is there for all to access as they like just doesn’t hold up. Often, the people with the greatest needs struggle to access services in the way they are presented. We need to acknowledge that engagement is a two-way process and therefore be more active in including people and removing the barriers which actively exclude.
Let’s think about holism
One of the biggest issues with medicine is that it has, for a long time, been just that – the provision of medical care. At medical school we learn how to spot patterns of symptoms which, together, allow us to make a diagnosis of disease to which we then apply the appropriate medical treatment and our job is done. A reader of this journal will spot the obvious flaw. While we learn, in detail, the pathophysiology of disease in the organism, little consideration is given to the social and environmental causes. Some consideration is given to the effect of the disease on the patient and increasingly we talk about shared decision-making and joint management plans, worked out in consultation with the patient, but these are still fairly scarce compared with the ‘take this for this many days and come back if it doesn’t get better’ model.
Treatment in context
Sometimes this works, often it doesn’t. If I had a ‘simple’ chest infection, a brief description of my symptoms, an examination and a five-day course of antibiotics might sort my problem. Add in any complexity, however, and the model falls apart. Try applying the same process to anyone with depression for example. Even the ‘simple’ chest infection would benefit from better understanding of context. Why do I have a chest infection? Perhaps because I live in damp, mouldy housing, which I cannot afford to heat. Perhaps I smoke. Perhaps I smoke because everyone around me smokes and I’m stressed and depressed. Why? My financial situation is precarious. I worry about being able to pay for food. I have a job but having to self-isolate due to this cough may mean I lose income. If I can’t pay the rent I become homeless.
If we place the infection in the context of an actual person and their life everything changes. We realise we are treating the symptom rather than the disease and if we want to sort the problem, we need to reach deeper into the underlying causes. Antibiotics won’t address the unhealthy housing or the smoking which underlie the illness or the poverty which has led to both of those. Often we can approach the causes but we’re not always set up to, and many doctors argue that it isn’t our job. So we continue to treat the symptoms and act surprised when they don’t get better or keep recurring. Figure 3 shows how we do better.
This model suggests healthcare contributes just 20% to making people healthy. Only 10% is quality of care so we should be the best doctors we can, but we can do a lot more. We’ve discussed access – just include and stop excluding and we’re back up to 20%.
We could do smoking cessation better if we ask why people smoke and address the causes. Same for alcohol. Even more so for drugs. As a junior doctor on the orthopaedic wards I met the same woman again and again who kept breaking bones. Her surgeons complained about her poor bone quality and how it made surgery much harder but they did a great job of repairing each fracture despite the technical difficulties. Her bones were brittle because of how much she drank and she kept breaking them because, when inebriated, she would frequently fall. We didn’t ask why she drank. We fixed the fractures, we never actually addressed her problems. But we could. So let’s see how.
Diet is important and directed by many factors other than just individual choice. A family in the poorest 10% in England would have to spend 74% of its disposable income on food to meet the government’s healthy eating guidance (Scott et al, 2018). How then would they buy clothes, shoes or the things the kids need for school? Look at the distribution of fast food outlets by an area’s socio-economic status to see how individual choice is subsumed by availability. All of this we can influence.
Sexual health is another health service function where we could get further upstream. Here but also more generally the NHS must enable promotion of keeping healthy and not just be a vehicle for treating illnesses. This re-focus on prevention is vital, and it must not aim only at individual behaviours but seek to nudge communities towards health. Enhancing public health should be a consideration in any plans involving schools, transport, parks and more, to positively influence social determinants of health. Once their crucial importance is recognised health creation can begin to share the space occupied so inadequately by healthcare alone.
Are social and economic factors healthcare’s remit?
Certainly. We can help with education and not just health education or health literacy.
As Nelson Mandela says, “Education is the most powerful weapon which you can use to change the world.” Education is the key to eliminating gender inequality, to reducing poverty, to creating a sustainable planet, to preventing needless deaths and illness, and to fostering peace.
