Anna Betz, Lead practitioner in Camden & Islington Foundation Trust; Medical Herbalist; Co-director of School of Commoning

Published in JHH12.2 – Works that reconnect

Ever since I woke up to the Commons in my life, or the Commons woke up in me, I started to experience life in a renewed, more connected and purposeful way. Knowing in my heart that a different world is not only possible but already happening amongst us inspired me to find examples of projects that model important parts of our future in health and social care.The realisation that as isolated disconnected groups we will not be able to transform the system as a whole inspired me to create an online platform called HealthCommonsHub. It serves to connect projects like the ones mentioned in this article in a meaningful and coherent way. Collectively engaging with what matters to us deeply seems our best chance to develop a shared roadmap for the future in healthcare.

Entrenched political and economic interests are standing in the way of change and inclusion of people and communities as equal partners in health creation. The change we need will naturally not come from those with invested interests in the way the system operates at the moment but from caring, capable and open minded individuals and networked communities that already model an important part of our future through their relational approach.

While material resources like water, oil and minerals on this planet are finite, our immaterial resources that emerge out of relationships, mutuality, imagination, love and compassion are infinite. In fact they grow the more we listen to each other, care for each other and collaborate.

Any healthcare system that is built on combating disease and sickness rather than creating health and wellbeing with healthier individuals and communities is expensive, unproductive and economically and socially not viable.

I ask myself: What would happen when the quality of healthcare was not just measured in terms of the skills and expertise of professionals in the system but the vibrancy of connection between healthcare providers and the resources of their local communities?

Also what are the layers of cultural and conceptual assumptions that define what we mean by health, evidence-based practice and effectiveness?

The mind–body split was first described by the 17th century philosopher John Locke, one of the architects of the liberal ideology that prepared for the move towards a capitalist economic system in the late 18th century

In his Second Treatise of Civil Government Chapter V Locke said:

The mind is a single mental substance, while the body is an aggregate of atoms comprising a variety of material substances which follow the laws of physics. Minds (mental substances which exist outside of space and time) are independent of bodies (material substances which exist in space and time). The mind is immaterial, independent and self-sufficient; but human bodies are forms of physical property, similar to land, houses or goods. Since the individual’s mind is not dependent on the existence of other minds or persons, people interrelate with one another only through their bodies.’

(Locke 1690)

Examining John Locke’s ideas more closely, James Quilligan, a contemporary commons economist and philosopher observed: ‘When individual human knowledge has no correlation with human interrelationship or inter-subjectivity there is only self-interest. The mind controls the body and practically everything else. Human beings act outside of the context of nature, culture and society, without meaningful relations to other living beings.

This surprising conclusion seemed to corroborate the theories of Thomas Hobbes (1588–1679), who claimed that the natural state of the world is ndividual against individual, a war of all against all. Thus unintentionally, Cartesian and Lockean metaphysics set in motion a hugely consequential idea: we are all disembodied individuals who engage only in competition with other disembodied individuals.

The dominant level of thinking in our culture is still based on the assumption of scarcity. The competition for scarce resources is a belief inherent in capitalism and its protection of private property rights.

I am convinced that we, the people, together, can come up with better and more creative solutions to the crisis of the NHS than any politician or NHS executive has come up.

Dr Margaret Hannah is a fellow of the International Futures Forum and deputy director of public health for NHS Fife, Scotland. In her groundbreaking book Humanising Healthcare (Hannah, 2014) she discusses existing examples of healthcare models that move beyond the scarcity frame of thinking and create a thriving and sustainable healthcare system enabled by community participation and community ownership. She writes that health can be co-produced and co-governed by citizens, as evidenced well by the astonishing results of Nuka in Alaska (Kings Fund 2015).

This healthcare model was created by the people of Alaska where families and communities have taken ownership of their own wellness and recovery since 1997. Nuka is a word used by the indigenous people of Alaska to describe this service and means ‘ a strong, large, living structure’. To start with, the pioneers of Nuka realised that entering into an open dialogue with the community and bringing it into the whole change process was absolutely crucial if they wanted to place the control of health and healthcare with the communities.

Hannah points out that a target and protocol driven system makes choices difficult especially as money is attached to targets. She calls our attention to the poorly developed governance system of primary care in the UK.

Apparently a few general practices have become social enterprises and others have opted to have more extensive partnerships with local agencies to create healthier options for patients, but for the most part there is no enabling structure in place that encourages doctors to work with patients and communities as partners or like in Alaska makes health professionals accountable to a Board of Directors formed by patients also known as ‘wise elders’ of the community.

