In healthcare our systems of governance are increasingly developed and vaunted. Yet these are very different from our capacities for stewardship.

Inevitably and predictably, the recent party political conferences each designated the NHS as a crucial battleground: each claimed the better vision, ethos, and competence. Yet there is something recurrently missed by politicians, planners, and orbiting think tanks. It is the crux of personal attitudes, relationships, and investments: the human conductors of our best personal continuity of care.

In the last 25 years, these important but fragile human exchanges have struggled to survive; their professional habitat has been steadily displaced or destroyed. This has happened as collateral damage: the victims of successive systems of standardisation and mass management.

Of course, such governmental hegemony also has its place and merit, without it we would still be plagued by smallpox and poliomyelitis. But, however valuable, such an approach necessarily occupies an opposite pole to personal continuity of care. And it is the latter that constitutes the art, heart, and soul of our best—now increasingly lost—pastoral healthcare.

In the last half of my long career as a NHS doctor, I have found it more and more difficult to deliver care as a personal physician or family doctor. For the last decade my peers have overwhelmingly come to this view, but their fatigue and dispiritedness has mostly led to their public retreat rather than assertion. This is one small but ominous sign of the overgrowth of our healthcare governance.

Here is a growing conundrum: the quintessence of our best personal healthcare is often driven out or destroyed by the very defensive measures designed to protect us from bad practice. This happens because too much management and regulation crushes personal engagement, spirit, and responsibility. For these are human qualities and activities that must have a natural life. No amount of governance can directly produce these, yet too much governance can rapidly destroy them.

In our relationship with our natural environment we are having to learn how stewardship is very different from governance. In healthcare, too, the consequences of our being heedless of this distinction can soon accelerate beyond our capacities for imagination—and then retrieval.

David Zigmond is a GP in London.

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