Humanising Healthcare

Talk of crisis in our health systems has become a political commonplace, with expenditures nearly doubling in the first decade of the 21st century. In this simple yet seminal book, Margaret Hannah not only analyses the factors underlying this crisis but presents 'patterns of hope for a system under strain' that should be required reading throughout the system as present attempts to contain spiralling costs are clearly inadequate and may indeed paradoxically result in further complications and a compromised quality of service. She quotes Aldous Huxley as saying that 'medical science has made such tremendous progress that there is hardly a healthy human left.' His adopted country of the US illustrates his maxim although the food industry must shoulder part of the responsibility.

The three parts of the book discuss the contemporary challenge, current responses and a third way. Margaret highlights some crucial issues in the first part, some arising from our history like the emphasis on machine and military metaphors, on objectivity and the clinical gaze, all of which tends to dehumanise the relationship between carers and patients. Medicine is implicitly being asked to address existential issues with technical equipment. The epidemiological transition from infectious to chronic conditions requires a systemic understanding grounded in culture and the realities of inequality, social dislocation and loss of meaning, sedentary lifestyles and an ageing population.

One illustration in the chapter on escalating costs comes from Scotland where, between 2001 and 2010, new cases of heart disease fell by 28% and deaths by 40% while in the same period the number of people living with heart disease rose by 70% from 500,000 to 850,000. The main cost factors are the inexorable rise in demand, medical technology, increased prescription of drugs, overdiagnosis and escalating staffing. Prescriptions in England rose from 374 million in 2001 to a staggering 961 million in 2011 with the average number of items prescribed per person going up from 12 to 18 – this seems to be going down the American road.

All this means that the brakes are failing. Responses in terms of increasing efficiency and productivity, cost savings, innovation and reorganisation are attempted by every government, yet they put huge strain on the carers and may lead to deteriorating standards of care and unfortunate oversights and accidents. Regulation and inspection are rife, intensifying pressure on staff, undermining morale and creating institutionalised anxiety. A critical chapter on randomised clinical trials exposes the limitations of a quantitative approach based on the biomechanical model that fails to recognise the complexity of life.

However, Margaret shows that another way is possible by telling the story of the South Central Foundation in Alaska, which takes a radical new approach of 'intentional design' to healthcare. They began with a two-year listening process encouraging participation and ownership and evolving a system consonant with local values. The results speak for themselves: between 1997 and 2007 there was a 40% drop in A & E usage, a 50% drop in specialist referrals and a 20% drop in primary care visits. The architecture is friendly and people are encouraged to chat in the front entrance; in other words they are creating a really human context. The UK Peckham Experiment before the Second World War took this kind of integrated family approach building up trust and stressing salutogenesis rather than disease management. Overall there is a shift of control towards patients, who are encouraged to take responsibility for their choices.

The current system – as do all systems – shapes behaviour in particular ways and we cannot expect a wholesale transformation. However, small-scale projects can be undertaken within existing structures, and Margaret provides some examples from her own experience – forms of transformational innovation that can be pioneered very inexpensively with a supportive policy framework. We can foster a human system of relationships based as much on being as on doing. She introduces a very useful framework used within the International Futures Forum (in which I am also involved) of the Three Horizons. H1 is the dominant system in the present trying to maintain itself; H3 is a place of aspiration, a patterning of hope; between lies H2, a place of opportunity and innovation but less radical and visionary than H3. This framework can provide a space for deepening non-confrontational conversations as a step towards genuine transformation. She recommends configuring round commitment rather than targets, growing the new in the presence of the old – real humanism in action.

Although I recommended this book at the beginning to health professionals it can and should be read by anyone wishing to understand the deeper dimensions of health within our current cultural context – and do take a copy in for your local GP!