Who is Responsible for Your Health?

Who should take responsibility for you health? Sounds like a straightforward question, doesn’t it? But I get so frustrated when complex issues get squashed into simplified, silo-thinking, ready for twitter or media sound bites, or the under-girding of political ideologies.

So….just as the economy is not just made up of the interplay between business and the household, but is in fact far more rich and complex, so too the interplay of responsibility for our own health.

Kate Raworth, really helpfully uses the following diagram to help us rethink the components of the economy. I would like to suggest that we use it to think about health, also.

So…who is responsible for your health and wellbeing?

  1. Your Family/Household
  2. Society/The Commons
  3. The Market
  4. The State
  5. You

In some ways, I feel like all of these are obvious, in their own way, but I will just unpack each one a little bit more.

 

Your Family/Household

We all have needs. We need to know we are provided for (water, food, clothes etc), safe, loved, welcome, encouraged, disciplined and given place to dream and live those dream out. It is the role of our families or the household to which we belong to ensure those things happen as we grow. So much of our ill-health, our brokenness and our long term physical and psychological pain is because these basic needs were never met and left us without a sense of wholeness. The lack of met need, has a huge impact on the development of our personality and character. When we speak of ‘personality disorders’, each type has it’s roots in early life when needs were unmet and therefore parts of the personality remained undeveloped. Let’s face it – no family is perfect! And so, I would argue, that all of us have ‘disordered personalities’, and until we confront the shadow parts of ourselves that are trying to overcome this sense of loss or inadequacy, we continue to project an ego version of ourselves to those around us. We do so to cover over this pain, but facing it head on and allowing ourselves to fess up to our deepest needs, would actually lead to us being a great deal more healthy.

When I work with head teachers and ask them what the biggest need they have in their school, the answer is almost always ‘parenting classes’. However, there are very few providers of this available (due to cuts at a county council level) and the classes available are often very ‘middle class’ in their approach. We need to completely rethink parenting classes in the context of the poverty-truth commission and think about less twee ways to really engage with communities about how we raise happy and healthy kids. The truth that Adverse Childhood Experiences are our greatest public health crisis is not going away. Grasping this nettle is going to be painful but really necessary if we are to breathe health and wellbeing into our society.

 

Society/The Commons

Just as we get our needs met by those in our immediate household, the same is true of society. The way we treat children, the things we expose them to, the way we love them and educate them has a massive impact on their current future health and wellbeing. It’s becoming clear that social media is causing significant harm to our mental health as a nation, particularly our young people, and yet we don’t know how to curb our enthusiasm for all our technology…let alone the rise of the robots…

The commons is fast disappearing, too easily privatized and made available to those who can afford it. How do we safeguard the commons and use it for the benefit of all? What would the Diggers say to us now? The breakdown of our communities, with increasing isolation and loneliness is having a detrimental effect on our wellbeing. What can we do to recover the spaces that belong to us all and help us rediscover the joy of connecting and being together?

The commons is also about our corporate voice. It is only really vast people movements, speaking with one voice that can really cause governments to sit up, listen and take heed of the needs of the people. It is only together, that we will make enough noise to change the health and wellbeing of all of us for the better. How might we speak and act together in a way that will take corporate responsibility for all our health and wellbeing?

 

The Market

Oh the benevolent hand of the market! If only…. But the Market plays an absolutely key (though currently over played) part in our economy and our health and wellbeing. We know for a fact that advertising is deliberately trying to misinform us so that we make irrational decisions. A key component is to make people feel worse about themselves so that they buy things they simply do not need. Supermarkets are being challenged for the ways they deliberately place products and arrange their stores to cause people to buy more unhealthy things and food chains are constantly trying to ‘up-sell’ their unhealthy products and downgrade our health in the process. They evangelize the masses with the idea that we are all free to make our own choices, but if this were so, they would not spend the billions of pounds involved in socially engineering our choices, so that we ‘freely’ choose that which harms us! Oh for a market that might redefine it’s moral code! The market could do SO much good, but unharnessed and left without true accountability or consequences, it serves to damage our health – something it is truly responsible for.

