"The ultimate paradox of thought: to want to discover something that thought itself cannot think."
I can’t be alone in seeing the contradictions in where we find ourselves in the great health service debate currently?
It's no coincidence of course that approaching one of the most hotly contested general elections in Scotland and the UK the health service is taking centre stage. With headlines of missed targets on each news report not only in Scotland but also across the UK are these headlines and blunt measures missing the point and masking the very things we need to be talking about?
In recent research (http://www.oasishumanrelations.org.uk/content/uploads/2015/01/7-Principles-to-Shape-the-Workplace-of-Tomorrow.pdf) I did with Oasis School of Human Relations I found studying the paradoxes that emerged from the question about the Workplace of Tomorrow were a vital clue as to where the heart of the issues lay. Those paradoxes illuminate the apparent contradiction and through this the connection to a possible undiscovered truth. That experience has led me to want to question what the paradoxes and fundamental questions of health and care are from my perspective.
The paradoxes of health?
The unparalleled access to treatments alongside a building need and desire to learn and access self-care:
Are they contradictory or are we at a stage in the process of healthcare and the pursuit of wellbeing, where we are awakening once more to the reality that our experience of wellbeing will be within ourselves? Yes medicines and other treatments have a role in the management of illness and disease but they will not make us well. The medicalisation of health means that as a culture we need to (re)learn to self-care and self-manage. And the answer to that is unlikely to be in traditional health systems but in wellbeing focussed approaches, peer based support, in community, in connection and also in increased self -awareness.
The gift of longer life or the curse of longer life?
Before we leap to complain about so many of us living longer can we pause to celebrate the longer lives that many can now expect? Age is not disease; surely our goal instead could be to create a society that celebrates ageing: that understands that memory loss does not makes us less human or valuable, just more vulnerable and that recognises as we age we can play a different role in society, not necessarily a worse one. Let's reframe our attitude to ageing, to disability, to caring and maybe we can start to experience it differently too.
Focussing on healthcare at the expense of enabling well-being
So used are we to the solution to health being in healthcare we have lost trust in our ability to self-care. We have set aside ancient and inner wisdoms in favour of a prescription. We even need prescriptions for exercise for us to know that keeping active will keep us well. The all-consuming machine of healthcare means it’s easier to fund expensive specialist treatment for our 90 year olds than it is to provide flexible compassionate care and support. Healthcare development has added life to our years and years to our lives, I know this well but I suspect we never intended it to take precedence over everything else. Let's start to look now at how we balance the specialist with the holistic; creating a more mindful, person-centred service.
An emphasis on social independence at the expense of interdependence
Ours is a culture that has valued independence above so much. We have praised those who have survived alone, we live in glorious isolation even as we recognise our need for social interaction and we see dependency as failure. Loneliness is becoming our worst long term condition without a smoking ban equivalent to hold it in check. Is it time to question this value on independence now? Can we begin the conversations that say as my need grows I want you to help me understand and achieve what helps me live a fulfilling life and contribute to the world. Can we start that process for ourselves even, rather than our only directive to our children being; don't let me be a burden?
The acute care distortion and the impact on research and resource for long-term care and support
It's long since been the accepted assumption that the successful doctors and nurses worked in hospital with consequent lesser respect for people who worked with those with long term needs, with families or with community. One of the consequences of this prejudice is that acute care isn't just seen as the “sexy” side of healthcare but also the most deserving of our money and our attention. This matters because it’s almost impossible to get funding for research in to the so called Cinderella services unless it’s for profitable drugs. And without evidence it’s very hard to change practice and policy. This way drugs become the only answer and for long-term care, particularly for older people this means we are distorting our focus. Is it time to question the balance of priorities and value and support the practice of those who care as much as those who cure?
Political focus on targets in contrast to people's concerns about the human side of care
Missed targets, if leading news stories are to be believed, are a sign that our NHS is in crisis. Although when pushed its acknowledge that in the main in Scotland at least we are actually doing well. It's rarely I hear mention of huge waits for treatment as there were a number of years ago. Targets have improved waiting times for things like orthopaedics and it’s a welcome improvement for so many waiting in pain for treatment. But when you look at things like the wait for Children and Adult Mental Health services for example the story is rather different. That is a situation that we must address but it needs more than simply investment in more of the same, it also needs new models of care. I suspect they are community based and designed by and with young people themselves.How much resource do targets distort and distract us, from this service and others, from looking at what are the long-term changes that are needed? A focus on targets risks creating a focus on short-term fixes that perpetuate the issues.
So often feedback to improve the NHS in general is for better communication, for more mutual respect and for more information and support at the right time. Targets can't fix this, focusing on people can.
Evidence-based focus contributing to declining compassion and care
I have begun to believe that perhaps the focus on evidenced based medicine in training medics and others may have had the unintended consequence of leading to a loss of the care for the person. When someone can write as I have read " there is no evidence compassion improves outcomes" we have to accept that things have tipped too far. A focus on finding the answers through medicines and interventions has perhaps inevitably led to us being distratced from the human being in our care. How do we rebalance care to ensure that the art does not trump the science of care?
These are contradictory and complex times in healthcare which is why when the answer is seen in one dimensional terms, no answer will be right. The truths are multiple. Undoubtedly there is outstanding care given to people now in our health and care services. I work today with some of the most motivated, compassionate and informed teams I have ever done. They are outstanding in the care they provide and also in their efforts for change to a more partnership approach to care and support. But what's also true is that they are stretched by the sheer numbers and complexity of the people they serve.
Alongside the complexity of the health and care issues people present sits a consuming bureaucracy. What I notice is an increased focus on processes that were thought to help but instead create their own disorder, their own tyranny of wasted energy and distorted focus. We need to free people up to do what’s right and re-engage them with their own human response to need; free of unnecessary bureaucracy. Neoliberal politics and policies have infected our culture at all levels and healthcare culture too has not been immune to its impact. What could we enable instead by simply trusting more?
Perhaps the ultimate paradox for me is that we maintain a focus on fixing the damage and yet march on with a system which widens social inequalities which in turn have a serious impact on health outcomes and also perpetuates the myth of a pill as an answer to every problem? I urge us to awaken to all of those paradoxes and identify the many more that exist, to start to explore the deeper challenges, to recognise that these are the things we need to tackle and we won't do that by keeping doing the same at a personal, societal and indeed political level.