Redesigning Health and Social Care

Part of my personal approach to good physical and mental health is to go for a brisk walk in the early morning before sitting down at my desk. This morning there was the first frost of the season and there were noticeably more leaves on the ground. Perhaps because of the particular atmospheric conditions of a cold still morning I was very aware of the air quality which felt good as I walked alongside a local sports field. However, as I walked on there was a pall of smoke from an enormous bonfire in someone’s garden and then traffic fumes from the long line of stationary cars in the city street I had to cross to get home. Having had occasional bouts of asthma in the past I was starting to feel uneasy and was relieved to get back indoors! What had started well ended up being rather disappointing.

This brings home to me how interconnected we all are. Whatever lifestyle choices I make for my own health and wellbeing my individual actions can only go so far when other people’s lifestyle’s impact on my own. Similarly, but less immediately visible I’m sure that the standard of living I have come to expect as an inhabitant of a relatively prosperous country has a significant impact on the populations of poorer countries who supply us with our material goods. So while health may seem to be an individual concern, my morning walk suggests to me that we should see it as a collective responsibility.

Having worked in the voluntary mental health sector for ten years before becoming an academic, and having also faced some weighty challenges to my own wellbeing in the past, I have had a longstanding interest in what makes people happy with their lives despite facing many difficulties along the way. For many years this topic seems to have been the domain of philosophers, religious thinkers and poets. The scientific community appears to have been more interested in exploring what makes things go wrong, looking at ‘pathology’, rather than seeking the ingredients for a contented and satisfying life. 

In recent years this deficit has started to be addressed, especially by proponents of ‘positive psychology’ who have studied the factors which make people happy with their lives. Personally I have welcomed this approach as I think it provides some useful insights into what really makes people happy, offering an alternative to the messages peddled by advertisers that we can buy our way to happiness. 

So, in theory, I should be pleased when politicians embrace the messages coming from positive psychology. Richard Layard is an economist and Labour Peer who has written a popular book on happiness and has promoted policies focusing on increasing psychological and emotional wellbeing. Conservative leader David Cameron has been on record as saying that GWB (general well being) should be as important as GDP (Gross Domestic Product). Both talk about the dangers of thinking that more money equals more happiness. However, in practice I feel disturbed by such messages coming down to the populace from people with positions of power in our society. While they may be genuine in their intent, there is always a danger that positive psychology will become associated with ulterior political motives – a new ‘opium of the masses’. If the move towards being a happier society is to be a liberating experience doesn’t it has to come from the bottom up and not the top down?

If you watch BBC TV over the next two weeks you will not escape the
Wimbledon phenomenon, where even the most dedicated couch potatoes in the viewing public become obsessed with fine physical specimens like Andy Murray throwing themselves around the courts. Meanwhile, if previous years are anything to go by, the public tennis courts in my local park will suddenly be full of people not looking anything like so fit trying to emulate their sporting heroes.

Some months ago, quite by chance, I used tennis as an analogy for life in some materials I was writing on health and wellbeing for the Open University’s forthcoming new 2^nd level health and social care course.

“Not surprisingly health and social care services tend to focus on what is going wrong in the lives of their service users, as they have to try to find ways of tackling their problems. However, in order to recognise what constitutes a ‘problem’ it is useful to have some understanding of what a good quality of life might look like, as this provides a point of comparison between what might be and what is. To use an analogy, if you wanted to improve your ability to play tennis it would help to know what a good game of tennis is like, what makes for a good tennis court and for your coach to know how successful tennis players operate, as well as having an understanding of the circumstances under which people play tennis poorly. Knowledge of quality of life and the factors that contribute to an individual’s wellbeing can similarly be useful to those who provide and use health and social care services.”

What I didn’t consider at the time was that, in comparing ourselves to the likes of Andy Murray or Venus Williams, whilst we might be inspired to greater things we could also become dissatisfied with our less than perfect bodies and with our less than optimal performance. The balance between inspiration and desperation is a delicate one. How do you react to this week’s Radio Times cover?

As NICE points out in its recent report on the matter, a lack of evidence doesn’t equate with evidence of ineffectiveness. Nevertheless, NICE will not approve NHS funds for interventions without a sound evidence base, and research points to the efficacy (and dare I say it, cost effectiveness) of many alternative therapies in the treating of back pain. A couple of trips to an acupuncturist or osteopath can work out far cheaper than a MRI scan, for example. A major stumbling block for CAM in the past has been a lack of funding to support the large quantitative trials needed to evaluate interventions, although some CAM practitioners have argued that alternative therapies cannot be measured in the same ‘scientific’ way as orthodox medicine and instead require a more qualitative approach to research. Either way, NICE’s decision is surely good news for patients who have, in the past, been forced to pay privately for services that GPs argued should be available to all.