Hannah describes in detail the astonishingly successful story of the Nuka approach which started small in 1997 and is still going strong. In 2007 they had reduced A&E use by 40%, referrals to specialists dropped by 50% and use of primary care had decreased by 20%. Both patient and staff satisfaction score exceptionally highly (Hannah, 2014)

The success of Nuka, according to Hannah, can be attributed to ‘intentional design’ (Hannah, 2014). The design of the system was resonant with peoples values, owned by the people themselves, and always responsive to their wishes. It started small and gradually took over more elements of the health service. For Nuka every health encounter is seen first as a conversation and second as a diagnostic and treatment process. By placing their values and commitment in the foreground, the issues of lack of resources have been effectively addressed almost as a side effect.

Some of the enabling principles that make Nuka sustainable and successful are:

• use of local materials
• creating light and airy places with a circular gathering place with comfortable seating and plenty of light; the design encourages people to sit and chat whether they came for treatment or not
• GP consultations by phone to allow same day access; face-to-face interviews are 10-40 minutes
• while patients make their way to the primary care centre, records are checked so that other tests can be carried out to save multiple visits in the future
• office space is non-hierachical; doctors, nurses and receptionists for each team work in the same room with same sized desks
• consulting rooms are called talking rooms because 80% of primary care visits only require a conversation and very simple examination
• talking rooms have equal size chairs and both doctor and patient sit at the same side of the computer
• for conventional examinations there are adjacent examination spaces
• family rooms that hold up to 15 people. Every room has a speaker phone to allow distant relatives to be part of the consultation, discussion and preparation for care that may be needed.

Awakening to our collective potential

The signs of our time show us clearly that a new impulse of awakening is felt by many individuals everywhere. Groups, projects and movements are growing which want a shift in healthcare towards treating the whole person, co-production of health, practising compassion in healthcare, working with rather than against nature and becoming sustainable.

Together they already form a kind of movement out of which a new larger perspective of what health is can develop. It is the purpose of an online platform called the HealthCommonsHub to enable the awakening to our collective potential in health and social care.

Awakening starts with becoming visible to each other, having meaningful conversations around our shared vision and finding ways to share practices and resources to transition from our shared vision into our shared reality.

The following projects are examples from all over the UK that model different aspects of the future potential of health and social care. The list is not complete by far.

By becoming visible to each other projects can start to synchronise with each other and grow a collective field that eventually becomes coherent and strong enough to bring about a shift.

People-powered health projects

Healthcare models in the UK (past and present) presencing our future potential:

Pioneer Health Centre in Peckham co-owned by GPs before the NHS

A curated space that was designed to create the conditions for health.

Doctors saw health as being the flow of life through many forms. They believed that when given the right conditions, each person will grow, develop and flourish. Their emphasis was on health rather than disease, on families rather than individuals, on community ownership rather than state or independent contractors.

Some of their guiding ideas were:

• access to a doctor who was also a friend
• providing facilitated safe spaces for people to share their stories at a deep level with each other. This builds trust and repairs damaged relationships
• the GP practice being a place for the whole family. Families became united as individual members blossomed in the environment
• attention to maternal health from the moment when a couple considered starting a family
• the focus of parents to shift from what they would give to their children to modeling it in their own lives by being active, engaged and learning new skills
• wholesome fresh locally grown food
• physical activity
• family wellness and social gatherings

Maggie’s Centres

These are cancer and drop-in centres designed by leading architects.

They are like guesthouses that invite mutuality in the encounter where people give and receive.

Each centre is unique but they all have three features in common:

• feeling of homeliness centred around a kitchen table
• widespread use of artworks
• calm almost sacred feel.

www.maggiescentres.org

The recovery approach as pioneered in Scotland

This involves:

• restoring coherence in life, restoring meaning, purpose and wellness feeling rather than fixing worn out parts • recognition that medication can be useful especially short term. Longer term recovery requires that people find their own narrative for why they became unwell and create an outlet to discover a deeper meaning and value in their lives

People have found music, art, poetry, journaling, wilderness experience, gardening and all kinds of craft activities useful in rediscovering and reinventing a sense of themselves.’

People in recovery can become peer workers for others.

www.chrysm-associates.co.uk/images/PSWresearchFindings Nov09.pdf

Horseback UK

This organisation practices a whole person approach for soldiers who have lost limbs.

Through their riding activities they help soldiers to recover a sense of self worth; sitting high up above the ground helps them to feel valued and to be seen.

Their work addresses the existential need for value and purpose in life, particularly in the face of the catastrophic loss of limbs, sight or hearing.

www.horseback.org.uk

Chaplaincy Listeners Network in Scotland

Spends time in primary care settings and simply listen to patients stories.

