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Holistic health care: our future?. Dr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel : +44-(0)1865-737310 Fax : +44-(0)1865-737309 email : [email protected] Themes. Aim for person -centred healthcare

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Holistic health care our future
Holistic health care: our future?

Dr Derick T Wade,

Professor in Neurological Rehabilitation,

Oxford Centre for Enablement,

Windmill Road, OXFORD OX3 7LD, UK

Tel: +44-(0)1865-737310

Fax: +44-(0)1865-737309

email: [email protected]


Themes
Themes

  • Aim for person-centred healthcare

    • Not patient-centred health care

  • Actions & decisions depend upon way of thinking

  • Person-centred healthcare depends upon having a holistic understanding of health

    • No social admissions, bed-blocking patients, difficult to discharge patients


Nuffield orthopaedic centre
Nuffield Orthopaedic Centre

  • 1872 - Wingfield hospital: “It was designed to accommodate eight men and eight women who were well enough to leave the Radcliffe Infirmary but were not well enough to go home.”

  • 1914-18 – orthopaedic workshops

  • 1921 - officially orthopaedic (WW I)

  • 1933 – Wingfield-Morris Orthopaedic hospital

  • 1948 – joined NHS

  • 1950 - renamed Nuffield Orthopaedic Centre

  • 1991 - became NOC NHS Trust


Three puzzles
Three puzzles

  • Why is ‘invalidity’ (being ill) increasing when disease treatment is improving?

    • E.g. Sickness benefit payments are increasing

  • What disease causes firemen to retire on medical grounds at 20 years service?

    • Steady rate up to 20 years and after 21 years

    • Sudden jump at 20 years and falls again at 21


What causes functional illness
What causes ‘functional illness’?

  • People who experience symptoms (and disability) but have no disease to account for/explain their illness

    • Form 20% of all new out-patients in all clinics

    • Example diagnostic labels include:

      • Fibromyalgia, migraine, chronic fatigue syndrome, low back pain, chronic regional pain syndrome, non-cardiac chest pain, irritable bowel syndrome, myalgic-encephalomyelitis etc etc


To answer these puzzles
To answer these puzzles

  • Need an appropriate model of illness.

  • A model is:

    “A simplified or idealized description or conception of a particular system, situation, or process that is put forward as a basis for calculations, predictions, or further investigation.”

    (OED 2006)


Common current assumptions
Common current assumptions

  • Disease refers to disorder of organ within the body

    • i.e. Disease is malfunction of part of whole

  • All symptoms and illnesses are attributable to disease

    • i.e. A person with symptoms is ill and must have an underlying disease within body

  • All disease causes symptoms and illness

    • i.e. Sooner or later disease manifests itself


Biomedical model of illness
Biomedical model of illness

  • These assumptions are central to the biomedical model of illness

    • Ill-defined; no standard definition

    • Current dominant model

  • Basis of model is the scientific method:

    • Reductionist approach; identify single causes

    • Focus on pathology/disease within the body as primary cause of illness


Biomedical model
Biomedical model

  • Incorporates other important assumptions:

    • Patient is passive:

      • A ‘victim’ of disease, and

      • A ‘recipient’ of treatment

    • Mental phenomena are separate domain unrelated to ‘physical’ phenomena (Cartesian dualism)

      • ‘physical symptoms/signs’ are not caused by ‘mental’ processes


Biomedical model1
Biomedical model

  • Has been very successful over 100+ years

  • Socially very important

    • Determines political policies

      • Organisation of bureaucracy (e.g. CRS etc)

      • Allocation of resources / basis of payment

    • Guides most people’s actions & decisions

    • Leads to ‘sick role’

      • Lack of responsibility for illness

      • Allowed to avoid social duties


Main assumptions are false
Main assumptions are false

  • Disease without symptoms is common

    • Screening programmes based on this

    • 5% of 70 year old people may have ‘silent’ cerebral infarction.

