human contact. What happens if we unimaginatively and excessively medicalise this? Gladys, in the 1980s, forewarns us.
(9 pp). Mental Health and Hidden Psychology

[17] The Front Door of Psychotherapy: Aspects from General Medical Practice. (1989)
The communicative skills – enabling others to heal, grow and become more resilient – have been distilled and documented, especially by psychotherapists. What happens in other venues with these kinds of complex exchanges? How is this enacted in General Practice?
(19 pp). Mental Health and Hidden Psychology

[18] The Shadow of Venus: Atavism and Sexuality. (1995)
Our sexuality is one of the more tragi-comic deciders of destiny. Can an understanding of our evolution, as a species and as individuals, explain why?
(10 pp).    Particular Interest

[19] Edward: shot in his own interest. Technototalitarianism and the fragility of the therapeutic dance. (2005)
We have become accustomed to almost everything being prepacked, containerised and computer-coded. This has happened to knowledge. What happens to personal knowledge?
(10 pp). Balance of Governance

[20] Planning, Reform and the need for Live, Human Sacrifices : Homogeny and Hegemony as Symbols of Progress. (2006)
What are the hidden psychological currents that may lie behind zealous attempts to ‘modernise’ and standardise? Some motives may be obscured and dark. How are they expressed?
(12 pp). Balance of Governance

[21] Modern Times: True Parables from the Frontline of the NHS. (2007/2017)
Change is often called ‘progress’. Looking at changes in healthcare, this considers two themes: ‘Imagination’ and ‘Belonging’. When is change progress?
(16 pp). Balance of Governance Mental Health and Hidden Psychology

[22] No Country for Old Men: The Rise of Managerialism and the New Cultural Vacuum. (2009)
The more we control, the less free we are to explore. If we increase the culture of management, what happens to the spirit of enquiry? And patient care? A historical account.
(12 pp). Time Traveller Mental Health and Hidden Psychology

[23] Psychiatry: Love’s Labour’s Lost: The pursuit of The Plan and the eclipse of the personal. (2010)
In psychiatric and psychological healthcare, personal attachments and investments in therapeutic work have been eclipsed by ‘objective’ attempts at management. What has this been like for patients and staff? A thirty-five year spanned portrait.
(13 pp). Time Traveller Mental Health and Hidden Psychology

[24] Why Would Anyone Use an Unproven Therapy? Treasures in the Mist. (2010)
Much of the most effective work healthcare workers do is inexplicit and undesignated. What does it, then, consist of? The Wizard of Oz has much to tell us.
(9 pp).    Particular Interest

[25] Idiomorphism: the Lost Continent How diagnosis displaces personal understanding. (2011)
Diagnosis is a professional convention enabling us to cluster and code. Sometimes it is essential and crucial to help. At other times more is lost than gained. What? Why? Who?
(12 pp). Balance of Governance Mental Health and Hidden Psychology

[26] Resolved or Abandoned?Irresponsibly lost Transference: a professionally embarrassed tale. (2011)
Psychotherapists increasingly talk of managed and schematised personal change, but often the catalysts are serendipitous. What can happen?
(4 pp). Time Traveller Mental Health and Hidden Psychology

[27] Sense and Sensibility: The danger of Specialisms to holistic, psychological care. (2011)
Few would want an operation done by a non-specialist. So is specialisation always a good thing, with every kind of distress? Can we go too far? What happens then?
(8 pp). Balance of Governance Mental Health and Hidden Psychology

[28] How to help Harry – Friend or Foe? The scientific and the scientistic in the fog of the frontline. (2012)
Helping others to change can be a very delicate dance. Attempts at ‘civic engineering’ frequently miss nuances of meaning and opportunity. Does this matter? Why?
Published in Journal of Holistic Healthcare, vol 14, Issue 3, Autumn 2017
(8 pp). Time Traveller Mental Health and Hidden Psychology

[29] Eric – diagnosis may sometimes be.necessary; it is rarely sufficient. (2012)
Centralised planning and control are key to the success of many healthcare initiatives, for example the containment of dangerous infectious diseases. But what are the limits of this approach? Eric shows us what can happen in mental healthcare.
(14 pp). Time Traveller Mental Health and Hidden Psychology

