Hilary Cottam > Blog > Uncategorized > Radical Health

Radical Health

Joe needs his toe nails cut.  Last week his General Practice doctor who I know well, wrote to me, incensed by the impossibility of organising this simple task.

The regional assistant head of community commissioning – let’s call them Jamie, so as not to shame them, responded to her email for help, by suggesting that the patient was given a leaflet from the National Podiatry Association that might help with ‘self-care’.

Of course, the reason that Joe had come to see his GP in the first place was because he can’t ‘self-care’; he can’t cut his toenails; he has balance problems, he suffers from epilepsy, he can’t bend over.  He is so ashamed he can’t walk – he can’t get his shoes on – and he won’t go out.

He was in hospital for several months a little while ago for skin cancer – despite his toe nails, like small horns, curled over under his feet, still nobody suggested he saw podiatry the whole time he was there.  Later district nurses came to his home to dress his skin cancer wounds, but the toe nails weren’t their problem either so again nobody sorted the problem.  Unfortunately, Jamie’s idea of giving Joe a leaflet is also not likely to sort things.

Jamie wrote ‘I recognise that this (an approach of simply signposting through a leaflet) is not ideal for older people who require support with personal footcare including toe nail cutting, but given the challenges I think the above response (the leaflet) is reasonable and pragmatic.’

I’m not a clinician but like most of you I have read the data.  I know that taking care of the small and unglamorous things – vigilance over diet, toe nail cutting, living situations, saves lives and reduces the need for high cost interventions.  I’ve read the work of Atul Gawande – Jamie probably has too – so I know that what they call ‘pragmatic and reasonable’ is in fact the very opposite. Jamie is talking a sort of double-speak in their refusal to acknowledge what Joe needs and the difference between sign-posting and care.

How did we get here?  I want to come back to this, but first, let me tell you another story.

About Kate.  When I first met Kate, she was slumped in a chair that is too small for her bulky frame, her eyes cast down.  In a monotone she listed her ailments: she’s anxious, she also has painful feet, she’s tired but she can’t sleep, she thinks she’s depressed, her back aches, her weight has been creeping up and up, she has been diagnosed with diabetes.

I’m sure this story sounds familiar to you.  Kate’s medical notes were full of the acronyms of modern illness: TATT, MUSand the records of countless prescriptions, each one written by a different and harried doctor faced with the impossibility of really helping Kate in the 10 minute slot allowed.

We are not feeling well.

And the health service is struggling to cope.  At the sharp end, GPs can reach again for their prescription pads and commissioners like Jamie can numb out recommending leaflets and refusing to acknowledge what needs to be done.

But it’s not just we the people who are not well, it is our health systems too. Despite the dedication of clinical and support staff, the coming together across departmental divisions and hierarchies that we saw in the early stages of the Covid-19 epidemic, and the long hours worked, our waiting lists are spinning out of control.  We are haemorrhaging talented people and basic humanity and common sense is too often squeezed out.

We are gathered here in a gale of words: transform, improve, innovate, integrate – I’ve heard people talking about secret weapons, others of patient pathways –

What is really going on here?

I chose the title of my talk – Radical Health (although I actually wanted to call it Marooned on a Toe Nail) – because radical means going back to the root of things.

I want to spend my time with you today asking, what would happen if – instead of focusing on fixing the National Health Service, we went back to first principles and asked; how can we create and sustain health; how can we always attend to the small things…as intended by the founders of our systems.

What does it mean to flourish as opposed to simply surviving?

Kate was part of an experiment I started over 10 years ago.  Setting up in GP surgeries we asked GPs to send us their heart sink patients – those like Kate and millions more who suffer from a complex range of social, emotional, economic and physical ailments that can’t be addressed in a 10 minute appointment.

Recognising that chronic health conditions are part of every-day life, we did not focus on any specific condition and when we met Kate and the thousands of others who used the service we eventually called Wellogram – we did not actually ask them about their health.

We asked them about their lives and what they would like to change.

Sitting with Aimée – a Wellogram worker – Kate said in a barely audible whisper ‘I’ve lost myself’.  They sat for a while in a shared silence and then, Kate shifted in her chair – ‘you’re really listening’ she said to Aimée.

Kate explained how she is the carer for her husband and her son and how, as Kate has been increasingly overwhelmed, things have unravelled with Kate herself becoming ill.  This too is a familiar story.  Together they worked out a plan.  Kate felt that the thing that would most help her would be to take up her embroidery again.  Just to have that moment to herself.

Kate and Aimée agreed to meet again in a few weeks.

This story is part of a pattern.  Almost no-one when asked chose a health intervention to start with but slowly, in every case health improves – we know because we have the clinical data -it’s one of the advantages of working in the GP surgery.

Listening takes time – time that busy doctors don’t have, but this open listening – the sense of truly being heard is empowering.  The ‘psy’ disciplines understand -and have evidence – that to make change you have to be able to tell a story about yourself – to have a sense of direction, to imagine new possibilities – to make shifts in how we see ourselves and what we can do.