  • ‘Symptoms’ (i.e. Experiences considered outside ‘normal’) are very common

    • Daily occurrence

    • Two ‘life-threatening symptoms’ each six weeks


Conclusion
Conclusion

  • The current biomedical model:

    • Is incomplete

      • E.g. not explain functional illness or lead to treatment

    • Is unable to resolve modern problems

      • “Payment by results” tariff not able to work

        • Major determinants of cost are social and disability

    • Incorporates a mereological fallacy

      • The fallacy of attributing to parts of an animal attributes that are properties of the whole


What did he mean
What did he mean?

“The NHS must focus on good case management where patients with complex needs are identified and supported by skilled staff working in a holistic fashion in an integrated care system.”

From

Speech by Rt Hon John Reid MP, Secretary of State for Health, 11th March 2004:

Managing new realities - integrating the care landscape


Holism
Holism

  • “The tendency in nature to form wholes that are greater than the sum of the parts through creative evolution.”

  • Smuts JC. 1870-1950. South African lawyer, general and politician (Prime Minister 1919-24; 1939-48), also a philosopher.

  • Book: Holism and Evolution. 1926 (second edition 1927).


Holism1
Holism

  • Concept led on to General Systems Theory (Ludwig von Bertalanffy, 1971)

    • Concepts of:

      • System being more than the sum of its parts

      • Hierarchical and interacting organisations

  • and hence to:

    • Complexity, and Chaos Theories etc

      • Stressing importance of non-linear relationships

        • Minor change in one factor may have major effect elsewhere


Holistic medicine
Holistic medicine

  • Holistic medicine first mentioned 1960 by F H Hoffman:

    • “.. concern with teaching about the whole man – ‘holistic’ or comprehensive medicine ..”

  • Best definition:

    • “… holistic medicine that integrates knowledge of the body, the mind, and the environment …” (Annals of Internal Medicine, 1976)


Holistic Medicine - 2

“Holistic medicine is the art and science of healing that addresses the whole person - body, mind, and spirit. The practice of holistic medicine integrates conventional and alternative therapies to prevent and treat disease, and most importantly, to promote optimal health. This condition of holistic health is defined as the unlimited and unimpeded free flow of life force energy through body, mind, and spirit.”

American Holistic Medical Association

http://ahha.org/articles.asp?Id=81


Holistic healthcare conclusion 1
Holistic healthcare: conclusion - 1

  • The concept has mutated to encompass and even exclusively represent ‘alternative’ health care:

    • Often said to be ‘an approach’

    • Often focused on ‘spiritual care’

    • Always difficult to specify


Holistic healthcare conclusion 2
Holistic healthcare: conclusion - 2

  • Health (and illness) is comprised of various hierarchicalsystems.

  • A person (ill or healthy):

    • encompasses several ‘components’

      • Spirit, mind, body etc

    • lives within a context

      • Past, personality, social milieu

    • lives in a certain way, their ‘life style’

      • Have their own goals, expectations etc


Achieving holistic healthcare
Achieving holistic healthcare

  • To achieve holistic healthcare effectively requires

    • a model of illness that is holistic, giving

    • a systematic and comprehensive approach

    • to all domains of health and

    • to all domains influencing health

  • Biomedical model is not holistic


There is an alternative model
There is an alternative model

  • Biopsychosocial medicine

    • 1977, Engel (building on sociology etc)

    • Systems approach to illness

    • Psychiatry and chronic back pain

  • At same time World Health Organisation was developing a new classification of consequences of disease


World Health Organisation’s Inter-national Classification of Impair-ments, Disabilities and Handicaps

  • WHO ICIDH - developed in 1970s

    • Published first in 1980

  • Put forward as a classification system

    • like ICD, to complement ICD

    • for all consequences of disease

      • Impairment, disability, handicap

  • Did not acknowledge environment


Who international classification of functioning
WHO International Classification of Functioning of Impair-ments, Disabilities and Handicaps

  • Revised ICIDH > ICF (1996-2001):

    • added contextual factors:

      • physical (buildings, carers, clothes etc)

      • personal (experiences, strengths, attitudes etc)

      • social (family/friends, culture etc)

    • changed words (not concepts)

      • disability -> (limitation in) activity

      • handicap -> (restriction on) participation

    • added global concept of ‘functioning’


Adapted who icf model
Adapted WHO ICF model of Impair-ments, Disabilities and Handicaps