Arne Duncan (2013)
Children excluded from schools may fall prey to gangs that recruit them. And so contact with the criminal justice system begins. But this is could be prevented were we to ask why, and identify a solution. The behaviour of disruptive’ children may be the result of an undiagnosed learning difficulty or unmet educational needs; or the consequence of a disrupted home life. Liaison between doctor and school could avoid exclusion and allow a better educational and hence better life and health outcome for these children. This takes time but the early investment will pay lifelong dividends.
Getting people into or back to work is a huge boost for mental and physical health. A doctor can get someone well enough to work or use fit notes with recommendations for workplace adaptations or amended duties. Better still, we can together work out what it was about work that made a person ill, and work with the employers to rectify it.
We repeatedly return to poverty causing ill health and we know that reducing poverty improves health. The Deep End movement in Scotland put a financial advisor into practices. From 276 referrals they generated £850,000 of income – all benefits people were entitled to but weren’t getting (Sinclair, 2017). All this avoidable poverty was changed by doctors who saw health benefits beyond the prescription pad.
Family and social support
Loneliness causes early mortality (Rico-Uribe, 2018) so preventing it is truly a form of health promotion. Social prescribing can really help and is on the ascendency. We may have to work harder, however, than simply saying, There’s a men’s group on Thursdays. You should go. People become withdrawn for reasons that may need addressing or they may just need someone to go with them that first time. Some doctors argue that we’re already too busy and lack capacity for any of this; others that as we haven’t been trained we make poor social workers. If we are to work at these beyond-theprescription-pad levels we and the system will have to change. We are seeing that happen already with new roles, such as linkworkers, focused care practitioners and social prescribers joining the primary care team.
Care in the community
Community in healthcare terms has come to mean all the stuff that doesn’t happen in hospitals. We tend to forget the real meaning of community and its power to create health, perhaps because we mostly train in hospitals and around hospital-related specialties and interventions. Though even our sickest patients spend only a small fraction of their lives in hospitals, and very little time in contact with a GP, we remain oddly hospital and prescription oriented in healthcare. Now, slowly, medical schools are re-orienting healthcare students towards the social determinants of health and how to address them. As Jackson and Purvis (2020) say, good health outcomes find their foundations in good social care and self-care.
All our healthcare efforts are small compared with the self-care and care-for-each-other that happens in the community. Covid has reminded us we are part of communities and those communities, working together, can go a long way to protecting their members’ health and wellbeing. Volunteers from our community going door-todoor shifted the balance for testing and regaining control locally. We just lent them our community room as a base.
Air and water quality? Housing and transit? We can help. At the individual level a doctor’s letter stating that someone’s mobility is impaired by arthritis can get them a bus pass and expand the world that is accessible to them or boost their priority in the housing list for a bungalow they can get around. Or we could be like the psychiatric nurse who, on finding that their client’s house was flooded with sewage, refused to leave the housing office until it was sorted – which it then was, the same day. At a larger scale we can advocate, not just for our individual patient’s issues, but about the issues that affect them all – like air pollution. As healthcare workers we have a platform, with a stethoscope around our necks, that gives us an influence many don’t have, which we can use for the good of our patients.
The person-centred care approach gives people more choice and control in their lives by providing an approach that is appropriate to the individual’s needs. It involves a conversation shift from asking “what’s the matter with you” to “what matters to you.”’
Person-centred care is on the lips of the NHS at present and it’s in our hearts. Alas, often because time is short, it is less evident in our actions. Its ethos of working alongside patients, lending them our medical expertise but empowering them to take control of their health and prioritising the issues important to them is very much part of the holistic re-imagining we have discussed. But it’s labour-intensive. Those stockpiles of unused medications filling cupboards that we find on home visits testify to all our unasked for medical interventions and the importance of engaging slowly with ‘the patient agenda’ rather than handing over the swift prescription. An NHS more oriented to the needs of the patient, or better still, the person, shouldn’t sound so far-fetched: in fact it would waste less and succeed more often.
When I re-imagine how our National Health Service might look, learning from the Covid pandemic but also in view the many long-term challenges to health that society will have to face, I see the NHS using all the strengths it already has, but re-oriented: re-oriented towards working in partnership with people, as part of communities, and focusing more on the people with the greatest needs, to deliver healthcare and create health, and build the conditions which maintain health in the future.
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