[30] Fallacies in Blunderland: Overschematic overmanagement: perverse healthcare. (2012)
Competition, commissioning, contracting … do such devices really ‘drive up’ the quality of healthcare? Are there other, absurd and darker consequences? What are these?
(11 pp). Balance of Governance

[31] From Family to Factory: The dying ethos of personal healthcare. (2012)
NHS healthcare has transformed looser, informal, colleagueial networks of care into tighter, sharper, more managed ‘production units’. We have turned families into factories. What have we lost?
(7 pp).  Balance of Governance

[32] Understanding the Other: Four elemental questions for therapeutic psychology. A personal view. (2012)
When attempting to understand and help the anguish of another, what kind of knowledge helps us most? What lies behind and beyond designated systems? Can one have a ‘holistic psychology’?
(4 pp). Mental Health and Hidden Psychology

[33] Words and Numbers: Servants or Masters? Caveats for holistic healthcarePart 1. (2012)
Holism’s fuller engagement with realities is an aspiration and ideal. It can never be complete, and in practice, there are many obstructions. These range from our use of language to our highly managed and industrialised culture. How does this happen? What are the consequences? This is the first of two articles.
(12 pp).    Particular Interest    Holism

[34] If you want good personal healthcare, see a Vet. Caveats for holistic healthcare Part II. (2012)
The over-explicit and over-schematic can block our perception of larger and more subtle realities. This second of two articles portrays how this happens, and what we may be left with.
(10 pp).    Particular Interest     Holism

[35] Democratic Fatigue: information overload. (revised) (2012)
Is increasing choice and information always what we want? Do these necessarily facilitate democratic sense and empowerment? The non-participation in recent Police Commissioner elections suggests otherwise. Parallels in healthcare are instructive.
(2 pp).    Particular Interest

[36] Missed and Miscommunications: Personal disconnections in Psychological Healthcare. A letter for embattled colleagues. (2013)
Throughout our most important, difficult and intimate relationships we must be able to listen carefully to what we do not want to hear – without this much is jeopardised. This is true, too, in many of our healing encounters – often these require our best attempts to creatively contain dissonance.
(10 pp). Mental Health and Hidden Psychology

[37] PsychoTapas. (2013)
PsychoTapas! Sound-bite seminars for modern conferences!

[38] Institutional atrocities: The malign vacuum from industrialised healthcare. (2013)
Flagrant neglect or abuse in our care of the vulnerable within our advanced Welfare State seems shockingly perverse. How and why does this happen?
(11 pp). Balance of Governance

[39] Beyond Orwell: Healthcare’s hollow governance. (2013)
Our smallest difficulties with others are often rich in political complexity. What does this mean? Two apparently trivial examples from healthcare administration are explored.
(12 pp). Balance of Governance    Particular Interest

[40] Language is not just data: it is a custodian of our humanity. (2013)
Computers and informatics have become central to NHS healthcare. All experience and activity are now subject to official technical designations. This changes our communications: language becomes increasingly lackeyed to the computer’s requirements. Much else is lost. What?
(6 pp). Time Traveller    Particular Interest

[41] Post Mid Staffs: A Plenitude of Platitudes. (2013)
Can the harmful excesses of depersonalisation in healthcare be usefully addressed by further redesign of systems and management? Or do we need a different kind of thinking and vocabulary?
(4 pp). Balance of Governance

[42] ‘GPs know their patients, families and communities’ – Really? (2013)
GPs are increasingly employed as task-directed, upper-echelon healthdroids. They are losing the pastoral skills that depend on holistic views and vernacular understandings. Why is that?
(3 pp). Balance of Governance

[43] Hello, Health Commissioner. Goodbye, Family Doctor? The new healthcare reforms and their threat to personal doctoring. (2013)
The idea, now diktat, that GPs should lead the complex provision of healthcare for localities may subtract more than it adds to overall health-welfare. How and why could this happen?
(5 pp). Balance of Governance

[44] All is Therapy; All is Diagnosis. Unmapped and perishing latitudes of healthcare. (2013)
Advances in medical science have often subtly and inadvertently subverted human connections and understandings. Vignettes spanning sixty years show how and why.
(12 pp). Time Traveller