  • Basic WHO ICF model is incomplete:

    • No mention of ‘quality of life’

    • No mention of choice (‘free-will’)

    • Only takes perspective of outsider (not ill person)

    • Does not take time into account

      Wade DT, Halligan PW Do biomedical models of illness make for good healthcare systems? British Medical Journal 2004;329:1398-1401


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF Description of illness

Three Contexts

Organ (pathology)


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF Description of illness

Three Contexts

Organ (pathology)

Person (impairment)


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF Description of illness

Three Contexts

Organ (pathology)

Person (impairment)

Person in environment

Behaviour (activities)


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF Description of illness

Three Contexts

Organ (pathology)

Person (impairment)

Person in environment

Behaviour (activities)

Person in society

Social position (Participation)


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF Description of illness

Three Contexts

Organ (pathology)

Personal

Person (impairment)

Person in environment

Behaviour (activities)

Person in society

Social position (Participation)


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF Description of illness

Three Contexts

Organ (pathology)

Personal

Person (impairment)

Physical

Person in environment

Behaviour (activities)

Person in society

Social position (Participation)


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF Description of illness

Three Contexts

Organ (pathology)

Personal

Person (impairment)

Physical

Person in environment

Behaviour (activities)

Social

Person in society

Social position (Participation)


Four Levels of Impair-ments, Disabilities and Handicaps

Traditional Model of illness

Three Contexts

Organ (pathology)

Personal

Person (impairment)

Physical

Person in environment

Behaviour (activities)

Social

Person in society

Social position (Participation)


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF model of illness (1)

Three Contexts

Organ (pathology)

Personal

Person (impairment)

Physical

Person in environment

Behaviour (activities)

Social

Person in society

Social position (Participation)


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF model of illness (2)

Three Contexts

Within body

Organ (pathology)

Personal

Well-being

Choice

Person (impairment)

Physical

Person in environment

Behaviour (activities)

Social

Person in society

Social position (Participation)


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF model of illness (3)

Three Contexts

Within body

Organ (pathology)

Personal

Well-being

Choice

Person (impairment)

Physical

Person in environment

Behaviour (activities)

Body & physical environment

Social

Person in society

Social position (Participation)


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF model of illness (4)

Three Contexts

Within body

Organ (pathology)

Personal

Well-being

Choice

Person (impairment)

Physical

Person in environment

Behaviour (activities)

Body & physical environment

Social

Person in society

Social position (Participation)

Person and social environment


Four Levels of Impair-ments, Disabilities and Handicaps

WHO ICF Model of illness

Four Contexts

Organ (pathology)

Disease/diagnosis

Well-being

Personal

Attitude, beliefs, etc

T

I

M

E

P E R S O N

Body(impairment)

Symptoms/experiences

Choice

Person in environment

Goal-directed behaviour Activities/disability

Physical

Close & distant

Person in society

Social position Participation, social roles

Social

Friends, colleagues


Who icf holistic healthcare
WHO ICF & holistic healthcare of Impair-ments, Disabilities and Handicaps

  • Model suggests that a person

    • Has a body which

      • Functions as a whole

        • Experiences, skills etc

      • Has subsystems

        • Organs,

      • Interacts with physical environment

    • Acts as a conscious social being

      • Has goals , makes choices, experiences spirituality

      • Interacts with other people (social context)


Who icf model and illness
WHO ICF model and illness of Impair-ments, Disabilities and Handicaps

  • Illness arises when the system of:

    • Person within their context

    • Fails to adapt to demands (stresses):

      • Externally (e.g. prolonged cold)

      • Internally (e.g. reduced function of an organ)

  • Illness is a phenomenon of the person,

    • Not of a part of the person


Who icf noc
WHO ICF & NOC of Impair-ments, Disabilities and Handicaps

  • Brief discussion of how WHO ICF could be used to transform NOC

    • Clinically

    • Organisationally


Who icf holistic clinical care
WHO ICF & holistic clinical care of Impair-ments, Disabilities and Handicaps

  • Use it to analyse clinical situations

    • Identify all relevant factors related to situation

  • Use it to plan holistic clinical management

    • Intervene in as many factors as possible

      • Directly

      • Liaise with others


Achieving holism clinically
Achieving holism clinically of Impair-ments, Disabilities and Handicaps

  • Key is to consider a person’s social role functioning

    • What roles do they have or aspire to?

