Holistic health care: our future?

1. 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: derick.wade@ntlworld.com

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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).

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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

22. 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

24. 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

25. WHO International Classification of Functioning • 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’

26. Adapted WHO ICF model • 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

27. Four Levels WHO ICF Description of illness Three Contexts Organ (pathology)

28. Four Levels WHO ICF Description of illness Three Contexts Organ (pathology) Person (impairment)

29. Four Levels WHO ICF Description of illness Three Contexts Organ (pathology) Person (impairment) Person in environment Behaviour (activities)

30. Four Levels WHO ICF Description of illness Three Contexts Organ (pathology) Person (impairment) Person in environment Behaviour (activities) Person in society Social position (Participation)

31. Four Levels WHO ICF Description of illness Three Contexts Organ (pathology) Personal Person (impairment) Person in environment Behaviour (activities) Person in society Social position (Participation)

32. Four Levels WHO ICF Description of illness Three Contexts Organ (pathology) Personal Person (impairment) Physical Person in environment Behaviour (activities) Person in society Social position (Participation)

33. Four Levels 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)

34. Four Levels Traditional Model of illness Three Contexts Organ (pathology) Personal Person (impairment) Physical Person in environment Behaviour (activities) Social Person in society Social position (Participation)

35. Four Levels 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)

36. Four Levels 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)

37. Four Levels 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)

38. Four Levels 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

39. Four Levels 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

40. WHO ICF & holistic healthcare • 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)

41. WHO ICF model and illness • 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

42. WHO ICF & NOC • Brief discussion of how WHO ICF could be used to transform NOC • Clinically • Organisationally

43. WHO ICF & holistic clinical care • 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

44. Achieving holism clinically • 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?

45. The importance of social roles “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)

46. Changing roles:an 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

47. Holistic healthcare systems • WHO ICF model can help organisation

48. Focus changes over time • Level of illness • Context • Type of expertise needed Pathology Acute phase Impairment Social roles Activities Social context Physical context Expertise - locality Expertise - condition Time

49. Acute phase 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

50. Holistic healthcare requires: • 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