[45] Our Ill-faring Welfare. The hinterland of our headlines. (2013)
Despite ever-increasing funding and management initiatives, our public welfare services seem riddled with unhappiness, corruption and sometimes cruelty. These are alarming paradoxes: how do we understand them?
(11 pp). Balance of Governance

[46] Bingo! Majoritarian Healthcare! (2013)
Transparency, Accountability and Democracy can seem like a protective triumvirate for public decision making, but these can easily turn shallow, demotic and false. Here is a small example of what is coming.
(5 pp).   Particular Interest

[47] Where in the World are You? Miraculous cyber; insidious dislocation. (2013)
What do mobile communications, Internet sex and modern schematised health systems have in common? – a computer mediated disconnection of intended content from embedding human context. What happens?
(10 pp).   Particular Interest

[48] Form Devouring Essence: When brokered services tend broken hearts. (2014)
Our healthcare rhetoric of data and systems has largely destroyed our capacity to make the kind of personal bonds that understand and heal human dissonance. Stephen and his plight serve to illustrate and explore this.
(8 pp). Balance of Governance Mental Health and Hidden Psychology

[49] Autoasphyxiation: The doomed brief of GP Clinical Commissioning Groups. (2014)
The corralling of GPs to design and commission health services cannot counter the inherent disintegration and depersonalisation of Marketisation. A glimpse from the frontline.
(5 pp). Balance of Governance    Particular Interest

[50] Some Countercultural Caveats for Pastoral Healthcare – the fractious coexistence of packaged care and therapeutic spirit. (2014)
Pastoral healthcare has a crisis of competence, morale and humanity. This currently eludes enormous funds and myriad think-tanks. The elusions are subtle. What are they?
(7 pp). Balance of Governance

[51] Neglect in NHS Healthcare? (2014)
We have turned families into factories.
(3 pp). Balance of Governance

[52] Packaged Mindfulness? Some unpackaged pieces of mind. Can our integrity and wisdom thrive with mass-production? (2014)
Our increasing push-buttoned and systems-managed world has produced myriad losses of human relationship and personal sentience. Can this then be countered by modern packaging of ancient wisdom and practices? Is this our wisest approach?
(16 pp) Mental Health and Hidden Psychology

[53] A day in the life. (2014)
Man Overboard! A brief autobiographical cross-section
(6 pp).

[54] NHS England 2014: Vichy France 1941: The old ghosts in our new NHS machine. (2014)
Governmentally prescribed schemes to increase democratic accountability in Welfare are easy to intend, yet very difficult to implement. They can easily backfire to unanticipated forms of oligarchy or totalitarianism. How does this happen?
(15 pp) Time Traveller    Particular Interest

[55] Our unravelling humanity: do we need more regulations? (2014)
To its credit the government seems to now be understanding the importance of lost human connections. The response, though, is predictable: it is to add to Healthcare’s already massive regulation. This may add rather more to our problems. How?
(6 pp). Balance of Governance

[56] PBR, PBC, PCT, CCG, CMHT, CBT, NICE, QUOF: NHS Alphabetti spaghetti? A guide for the perplexed: a critical glossary. (2014)
What do the plethora of NHS institutional terms mean? Why are they important to understand? And what is their relationship to one another? Can this help explain our current malaise in healthcare? Here is a critical glossary.
(10 pp).    Particular Interest

[57] Mass-produced Mindfulness for Common Mental Health Problems: The awkward dance between managed systems and human meaning. (2014)
A greater and calmer sentience is key to much of our better health and life-experiences. Can we mass-produce methods to achieve this?
(5 pp). Mental Health and Hidden Psychology

[58] Our Welfare is ill-fared by yet more strictures and structures. (2014)
Surely, all Welfare professionals should forever be more strictly appraised and registered? Here are some reasons why not.
(4 pp). Balance of Governance

[59] Six Suicides and One Homicide. The catastrophe of jettisoned personal containment in healthcare. (2015)
Care and treatment are different though synergistic. The increasing trend to executise treatment over care destroys this critical complementarity. The consequences show us how important are such balances.
(9 pp). Balance of Governance Mental Health and Hidden Psychology

[60] Healthcare’s Hole in the Heart : Can we have value for money and not lose our humanity? (2015)
Efficiency has now become cardinal in healthcare management. Increasingly methods from competitive production industries have been adopted. Yet the results are often paradoxical and demotivating. Why is that?
Published in British Journal of General Practice, November 2019
(11 pp). Time Traveller

