Introduction
There is a consistent thread which runs through the various contributions to Reform Scotland’s NHS 2048 debate which is a desire to keep our NHS public and largely funded from central taxation. Equally consistent is a concern that this is becoming unachievable: waiting lists are sky-high, the workforce depleted, governance and decision-making are poor and there is an over-reliance on short-term, disjointed and incremental solutions. More hopefully, there have been hints from some contributors and examples from around the world showing we could organise very differently and build a more effective and resilient NHS for the future. But this requires a deep culture shift and has to be underpinned by fresh thinking – a new paradigm for health and care.
In this contribution, I describe such a paradigm shift taking place which sees relationships and community health as essential alongside care and treatment for individuals. Effective reform of the NHS is being enabled by a shift in the mindset of the clinicians who work in it. There are pockets of a new system growing in Scotland and around the UK. I will conclude with a brief update on IFF’s work in this arena – humanising healthcare for NHS 2048.
Body-part medicine
There is much to celebrate in modern medicine which can treat and extend survival in a large number of well-defined conditions. But patterns of disease are changing. If you are over 65 years old in Scotland, you are more likely to have two or more health conditions than one. Over 75, over 50% of the population has three or more health conditions. It is not uncommon for younger adults to have long-term conditions with the impacts of COVID on physical and mental health well-documented. This change in the pattern of disease means many more people require healthcare treatment for long- term conditions. Part of this is because of the improved survival from many previously fatal conditions. In this sense, we are victims of our own success.
It is taking a long time for the healthcare system to adapt and respond effectively to this changing pattern of disease. Whereas attention on individual pathology within different body parts has led to major discoveries and treatments for specific forms of trauma and diseases, there is a limit to the effectiveness of this reductive approach when dealing with chronic ill health.
Moreover, many people and clinicians are finding medical definitions inadequate to describe the nature of what is being experienced as ill health. Even when physical markers of disease are found, treatment options can be limited and are rarely curative. The traditional body-part approach to illness is no longer sufficient as a treatment response.
Research in the last two decades has gradually revealed connections between our life experiences (biography) and our health (biology). Chronic stress from poverty, discrimination, institutional bias, poor housing and air pollution have cumulative effects. Arlene Geronimus has described this as “weathering” – the impacts on the body of living in an unjust society. How effective can healthcare be if someone returns to an unheated home, with no-one to call in to check how they are getting on? What happens after someone is treated for head injury if they go back to a violent partner? A child treated for their asthma attack can only partially recover if they live in a damp flat.
Relational health
There is growing acknowledgement of the social nature of health and wellbeing: the paradigm is shifting. For example, in a recent report on the epidemic of loneliness the US Surgeon General’s states: “Our relationships are a source of healing and well-being hiding in plain sight – one that can help us live healthier, more fulfilled, and more productive lives.”
Quality relationships provide a web of human connection and help grow collective approaches to improving health and reducing the burden of disease. They are integral to achieving local collaboration for whole community health.
To give a flavour of what’s different about this way of working:
- It sees the whole person, not only the disease, problem or condition people present with. This enables people to understand what’s happening to them in the context of their own lives. It helps them work towards recovery from illness and distress by drawing on a range of help which comes from personal and lay networks as well as professional health and care providers, reducing reliance on the latter.
- Health and care staff have person-centred conversations routinely with people, helping them discover for themselves what matters to them and enable them to shape their lives accordingly. The word “Patient” is used less and “People” or “Agents” is used more.
- It sees staff as having their own health needs and takes their wellbeing seriously. This restores and sustains staff, leading to better retention and reduced sickness absence.
- Managers are working towards people achieving their personal outcomes with governance and resources to enable this. This turns out to be much more cost effective than current use of funds.
- With the system designed to help people and communities achieve what matters most them, it improves working lives and generates mutual thriving, reversing the current trend in costs and workload pressures.
- Advanced technological treatments are still available but used in conjunction with well-informed shared decision-making. People are given time to come to their own judgements on risks and benefits in the context of their own lives.
- The system is not confined to individual care. Rather, people (formerly known as patients) are seen as whole persons with histories and cultures, embedded in families, personal networks and communities. Practitioners are skilled in producing inclusion to enable everyone to feel their views are listened to and taken seriously.
- The system creates a strong synergy between the needs of our planet and of people with both supported by transformation of the health and social care system. As such, it configures around an economy based on reciprocity, mutuality and sources of abundance.
What is evolving is a practice of community health – creating the conditions for better health and care through the combined efforts of everyone in local communities. Where this is working well, health centres are doing less one-to-one care and more group work, signposting, connecting and working with people in their communities in health-related activities. The Queen’s Nursing Institute for Scotland understands the value of this way of working and is enabling community nurses to work effectively in real partnership with local people. Health Connections in the Mendips, Somerset starting in the Frome Health Centre is now operating across a large number of connected towns and villages in the region. Working with local people, they are speeding up hospital discharge, helping people to stay well at home for longer and through group work, increasing health literacy in self-managing many health conditions.
IFF is fostering learning and networking with practitioners, healthcare managers, educators and others keen to evolve this way of working. Slowly this paradigm shift is taking hold, enabling a humane, responsive and resilient system in health and care to grow across the UK.
Dr Margaret Hannah FFPH is the Director of Health Programmes at the International Futures Forum