Spends time in primary care settings and simply listen to patients stories.

www.nes.scot.nhs.uk/media/859752/harriet_mowat.pdf www.sach.org.uk/journal/1501p21_mowat_bunniss_kelly.pdf

Values based reflective practice developed in Scotland

This initiative intends to grow reflective practitioners that can make difficult decisions by being clearer about what informs their decisions, ie their own likes and dislikes or fears.

Rather than cajoling and chasing poor practice, it is designed to enable staff to do what they want to do in most cases, which is to provide great care (see this idea also mentioned in Intelligent Kindness by Ballant and Campling)

www.ahpcc.org.uk/wordpress/includes/otherassocs/nespractitioner.pdf

Ayrshire Kitbag

A set of resources to promote psychological capacity in times of radical change. It is a practical resource to develop skills for self-care and mindfulness which has been designed by NHS staff. It can be used in various settings including team meetings and individually to provide emotional and spiritual (in a non-religious sense) support. Shifting the culture of healthcare so that it can again fulfil our deeper intentions is invigorating and fulfilling. But it will also demand a lot from us. It can start to ask too much. We must look after ourselves and each other and the kitbag can provide brilliant support.

www.internationalfuturesforum.com/reports/Using_IFF_Kitbag_to_ Support_Staff.pdf

SHINE

Good ideas only become good practice when there’s an opportunity to develop, test and gather evidence to support them. That’s why the Health Foundation has developed the Shine programme. It focuses on aspects of healthcare quality that reflect the key issues facing the UK health service. In 2012 the challenge was to find new approaches to delivering healthcare that aimed to achieve one of the following:

• supporting patients to be active partners in their own care
• improving patient safety
• improving quality while reducing costs.

The ultimate aim is to transform the culture, to free up resources sunk in maintaining today’s system to flow into growing a system fit for tomorrow.

http://www.health.org.uk/media_manager/public/75/programme_ library_docs/ShinePosterBook2012.pdf

WEL in Nairn, Scotland  

Current versions are: the GeneralWEL programme for anyone wanting to tackle health problems and build wellbeing; theWEL for people with CFS/ME; the PrimaryWEL, and the StaffWEL for professional healthcare workers.

The WEL course journey encourages us to learn how to draw on our own inner natural strengths that grow helpful change, wellbeing and any healing and recovery that is possible. The key is learning to create the conditions that enhance this wellbeing and in turn the key to that is our own self-care.

There are sections on making change, nutrition, on relaxation and meditation, plus practical ways to change the relationship to our thoughts and feelings that help reduce stress and suffering and enhance wellbeing. It considers a similar mindful way of caring for our body. Most of all it explores what it takes to be able to apply such changes in a sustained way in our daily life.

www.thewel.org/theWEL/Home.html

Blackthorn Centre and Trust, Barming, near Maidstone

This has pioneered helping people to release their own self-sustaining capacity in the context of living with chronically painful conditions. The centre is a charitable organisation that enjoys a lot of local support.

Kairos Project

The Blackthorn project has been taken up in Greenwich, working alongside a GP-led pain clinic, and called the Kairos project.

Patients are assessed by a GP for their willingness to engage with the therapies and voluntary work on offer. The latter includes craftwork and a garden that volunteers have created next to the health centre. These volunteers are the very patients who for years were incapable of doing much because of their pain and were frequent surgery attenders. Now they dig, plant vegetables etc. They also come together as a community, organising events.

www.kairosrehabilitation.org.uk

Bromley by Bow Health Centre

This community centre is in Bromley-by-Bow, in the East End of London. It was founded by Andrew Mawson in 1984 with the aim of transforming the local community. Over the years, the centre has grown to encompass a GP surgery, church, nursery, children’s centre, community facilities and a cafe. It is the site of the UK’s first Healthy Living Centre, and around 2,000 people use the centre each week. In addition to team members such as psychologists, nurses, counsellors, and phlebotomists, the centre also houses artists, stonemasons, gardeners, and stained-glass makers.

The Bromley by Bow Centre works in partnership with Poplar HARCA to deliver community regeneration work in its local neighbourhood.