[61] Appraisals: how do we assure safety without asphyxiation? (2015)
‘We can’t carry on like this!’ is now a familiar cry of impotent frustration throughout Welfare services. Clearly we need challenges to our dysfunctional order. Yet our officials’ responses are often redolent of the last gasps of Empire: draconian authority with officious nervousness. What is happening?
This example – of General Practitioner Appraisals – is a telling microcosm.
(10 pp). Balance of Governance

[62] A Fortunate Man: the vulnerability of vocation. A major work revisited. (2015)
A Fortunate Man – a searching portrait of a country GP by essayist and novelist John Berger – was first published in 1967. It projected a highly personal view of medical practice: one undertowed by rich human complexity. Nearly fifty years later, what does this anciently pioneering book offer us?
(12 pp). Review

[63] Rick and Ajita: How may we reconcile systems of healthcare with our subtle humanity? (2015)
Systems – our ordering of commonalities – have contributed greatly to our treatment of structural disease. Elsewhere systems are much more problematic. Rick and Ajita show us how and why.
(9 pp). Balance of Governance Mental Health and Hidden Psychology

[64] Evidence from Professional Appraisals? We learn more about the governors than the governed. (2015)
Professional Appraisals have become often absurdly complex, cumbersome and remote, and then blindly authoritarian. Now they obscure and destroy more than they can assure. What, then, do Appraisals tell us?
(3 pp). Balance of Governance

[65] Off-piste: only fresh tracks lead to fraternalism in healthcare. (2016)
Care Pathways – executively designed systems for all – can easily displace the nourishment of our healthcare from fraternalism. What is that? Two intimate vignettes illustrate.
(10 pp). Mental Health and Hidden Psychology

[66] From Balint to Square-bashing. Fifty years’ experience of General Practice. (2016).
Our healthcare’s increasing employment of complex technology is often accompanied by a disinheritance of our human complexity. This inverse relationship is undesigned but ever-more important. A personal history of the culture explains.
(9 pp). Time Traveller

[67] Preventing Overdiagnosis? Yes, but what kind? Part 1: Geography. (2016)
‘Preventing overdiagnosis’ should be an undeniable call. Yet even to agree a definition will prove impossible. To understand why it requires us to look far beyond the workaday tenets of our professional practice: the hinterland is vast. This is the first of two parts.
(9 pp).    Particular Interest

[68] Preventing Overdiagnosis? We need fewer systems and more philosophy Part 2: Geology. (2016)
Contemporary medical practice now harvests two new and increasing tranches of diagnosis: first, subjective experiences of discordance, disturbance or distress; then symptomless but risk-linked biometric anomalies. These have led to a massive medicalisation of areas of life often better otherwise understood.
(13 pp).    Particular Interest

[69] Revitalising Holism. We need literature of wit and grit more than piety and idealisation. (2016)
‘Holism’ can easily become a politically correct, liberal healthcare catechism. A recently published book of sterling values, The Snake in the Clinic, illustrates the problem. Here is a review.
(5 pp)   Holism

[70] Our ailing profession. We need more than resilience and replenishment. (2016)
The malaise among NHS healthcarers is akin to the patient dying from an internal haemorrhage: oral replenishments, or even transfusions, may be very inadequate. A recent day conference parried this perspective.
(8 pp). Balance of Governance

[71] Can Art’s courageous experiments also be accessible? A review of a brief work of brilliant obscurity. (2016)
Sometimes art and philosophy tantalise us with ideas or experiences we can never quite ‘get’. Sometimes, we may suspect, this is the author’s intent. Can this, nevertheless, enrich us?
(4 pp). Review

[72] How and Why Do We Retire? Ill omens for younger doctors. (2016)
The nature of our departures from our work often tells us much about what kind of problems are being left behind. The individual may escape, but what about the wider community?
(6 pp). Balance of Governance

[73] Introductory note to Death by Documentation. (2016)
(3 pp).