 

The State

The state has a vital role and responsibility in caring for all of our health and when it washes it’s hands of that responsibility or tries to pass it over, we see a massive rise in health inequalities and overall worse-health for all. The NHS in the UK is one of the great triumphs of the state. Providing brilliant healthcare for those who need it whenever they are unwell is truly amazing. Imagine not being able to afford this because it depended on keeping up with insurance bills. It is not uncommon for us to see people in General Practice, who literally cannot afford to feed their families any more and are having to make some incredibly difficult choices (made far worse by long school holidays). Easy to point the finger and start creating a narrative about how it’s “all their fault”, but far harder to hear the truth of what it is really like to be a lived-expert in poverty and the trap it creates and harder still to look to alternative solutions, rather than believe the austerity narrative. There is clear evidence that the more unequal a society becomes, the worse the health outcomes – both physical and mental. When the market is allowed to behave exactly as it wants, we also see the health of people suffer. It is only through the right kind of government that the market can be tamed. It is only with the right kind of legislation that the economy can be skewed towards redistribution and regeneration of the resources needed – this would need to include a radically feminist approach that works on behalf of women, in particular, for equal opportunity, pay and recognition of just how much the ‘household economy’ contributes to the overall wellbeing of the nation. It is only the right kind of leadership that will tackle the inequalities we see and refuse to be wined and dined into maintaining the status quo. It is only brave leadership that will take the ecological issues, like plastic in the oceans, massive over antibiotic use in animals, and ongoing air and river pollution that will give us a healthy planet and human population in the future.

 

You

And where possible, and for some given various health issues, this is more possible for some than others – we do not all have an equal starting place or a level playing field – where we can  – we do have a responsibility to ourselves and to the wider society to care for our own health and wellbeing, so that when the health and social services are needed, they are available for all. It also means using the health and social care services in a way that creates sustainability, being grateful for them and ensuring they and the people who work in them are not abused.

 

It’s complex, but it’s vital that too much emphasis is not put on any one area. We must not play the blame game, especially not towards individuals when we haven’t taken the time to hear their story, nor understood the wider context of the role of the other vital players on the field. Each aspect of the economy plays a massive role in the health and wellbeing of the nation, and it is high time that each plays it’s relevant part to its fullest ability.

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What Next for General Practice?

Last week, I had a sixth form student spend the week with me. She is hoping to go to medical school and is gaining the necessary work experience ahead of her applications. It was so great to be able to share with her the variance of my work and the great privilege it is to be a GP in the community. On the first day, we saw people with all kinds of problems, often interlinked or overlapping. She was amazed by how well I know my patients, not just the conditions they have, but them as people and the complexities of their lives. At Ash Trees Surgery, the practice where I am a partner, we run personal lists, in which we as GPs always see the same set of patients, supported by 2 other doctors, for times when one of us is not around. It gives us the opportunity of building fantastic therapeutic relationships with the people we serve and we get to know them really well. Our patients love it, we love it, and it has been a ‘traditional model’ of General Practice in our local community.

 

However, things are changing (not immediately in our case, but faster than perhaps we would like), and we (as GPs) and people generally, are going to have to get used to it, not just in Carnforth, but across the whole of the UK. I’m not writing this blog post as an idealist, but as a pragmatist. There are many things I wish were not changing, but we are reaching a point at which the scales are tipping and things simply cannot remain as they have been. Many GPs know this already and are making bold and difficult decisions to try and work differently, but many of us keep harking back to yesteryear and wishing we could turn the clocks back.

 

The issues facing us are stark:

 

1) We simply will not have enough GPs within the next 5 years to carry on working in the ways we have done. 40% of current GPs will be retiring within the next 5 years or moving into other work. (http://www.telegraph.co.uk/science/2017/07/30/nearly-40-per-cent-gps-plan-leave-nhs-within-five-years/).

 

2) The promise of 5000 more GPs will simply not come to fruition and certainly not in the time frame needed. Actually, a plan is afoot to replace some of the GPs with ‘Physician Associates’, people who have a science or allied degree, who have then done a conversation course and can do some (but certainly not all) of the work of a GP. They will also neeed supervision by GPs. Health Education England are having to cut GP training in order to make way for this new breed of health care workers (yet unproven). The Royal College welcomes the development as a support, but not a replacement of GPs. (http://www.pulsetoday.co.uk/your-practice/practice-topics/education/gp-training-cuts-necessary-to-allow-hee-to-develop-physician-associates/20034643.article#.WUrZgli-YHU.twitter)

 

3) The new generation of GPs, do not want to become partners and therefore the old partnership model will soon become entirely unsustainable. The results of a recent survey, carried out by Pulse of GP Trainers about the future careers aspirations of their trainees is pretty stark:

Only 6% said their trainees wanted to go into partnerships;
49% said their trainees wanted to become locums;
28% said their trainees wanted to go abroad
30% said their trainees wanted to find a salaried post;
4% said their trainees wanted to change career.