Aimée is what I call a relational worker – she listens and through this active process, she forms a bond.  Almost everyone who took part in Wellogram knew what they should do  – they don’t need education or leaflets because they are aware of the behaviour changes required.  But practising change and sticking to it is hard – this is where the relationship comes in.  Aimée knows – and this is the most challenging bit – how to support Kate to make her own changes.  She is there as a trusted and steadfast support but she does not solve Kate’s problems for her.

When Kate came back a second time to see Aimée she confessed that she hadn’t really expected anything to happen; ‘ I just expected you to tell me things’ she said but it was so much more useful than that.  Kate was feeling more confident, she trusted Aimée and they were ready together for the next step, to look at Kate’s diet.

This was how Wellogram worked: a series of simple steps, each one guided by the growing confidence and the participant’s sense of what they can tackle next.

In the beginning no-one is keen to meet other new people, but once confidence is built, finding good company is important.  Wellogram is about weaving people together – at the right moment – to support continued good habits and to combat the social isolation that underpins so many problems.

Operating at the level of say, a London Borough Wellogram would cost £20 per person per year to run and our clinical data based on the long run outcomes of the first 2,000 people we worked with was impressive.

New Shoots: Open Relational Work

Wellogram is part of growing body of work and evidence that shows how open, relationship-based approaches in which workers have autonomy over their time, budgets and work, and in which clinicians are deeply integrated with their communities, makes lasting change.

The work of Birgit Valle in Norway for example.  Birgit is a clinical psychologist who leads a mental health service for families and adults in the Stange region of Norway.  Like leaders in the UK she received a huge number of weekly emails from others in the system informing her of new guidelines, new approaches her staff should be trained in, new innovation methods and so on.  What she noticed though was that the waiting lists for her services were growing and at the community level there was a pandemic of stress and ill health. Her teams were also suffering, overwhelmed by the workload.

Is this really the best we can do Birgit was asking herself?  She decided to go out and observe her services, and then to sit in homes and listen.  The results were radical.  The service introduced two things.  Firstly, they abolished all their assessment criteria – the tools by which they managed their waiting lists.  They invited everyone in.  It turned out that inviting people in, as opposed to managing the lists rapidly created less work.  In part due to the second factor.  Clinicians practised a new form of rigorous feedback: every patient was asked to feedback at the end of a session and this qualitative conversation informed the next step of practice.  The professionals were asked to adapt, to divert from their learnt pathways and this often meant smaller, but timely interventions.  There were failures along the way, but today Birgit Valle leads with a different culture and very different results.  She’s written a book called Beyond Best Practice if you are intrigued to know more – and she runs a podcast talking to other health leaders around the world that have taken similar steps.

There is Buurtzorg in the Netherlands a model in which nurses and carers work in self-managed community teams.  Some of you may be familiar with Buurtzorg because there have been attempts to replicate the model here in the UK.

Buurtzorg was first started by a nurse Jos de Blok in 2005. As health costs spiralled in the Netherlands and consultants and efficiency drives moved in, he wanted to provide a very different from of health care, one he was sure would be possible if the 30% of resource that was being channelled into bureaucracy was instead diverted to the front line.  With four nurse colleagues he set up a non-profit and started to experiment.

Today there are over 10,000 Buurtzorg nurses and carers.  They work in small autonomous teams making all decisions about the work together.  Technology is used to support the admin tasks in deft ways.  Communities taken care of in the Buurtzorg model need 40% of the interventions required in other parts of the Netherlands and there has been a two thirds reduction in hospitalisations.  The nursing teams are stable – the enjoy their autonomy and the pay is good because there is no extraction for management costs or private sector profits.  In Buurtzorg, the finance system is transparent – nurses know what they must achieve for good care and for the business model – Jos describes it as a psychological contract.

Brendan Martin leads Buurtzorg in the UK. Often attempts to replicate the model in the UK have struggled because the NHS commissioners have not given full autonomy over management or budgets.  But in Medway something different is happening.  Nurses involved speak about how the system treats professionals like children and how they have been freed.  Brendan calls the model ‘retro-innovation’ because of this important way Buurtzorg restores autonomy that was once taken for granted in our health systems.  Early work in also shows signs of success, demonstrating that the Buurtzorg modela can be adapted for a new culture.

These new models are always less costly (although that is not their purpose – flourishing is their purpose and savings are a by-product).  Many of them come from parts of the world where relationships are strong but resources are scarce.  Another example is the community health work in Westminster started by the GP Cornelia Junghans.

Borrowing from a very successful low-cost model which has been running in Brazil since 1994, Connie and her team have trained local residents from the Churchill Gardens estate as health workers -they make monthly visits to residents regardless of need to build relationships with the entire family.  It’s a model that could – should – revolutionise population health and you can hear Cornelia talking about it here.