[74] Death by Documentation: The penalty for corporate non-compliance. (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.
(25 pp). Balance of Governance

[75] General Practice is the Art of the Possible: but we are turning it into a tyranny of the unworkable. Reflections on our inspections regime. (2016)
There used to be a tacit assumption that healthcare (and welfare generally) was mostly imperfectible, but that practitioners would generally do their best. All that has been replaced by something very different. This long letter – to an NHS inspection manager – shows in detail how we lose our professional trust, identity and integrity.
(25 pp). Balance of Governance

[76] CQC Inspection and closure of my NHS General Practice. Farewell from a long career. (2016)
Letter to Chief Medical Inspector of Care Quality Commission, November 2016
(2 pp). Balance of Governance

[77] The Proof of the Pudding is in the Eating: Actual and virtual realities: how our inspection culture unhinges. (2016)
What’s really going on? How do we know? Who do we listen to: the participants or officially designated inspectors? This response to a contended official report – that rapidly closed down a small and very popular GP surgery – portrays our difficulties.
(33 pp). Balance of Governance

[78] Is expedience the death of our professional spirit? What our colleagueial utterances are telling us. (2016)
Short-term adaptations to survive may – longer term – have the reverse effect. How can this be? This short dispatch, from an ailing frontline of our NHS, explains.
(5 pp). Balance of Governance

[79] Too Big to Talk About. Organisational momentum: its paralytic wake. (2016)
Corporatism often enlarges and entrenches itself by increasing demands for compliance. Eventually though, unchecked, this will sicken any organisation. Such is now evidently ailing our NHS. A brief glimpse from a small conference provides a sample.
(6 pp). Balance of Governance

[80] I, Daniel Blake. Industrialised humanity: why and how should we care for one another? Fraternal wisdom from a film maker. (2017)
How do we best assess the complex needs of others? Are these best served by always increasing systems – now particularly computerisation and proceduralisation – to determine our human contact? A recent film I, Daniel Blake, cautions with courageous wisdom.
(11 pp). Review    Particular Interest

[81] When is Compliance Necessary for Public Safety? The policing of Welfare: a personal story. (2017)
Imposing managerial order onto some aspects of our natural human complexity is far more easy and attractive to design than to sustain. Our misplaced and excessive efforts can lose us far more than we gain. Here is one salutary story and a broader analysis of social control.
(12 pp). Balance of Governance

[82] Holism is less about eliminating root causes than tending our many branches. Reflections on causation in healthcare. (2017)
Attributing causes to human behaviour and predicaments may seem often essential and sometimes easy: it is frequently tricky. With the pursuit of ‘root causes’ this is especially so – the greater our efforts, the more we are likely to miss. An intimately observed example explains.
(9 pp). Mental Health and Hidden Psychology

[83] Abolishing the NHS Internal Market. Too big to talk about? (2017)
Our healthcare culture is now largely controlled by notions of commerce, ubiquitous surveillance and micromanagement. The inevitable depersonalisation is increasingly disliked by both healthcarers and patients. Nevertheless we seem unable to reverse these effects. What is happening? How do we respond?
(13 pp). Balance of Governance

[84] When is Change Progress? Are we throwing the baby out with the bath water? (2017)
Risk management and quality assurance must always be good, surely? Not necessarily. More of something good is not always better. Sometimes we can add more problems than we take away. A complex public event and two private dialogues illustrate.
(9 pp). Balance of Governance

[85] David Zigmond: Biography for Centre for Welfare Reform. (2017)
(3 pp).

[86] Should All Doctors be Resuscitators? Unfactored costs of prescribed risk management. Rhetoric is easier than reality. (2017)
Being prepared for unlikely risk or adversity may sound like good counsel. But only so far: beyond that other things are damaged. This speculative analysis is of a recent safeguarding inspection. It demonstrates how apparently sensible procedures may, when extended, distort and implicate far more than we usually imagine or intend. What happens? How do we understand?
(11 pp). Balance of Governance    Particular Interest

[87] The Cost of Everything and the Value of Nothing. (2017)
A recent book NHS For Sale provides a trenchant analysis of how the market brings waste, expensive complexity and inevitable corruption to healthcare. But the damage is even more extensive: this review and reflection explores. Review (8 pp). Balance of Governance

[88] A Healthy Heart for the NHS? What is the price of sacrificing personal relationships for public money? (2017)
A recent article, Back in the emergency room, conveys clearly the twenty-five years of economic waste and organisational inefficiency brought by the serial reforms to our NHS. The author, though, does not address the human damage and cost. Here is a corrective.
(7 pp). Balance of Governance