 

So, in summary, the older GPs are retiring, we’re not recruiting enough new GPs and those we are recruiting, simply don’t want to work in the ways we have been used to.

 

The Five Year Forward View has been trying to encourage us all to reimagine General Practice and how we might hold true to the values of this bedrock of the NHS, whilst adapting towards the future that is coming. I think we have some options, and GPs need to think clearly and carefully about which direction they want to head in. But even more importantly, the people of the UK need to recognise that change is afoot and GPs are simply unable to work as we have done previously. The demand is too great and the resource simply is not there to carry on as we were.

 

The first option, is for GPs to bury their heads in the sand and hope that all this might not be true, to become more entrenched in their position and wait for things to be done to them. I believe this will be harmful for General Practice itself, as it will mean a decrease in resources, an increasingly burdensome workload and significant burnout. But I also believe it is detrimental to the NHS as a whole. We neeed to break down the barriers that have divided us and work more holistically across what is a very complex system. Waving the flag of traditional General Practice is admirable in some ways, but I think it might prevent us from stepping into the future that the nation now needs from its NHS.

 

The second option is for GPs to federate with other practices, keeping hold of some of what they love, (a perceived sense of autonomy, the ability to run their own business, to stay part of a smaller team) whilst benefiting from sharing some functions like training, recruitment and maybe some staff with other practices. We have done this in Morecambe Bay (thanks to the Stirling work of Rahul Keith, John Miles, Lauren Butler, Richard Russell, Graham Atkinson, Chris Coldwell et al).  However, the federated model has to be given true commitment and financial support or it will accomplish very little. Practices cannot go back to competitive mindsets or taking care of their own needs first. It requires a bigger heart and a more open mind with genuine behavioural change.

 

The third option is to form super-practices. We have two in our area now (Bay Medical Group in Morecambe – > 60000 patients  and Lancaster Medical Practice >50000 – also both part of our federation). There are some huge advantages in working “at scale”, but it is not easy and certainly not a smooth transition. GPs have to learn to trust each other and be willing to have difficult conversations around buildings, drawings, policies etc, let alone learning to work differently. But more than that it is very hard to learn how to deliver really good General Practice in a personal way, whilst trying to reconfigure the team and establishing a really good culture. However, this model definitely allows new ways of working to be more easily acheivable, if given appropriate OD support. Some recent work done in Gosport and showcased by the King’s Fund showed that perhaps only 9% of people who phone asking to see a GP actually need to see a GP. The reality is that people have become used to seeing their GP, but often they could be seen and treated more effectively by a pharmacist, a nurse, a nurse practitioner, a physiotherapist, a mental health worker, a physician associate or a health coach. Perhaps GPs need to let go, whilst patients learn to trust the expertise of others? How do we transition to this kind of approach without losing that amazing knowledge of a community and complex social dynamics, often held by a GP? How does a Multi-Disciplinary team function effectively for the best care possible for patients in such a dynamic? We are in danger of losing something very precious, but can we somehow hold onto it in a different way?

 

The fourth option is to allow a “take-over” and become a more active player in an Accountable Care Organisation. The take-over approach is not straightforward, but I’m not sure it is as terrible as it appears to many GP colleagues. What if an acute trust set up a separate company, lead by a GP as medical director, who understood and held the true values of General Practice in his/her heart (as they have done in Yeovil – https://www.england.nhs.uk/blog/paul-mears-berge-balian/)? The company, run by General Practitioners, holding true to the core delivery of General Practice, without all the difficulties of running a business, HR issues, estates, etc etc but with all the benefits of shared IT systems, easier access to scans, no duplication of work and direct access to services without all the current clunkiness, not to mention protected admin time! What if the salary was right and the dross was removed? What is it exactly that would not be appealing about this? It is interesting to me. Only a couple of years ago I would have been utterly opposed to this idea, but having given it thought and time over several months, exploring the possibilities involved, I’m in the place of thinking that the benefits probably outweigh the negatives both for GPs and our patients.

 

What we need right now is for us all to accept that the NHS, as we have known it is no longer functioning in a way that meets the need of the population we seek to serve. We know we need a greater emphasis on prevention and population health (I have blogged on this many times before and will do so again!). We also know that the system itself is vastly complex and is in need of major reform and reconfiguration. We need this not only for the people who use the NHS, but for those of us who work in it and are in danger of serious burn out. I hope with all my heart that General Practice does not drag its feet and prevent the revolution that is needed. Our case for more resource and more recognition of the fabulous work we do will only gain favour, if we also show that we are willing to be a part of the whole and a part of the change that must ensue.

 

 

 

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