    • What roles could they achieve?

    • Do they have any roles at all, other than patient?


The importance of social roles of Impair-ments, Disabilities and Handicaps

“And lest this last consideration - no mean or secondary one with Sir Mulberry - should sound strangely in the ears of some, let it be remembered that most men live in a world of their own, and that in that limited circle alone they are ambitious for distinction and applause. Sir Mulberry's world was peopled with profligates, and he acted accordingly.“

(Charles Dickens: Nicholas Nickleby, Chapter 28)


Changing roles an important goal for healthcare
Changing roles: of Impair-ments, Disabilities and Handicapsan important goal for healthcare?

“The kindest thing anyone could have done for me would have been to look me square in the eye and say this clearly:

‘Reynolds Price is dead. Who will you be now? Who can you be now and how can you get there double-time’”

Reynolds Price. A whole new life: an illness and a healing.

New York Atheneum 1994


Holistic healthcare systems
Holistic healthcare systems of Impair-ments, Disabilities and Handicaps

  • WHO ICF model can help organisation


  • Focus changes over time of Impair-ments, Disabilities and Handicaps

  • Level of illness

  • Context

  • Type of expertise needed

Pathology

Acute phase

Impairment

Social roles

Activities

Social context

Physical context

Expertise - locality

Expertise - condition

Time


Acute phase of Impair-ments, Disabilities and Handicaps

Time course of a long-term condition, and service needs

Post-acute phase

Specialist disease service

NOC√

NOC√

Specialist rehabilitation service

NOC?

Locality rehabilitation service

General practice complete service

Self-management

Time


Holistic healthcare requires
Holistic healthcare requires: of Impair-ments, Disabilities and Handicaps

  • Use of a holistic model of illness to:

    • Analyse clinical situations

      • Understand multi-factorial causation of illness

    • Plan healthcare interventions

      • Multi-factorial, not simply disease-focused

    • Organise services and notes etc

      • Around different levels

    • Be basis of commissioning and funding

      • Condition management notdisease management

      • Across all boundaries


Therefore the noc should
Therefore the NOC should of Impair-ments, Disabilities and Handicaps

  • Embrace WHO ICF in all its activities

    • Clinical, planning, administration etc

  • Develop seamless relationships with

    • Community services and primary care

    • Social services (and others)

  • Develop services centred on problems

    • Of people with relevant long-term conditions

    • Across their lifetime


Summary
Summary of Impair-ments, Disabilities and Handicaps

  • Holistic healthcare requires a comprehensive, coherent model of illness

  • The expanded World Health Organisation International Classification of Functioning biopsychsocial model is holistic

  • The Nuffield Orthopaedic Centre should join the Community Health Organisation to become the first healthcare organisation to use this model fully


1872 of Impair-ments, Disabilities and HandicapsWingfield Hospital - fever

1921 Wingfield Hospital - orthopaedic

1950 Nuffield Orthopaedic Centre

1992 Nuffield Orthopaedic Centre NHS Trust

2010 Oxford Holistic Healthcare NHS Trust?


Holistic health care it is our only future
Holistic health care of Impair-ments, Disabilities and HandicapsIt is our only future!

Dr Derick T Wade,

Professor in Neurological Rehabilitation,

Oxford Centre for Enablement,

Windmill Road, OXFORD OX3 7LD, UK

Tel: +44-(0)1865-737310

Fax: +44-(0)1865-737309

email: [email protected]


The WHO ICF model of Impair-ments, Disabilities and Handicaps

T I M E

Organ

Whole body

Symptoms & signs experienced

Impairments of function implied

Disease (actual pathology)

Personal context

Quality of life

experience, expectation, attitude, choice, belief, disease label

Social context

Physical context

Expectations, attitudes, beliefs etc of others

Objects, structures, bodies etc

Participation

Activities

Roles, patient’s interpretation

Roles, others’ interpretation

Behaviour: goal-directed interaction with environment


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