[89] WRONG, WRONG, WRONG … OUT! How can we contain one-size-fits-all policies? Three struggling letters. (2017)
Our welfare services are increasingly controlled by RMIC (remote management, inspection and compliance) regimes. Evidence of long-term benefits of RMIC are patchy and contentious; evidence of damage or harm is much more substantial, and by many indices. These problems, and the difficulty engaging authorities, are illustrated by three letters between a coercively ‘decommissioned’ GP and a governing authority (the Care Quality Commission).
(19 pp). Balance of Governance

[90] Hi Tech With Many Human Hearts. Vitalising humanity from a film maker. (2017)
A recent film Heal the Living (directed by Katell Quillévérré, 2016) weaves a rich tapestry. Life’s vicissitudes, human paradox and interconnectedness – all are here: holism at its most raw and tender.
Spoiler alert: This article describes much of the content of the film.
(4 pp). Review  Particular Interest

[91] Déjà Vu. Twenty-first century healthcare reforms and post-war urban renewal. (2017)
Two large reforming movements in recent history have lost their human sense as they have gained momentum. What did they overlook? What can we learn?
(25 pp). Time Traveller    Particular Interest

[92] Boadicea and The Machine. The price of survival as a frontline medical practitioner. (2017)
NHS doctors describe increasing stress, pressure, demoralisation and alienation. What is this like to work in? Why is this happening? A recent book, Your Life In My Hands: A Junior Doctor’s Story, offers vivid description and challenging analysis.
(13 pp). Review

[93] People or Procedures? Personalised treatment can be very different to personal care. Why? (2017)
Recent advances in genetic mapping herald some dramatically positive developments in hi tech healthcare. Yet this is paralleled by unprecedented ailing demoralisation and alienation within the service that will deliver these. How do we explain this discrepancy? What can we expect?
(13 pp). Balance of Governance

[94] Not So Sapiens After All. Lessons for Welfare from a history teacher. (2017)
The trials and tribulations of our Welfare system have deeper and more complex roots than many can imagine. A recent and remarkable book Sapiens: A Brief History of Humankind can greatly help deepen and broaden our understanding.
(10 pp). Review

[95] One Small Altercation: a Massive Residuum. How do large systems deal with outliers? (2017))
Speaking truth to power may be straightforward in intent but rarely in course. This essayed letter to a health service safeguarding board (NHS Care Quality Commission) illustrates typical difficulties – personal, practical, philosophical and ethical. The questions raised are crucial throughout our tribulated Welfare services.
(23 pp). Balance of Governance

[96] Whatever happened to professional judgement and responsibility? (2017)
The erosion of a gratifying sense of professionalism is now – belatedly – often cited as a major factor in the collapsing morale of NHS doctors. How has this happened?
(8 pp). Balance of Governance

[97] Why are we so resistant to holism? (2017)
Our technologies – so irresistibly convenient – often enter our lives with costs that are more subtle: our more natural senses of personal context, meaning and relationship. Why does this happen? What can we do about it?
(11 pp).    Particular Interest    Holism

[98] If we fast-track primary care, what do we lose? (2017)
Speedier access, diagnosis, treatment and despatch may seem like undeniable progress for our healthcare. Yet such benefits may come with a large, though less obvious, sacrifice.
(9 pp). Balance of Governance

[99] Prevention must always be better than cure, surely? The potential perfidy of our expanding pre-emptive regulation. (2017)Due to subsequent events this article was rewritten in 2021. Please see Article 136.
To effectively forestall trouble we often need prescience, strength and boldness. Yet greater wisdom and probity sometimes comes, instead, from nuance, discrimination and restraint. A current example from healthcare and an elderly yet prophetic science fiction classic show us how and why.
(14pp). Balance of Governance

[100] Collectivising the Personal. Seminal lessons from Bolshevism. (2017)
There is a time-honoured principle and skill involved in all medical practice: we must be vigilant to those times when our interventions are making people ill, or iller. Ignoring this in public policy can cause exponential damage. Unlikely co-examples? The USSR ninety years ago and our contemporary NHS governance.
(11pp). Time Traveller    Particular Interest