Listening to an osteopath on the television this morning defending NICE’s decision, I was struck by how far the CAM community has come in terms of identifying itself with conventional medicine. The osteopath commented that a few years ago CAM was ‘a bit wacky’, but codes, regulation, accredited training had changed that. The CAM field is by no means a homogenous one, and I can’t help but wonder whether there is a feeling in some quarters that uncomfortable compromises were struck in order for CAM practitioners to ‘professionalise’ and secure legitimacy in the UK healthcare system.

I I am currently writing some course materials on identity, health and wellbeing. I have not given much attention to thinking about my own identity in relation to health until now, but on reflection it seems quite important. Before being diagnosed with asthma in my mid-thirties, and borderline high blood pressure in my forties, my contact with health professionals was minimal, whereas now there are regular check-ups with practice nurses and occasional consultations with doctors. Whilst these encounters are usually reasonably satisfactory, I often feel that my sense of identity in the consulting room is quite different to that in many other aspects of my life.  

As time is limited in these appointments there is necessarily a focus on the medical aspects of my being. Should I happen to mention something else that is going on in my life it might at best be briefly acknowledged, or at worst ignored as irrelevant to the business in hand. One practice nurse, who thankfully has now moved on, was terribly patronising and would make generalised statements starting with phrases like ‘I find that asthmatics …..’. I used to leave those appointments simmering with anger and feeling thrown back into a frustrated child-like state of weakened identity. In the end I started wearing a jacket and tie to appointments with that nurse to try and assert a more powerful identity for myself in the room! 

I can also remember experiencing annoyance with well-meaning friends who suggested that these long-term conditions were probably brought on by suppressed anxiety, anger or other emotions which could be sorted out with one brand of psychotherapy or another. Now I do agree that mind and body are linked and I know that the role of genetic factors in physical health is still being debated in some quarters, but this just did not fit with my sense of identity and I resented the implications of emotional vulnerability suggested by these people. Whatever the causes of my medical conditions (as I am choosing to view them) my sense of identity clearly plays an important role in my willingness to engage with others in finding ways of managing them so I can get on with my life.

While on holiday last week I woke up one morning to hear John Humphries on Radio 4’s Today programme interviewing a choir leader and a professor of music education on the benefits of  singing in choirs. So many positive features were identified that Humphries was led to exclaim “it is complete health and social care!”

This got me thinking. Many people probably see health and social care as being delivered by dedicated services rather than as something that could also be derived from taking part in pleasurable activities. However, it is not unusual to spend time looking after many of our health and social needs through mutual support and taking care of ourselves without any interventions from professional practitioners, so why not expand the concept of ‘health and social care’ to include activities such as singing?

Singing is said to be good for the heart, lungs, immune system, brain functioning and emotional wellbeing (see for example an article in the Guardian last autumn). Singing with others brings additional benefits of friendship and social support which in turn can enhance our health and wellbeing. Many people, myself included, have thought they could not sing, perhaps due to earlier negative experiences, but have discovered that in a supportive environment with the right instruction they can sing and enjoy it. This inclusive approach to singing is supported in the UK by the Natural Voice Practitioners Network who view singing as everyone’s birthright. Now that evidence is emerging of the health and social benefits could we promote the creation of thousands of community choirs as a desirable public health objective?

Last year, I stopped taking my medication.  I didn’t think it was that important.  At my annual session with the consultant, he asked about my choice here.  Now this could have been tricky …

The philosopher Annemarie Mol describes the ‘Logic of choice’ in health and social care – facts are presented, the person weighs up advantages and disadvantages and makes a choice.  Often evidence that one treatment is superior to another makes choice unnecessary.  In my case – take my pills and avoid the possibility of serious illness.  Choice is easy right? Well kind of.  Problem is, the ‘weighing up’ is done in conditions of constant change – people are different and they’re constantly changing.  Choice isn’t straightforward.

Anyway, the consultant and I chatted for a while.  He explored my lifestyle and my work and home life.  We discussed why I wasn’t taking the medication, my understanding of what the drug did for me, alternatives to using it.  It was non-judgmental and understanding.  After the session, I resumed taking the medication – made a choice – but still was left wondering why I changed my mind.  Was it a ‘Logic of choice’ at work here?

Well yes and no.  Mol would describe the session as operating with a ‘Logic of care’.  Discussion involved recognising the emotional dimension, the reality of my life and my world view.  Care involves disentangling the problems the individual is experiencing that are unique to them and tailoring a response.  This discussion does not involve a disinterested “well, it’s your choice” but attentiveness, concern and mutual responsibility.

The right to choose our treatment, our hospital, our carers is one of the mainstays of 21st century health and social care.  Just visit NHS Choice for an example.  Having worked with people who have been denied real choice for years has imprinted on me the importance of choice as a powerful right.  However, a real challenge here is to continue operating with a logic of care.