Altogether Better & Health Champions Programme, Leeds

Working with citizens and services to improve health, Altogether Better has developed an award-winning model of working with citizens and services where change is needed to achieve better outcomes, transform relationships, create capacity and meet increasing demand.

www.altogetherbetter.org.uk/our-evidence-base

College of Medicine Innovators Network

The innovators share common values and exemplify the key principle of the College of Medicine: recognition that attention needs to be given to physical, psychological, spiritual and societal layers to illness. Some work at a community level – encouraging communities to grow, flourish and gain more control over their environments – creating health at a local level. Others take an integrated approach, going beyond medicine to include wholeperson care, information and guided self-care. Some are embedded within the NHS, others in the voluntary sector.

www.collegeofmedicine.org.uk/innovations/innovators-network

Open dialogue model

Open dialogue is a model of mental health care pioneered in Finland that has since been taken up in a number of countries around the world, including much of the rest of Scandinavia, Germany and some US states. It involves a psychologically consistent family and social network approach, where all staff receive training in family therapy and related psychological skills, and all treatment is carried out via whole system/network meetings including the patient. It is a quite different approach to much of UK service provision, yet it is being discussed with interest by several trusts around the country. Part of the reason is the striking data from non-randomised trials so far eg 72% of those with first episode psychosis treated via an open dialogue approach returned to work or study within two years, despite significantly lower rates of medication and hospitalisation compared with treatment as usual.

Several NHS trusts in the UK are considering setting up pilot peer-supported open dialogue services over the next couple of years (where peer workers are also trained in the methodology to act as integral members of the team), in order to evaluate them and deepen the evidence base, to enable more widescale take-up, should the outcome improvement and cost reductions remain consistent.

www.nelft.nhs.uk/mental_health/Open_dialogue

The College of Mindful Clinicians

The College of Mindful Clinicians is an association of healthcare professionals with a commitment to cultivating compassion through the regular practice of mindfulness meditation and mindful living. As relationships are at the heart of good healthcare, such regular practices can be a vital aspect of professional development. Research shows that the degree of mindfulness a clinician possesses can have a substantial impact on the therapeutic relationships he or she is able to foster, while at the same time significantly reducing chances of burnout.

The college helps clinicians from all branches of healthcare learn about mindfulness and initiate a regular personal practice through a series of mindfulness based professional development retreats. Feedback from the retreats is very positive and a follow-up study has shown increased empathy and reduced burnout among those who attend the retreats.

www.mindfulcollege.com

Well London

Well London is a unique multi-sectoral alliance between seven organisations, funded by the Greater London Authority since 2006. It delivers a new radical, community action health and wellbeing programme.

It provides an evidence based framework for integrating work with residents, volunteers and local organisations to build capacity for community engagement and action to improve health and wellbeing across all communities in London.

Community development principles are embedded within the model and it’s an effective mechanism to:

• involve communities to understand their needs and develop solutions
• facilitate health behaviour change
• inform and integrate service delivery.

www.welllondon.org.uk/1/home.html

The landing-strip of our future

What all above mentioned projects have in common is that they model a shift in power and control from topdown hierarchies to more distributed power that includes communities as equal partners with professionals. They also model an integrative approach that includes complementary approaches to health and wellbeing and make everyone feel as if their humanity and wholeness really matter. Furthermore they are creating enabling structures that unleash the latent potential of patients and professionals working together for the benefit of both as well as society at large.

Embracing challenges

To make a real shift in culture and prevent becoming absorbed by the still dominant hierarchical system both staff and patients need emotional support to maintain long-term motivation and commitment. We need to accept that it is not only external institutional structures that need changing to become more enabling to human creativity and innovation but also our internalised conditioned thinking and behavior that has become accustomed to top down power hierarchies and an assumption of scarcity. During times of crisis the human tendency is to drift back into old familiar habits unless we have a deeper understanding of the forces that motivate us, a trust in our ability to find new ways to create the life our hearts tell us is possible and the commitment to remain true to our values despite serious challenges.

To enable the radical change we need in health and social care, we need safe spaces where we can enter into open conversations with each other and discover and practice new ways of being together that enable us to see each other more deeply and behave as whole human beings.

If you feel curious, inspired and motivated to work with the HealthCommonsHub, do get in touch. anna@schoolofcommoning.com

References

• Hannah M (2014) Humanising healthcare: patterns of hope for a system under srain. Axminster: Triarchy Press
• Locke J (1690): Second Treatise of Civil Government Chapter V. Available at: www.constitution.org/jl/2ndtr05.htm (accessed on 28 May 2015)
• Quilligan J (2013) Toward a Common Theory of Value – Part 4. Kosmos Journal, Spring-Summer . Available at: www.kosmosjournal.org/ wp-content/article-pdfs/toward-a-common-theory-of-value-part-fourcommon-need.pdf (accessed on 28 May 2015)
• The Kings Fund (2015) Nuka System of Care Alaska. Available at: www.kingsfund.org.uk/publications/population-health-systems/nukasystem-care-alaska (accessed on 2 July 2015)