[151] Healthcare’s Metaplasia: we have transplanted for more than organs (2022)
Can we commission, design and manufacture healing cultures and relationships? Or are they better germinated from more natural and vernacular elements? If so, what are these? This retrospective tale, written in 2015, illustrates what and how much we can lose, and how this happens with our purblind yet insistent reforms.
(4pp) Time Traveller   Particular Interest

[152] Iconoclasm: is this our best route to ‘being on the right side of history’? (2022)
Do we learn from, or about, history? What is the difference? Who decided? Statues raise interesting questions about how and what we choose to remember.
(10pp)      Particular Interest

[153] Putin, Power and the Human Conundrum. Why do humans wish to dominate or eliminate one another? (2022)
Human cruelties and oppressions are often the major – certainly the most emotive – items of our newsfare. Our moral outrage and anxieties are more easily expressed. Harder to achieve are our deeper understandings: can we expand these?
(9pp) Particular Interest

[154] Commodity or Community? The predicament behind the terminal illness of general practice (2022)
Recent increases in violence toward NHS primary care staff probably signal cumulative senses of alienation and impotence that remain elusive to direct address. How and why is this happening?
(11pp) Then and Now 

[155] A Sinking Cornerstone: the vanishing of personal continuity of care (2022)

Like a nearly extinct species, the value of personal continuity of care is, at last, receiving some eleventh-hour anxious attention, at least from some healthcare academics and journalists. The clear benefits to patients are recognised. Hardly ever, though, are the benefits to healthcarers mentioned. Here is a short redress.
(6pp) Particular Interest

[156] Gender Dysphoria: healthcare’s Rubicon and humanity’s conundrum (2022)

In the last century medical science and practice has made such substantial advances in the control or elimination of physical illnesses that human lives and lifespans, in all but the poorest societies, are utterly transformed. But what about distress that does not have such clear physical causes? Then the misdirected expansion of medical sciences has very different consequences. A recent seminal example from the UK shows how different that can be. This long essay is a cultural and historical analysis with a view to where our society may be heading.
(23 pp) Particular Interest

[157] Manufacturing doctors is one thing; sustaining working communities is quite another (2022)
In an age of mass-production and commodification it is not surprising that the governmental response to our increasing losses of doctors is to recurrently and rhetorically press for greater production and wider recruitment. But in doing so are we avoiding deeper human problems of community and ecology?
[10pp] Then and Now 

[158] Why do we suffer? And how do we heal? (2022)
Author David Zigmond talks to Mind, Body, Spirit about his most recent book, Humanity’s Conundrum
What are the ideas in Humanity’s Conundrum? This interview with a literary journal provides a brief outline.
(5pp) Particular Interest

[159] Reading to Stay Alive. How possible is that? (2022)
A short review of a short book surveying a vast area of humanity’s tribulations
(2pp)   Review

[160] A Fragile Essence: a Personal View [How] can holistic healthcare survive in an industrialised and commodified world? (2022)
I was asked by Q, a freshly-hatched young GP, to summarise my experience and philosophy of attempting to provide holistic healthcare through my own five decades of NHS practice, and how I saw its future. Here is the condensed dialogue.
(13 pp)  Holism

[161] Time to Heal. But has that time gone? The spirited disaffection of a vocational doctor (2023)
What can one man’s personal reminiscences and reflections tell us about our community’s assets and losses? There are times when personal testaments can achieve this with greater clarity and evocation than any academic analysis or report.
(6pp). Review

[162] Our current commissioning system will utterly eliminate the personally known family doctor (2023)
Can commercially modelled commissioning bodies provide the kind of doctors we want and need? This explains why not.
(5pp). Balance of Governance

[163] Travesty at the Tavistock? Yes, but what does that say about the rest of us? (2023)
The Tavistock Clinic’s many years of providing gender reassignment to young people was initially vaunted as pioneering and profitable. But somehow that mission overstepped into a mire of contended personal damage and litigation. Apart from institutional culpability, what may this tell us about us, our society?
(4pp) Particular Interest

[164] Why have things gone so wrong? And what can we do about it? (2023)
After writing about these questions for twenty years, drawing from my background of five decades as a frontline NHS doctor, I was asked by the College of Medicine to summarise my thoughts in about three hundred words! Could I manage this? Not quite… This is 405 words
(3pp). Balance of Governance

[165] A Fortunate Woman. A skilfully upbeat offering for less fortunate times (2023)
What are the personal and human factors that most motivate and anchor our best healthcare? What best nourishes and sustains both patients and healthcarers to endure together life’s most difficult challenges? This book answers such questions with luminous and engaging clarity.
(10pp)   Review

[166] Our neglected impoverishment: the destruction of our healthcare communities (2023)
Can we arrest the haemorrhage of morale and staffing of our NHS general practice by fragmenting and devolving more of its traditional work? Probably not. Here is why.
(4pp). Balance of Governance

[167] To err is human – If you really want to screw up get a computer (2023)
Our mounting trepidation about the darker possibilities of Artificial Intelligence is already foreshadowed in many of our ‘smart’ automations and innovations. Here is a prophetic tale from our current NHS healthcare.
[10pp] Then and Now 

[168] The NHS: a 75th Birthday in Annus Horribilis – will we have any happy returns? (2023)
As our NHS shows increasing signs of its own sickness, many are calling for more funds, staffing and technology. These may be necessary but are certainly not sufficient. What else of importance are we missing?
(11pp). Balance of Governance

[169] And Finally. Matters of Life and Death. Wide-ranging reflections from the gloaming of a neurosurgeon’s life (2023)
What can a working life operating on the nervous systems of other humans tell us about our more universal predicaments and experiences? This review of an unusual book explores…
(6pp)   Review

[170] The Letby Murders – Individual and institutional pathologies (2023)
The shocking infant murders by nurse Lucy Letby represent a mercifully rare (we think) class of event. These remain extremely difficult to understand, predict or prevent, much as we must try. This is not true of the failure of our institutional responses to such events.
What does that mean?
(8pp)  Particular Interest

[171] A Long Day’s Journey Into Night. Pastoral healthcare, psychosomatics and professional intimacy – recollections and reflections (2023)
Our cleverness of invention and manipulation can so easily run over our wider responsibilities of stewardship and care. Is this happening in our healthcare evolution?  A multidecade personal odyssey explores
(25pp)  Particular Interest Then and Now 

[172] Israel, Gaza, Monsters and the Abyss – humanity’s self-immolating ideologies (2024)
The dark and startlingly violent Israeli-Hamas conflict rightly receives much historical and political comment and analysis. Less considered are the psychological hungers and anxieties that lie deep beneath. What are these? Can such understanding help?
(13pp)  Particular Interest

[173] Physician Associates; Dissociated Doctors: Verschlimmbesserung: an attempted improvement that will make things worse (2024)
There is a current plan to remedy the growing problem of shortage of doctors who are now overstressed and clearly unhappy: to delegate some of their tasks to much lesser-trained Physician Associates. Will this help overall? Or will it further fragment and alienate our already ailing healthcare.
(7pp)   Particular Interest   Balance of Governance

[174] Medicine for Beginners: maybe, but where does medical hegemony stop? (2024)
What is the legitimate nature and influence of scientific medical knowledge? This short, paradoxical and provocative book was written forty years ago by two young authors with no formal training in history or philosophy. Yet their prophetic insight should continue to disturb us.
(4pp)   Review

[175] Underinvested and Overwrought: the place of IT in NHS healthcare (2024)
More of something ‘good’ is not necessarily better; sometimes, like obesity, it will bring insuperable secondary problems. We must be careful what we wish for. The unlimited expansion of digital technology in our healthcare is a seminal example. Here is a broad-scoped and widely-sourced portrait and analysis.
(32pp)  Particular Interest   Balance of Governance Time Traveller 

[176] Jettisoned Communities: The Broken Heart of NHS Healthcare The human and economic cost of our industrialised reforms (2024)
The often impassioned and frustrated discourse about our current NHS problems often reduces these to notions and language better suited to manufacturing, commodities and utilities than to complex human bonds and interactions. What has happened? Why? And what can we do about it?
(13pp)  Particular Interest   Balance of Governance

[177] You won’t realise what you’ve had until it’s gone. The vanishing of communities in our healthcare
Personal relationships are the essential building-blocks of communities, yet these are increasingly imperilled in our current increasingly systemised healthcare delivery systems. This interview briefly explores the origin and nature of this impoverishment and what we might do.
(21pp)  Particular Interest   Balance of Governance