These are the shoots of a new health system – I am sure you have your own examples in the places that you live and work.  These are the stories that are told in the innovation boxes of formal reports – the challenge for us is how to bring the work of Aimée, the toe nail cutters, the community health workers, the professionals with new ideas, into the heart of our systems.  We need to turn things inside out and move this work from the margins to the centre.

We can’t fix the NHS Instead we need a fundamental pivot: in our thinking, in our systems, in our imagining of what health today in this century really is.

The Pivot

When modern industrialists, the designers of our digital systems, spot a fault or a failing in their designs, they have to decide whether to persevere and fix the problem or whether to pivot – to change course.

The decision to pivot looks ostensibly like a matter of reasoning – a logical response to questions around the resources available to fix the problem: is it likely the fix will work or would it all be too expensive, not viable, would it be better to start again?

The pivot seems like something that would be an objective response to quantifiable data.  Let’s get a toe nail cutting service up and running in the community, it will save us so much money.

But the reality is very different.  The pivot is all about emotions, about embracing a failure in our thinking, our plans, our mind-sets and starting again.  It takes immense courage to pivot, even when the evidence is in front of us.  The voices in our heads say ‘I have already invested so much time and money and energy in this current way of working – surely it’s worth one more try, one more adjustment.  Just imagine the upheaval if we changed course, let’s keep on pushing forward…’

In fact, the decision to pivot is so difficult that most organisations don’t make it and subsequently fail.

A pivot you see is not just another word for change.  The pivot is a special kind of change that involves a new vision, a different solution and a new economic model.  It offers the potential for transformation.

The pivot requires a particular form of leadership: one based on collaboration and the ability to take others with you on the journey.

The image below is a portrait of Chief Plenty Coups, the last leader of the Native American Crow Nation.  Plenty Coups lived through a time of profound upheaval.  The buffalo on which the Crow Nation were culturally and economically dependent disappeared.  There was nothing to hunt, nothing to trade with, no purpose to the rituals that glued the nation together.

Let’s just hang on, live in hope, walk a little further, persevere, many of Plenty Coups’ people argued.  But Plenty Coups realised that an old way of living had gone forever.  He knew a Radical Plan was needed and he also knew that a different set of possibilities were already present.  His people had started new ways of learning, new forms of agriculture – it was just that these things existed almost unseen at the margin.

Plenty Coups could see the need to pivot, to champion these emergent new systems and he could persuade his people to follow him into the unknown.

The story of Plenty Coups is told in a remarkable book called Radical Hope written by the philosopher and psychoanalyst Jonathan Lear.  Lear writes:  ‘at a time of cultural collapse, the courageous person has to take a risk on the framework itself’.

I’m not necessarily arguing that we are at time of cultural collapse although it seems likely that we are on the verge of eco-collapse and we are in a deep state of health collapse: of physical and nervous exhaustion. Many, many health workers feel this collapse and they are voting with their feet.

And the business models which underpin our industrial health systems are also crumbling: industrial and vertically organised public systems cannot flex, give the required autonomy at the frontline, or relate in new ways to the population.  Whilst extractive market models set the wrong incentives and, in their siphoning off of profits leave too little to go around.

It is clear that the shifts in our economic, social and health realities are so fundamental that we too need to take a risk on the framework itself.

Like Plenty Coups we have to acknowledge that things are going to change in ways beyond which we can currently imagine. We know that we can’t face the future in the same way we have been doing.  We can’t plan another re-organisation or hope we can bid for some new pot of funding and carry on.  With others in our community, with like-minded leaders, we must open our imaginations to a radically different set of future possibilities.

What I am saying is, that it is no longer appropriate if you are leader in our health systems to persevere with ideas of efficiency, to tinker with new forms of payment, outcomes or work force reform, or to hide behind an innovation project whilst the rest of the work continues untouched.

You have to have the courage to address the profound re-design needed.  You have to take a risk on the framework.

Three Reasons We Cannot Continue

The nature of the problem has changed – our health systems are modelled on the idea of the cure. The cure is produced in vertical systems of command and control – but you can no longer cure – you need to prevent, care and support – and this needs a completely different way of working.

Care Beveridge and his contemporaries did not know how to address the problem of care – they swept it behind our front doors decreeing that tending for small children, for our elderly parents, for neighbours in need would be women’s work.  But this system broke down in the 1960s – as Helen Gurley Brown wrote in Cosmo ‘women just want to go out and have sex’ – – more importantly men and women want to care and, as I have written here,  this requires a profound re-organisation of work and our social systems.

Today the lack of care, can’t be hidden behind our doors it is threatening to bring the whole edifice down.

But neither can care be ‘delivered’ through new systems that simply replicate the industrial, post war organisational models of the NHS   – or through trying to stitch together threadbare public health models with exploitative private forms of care.

Like Plenty Coups we can look around and see radical new forms of care– Wellogram, Circle, Buurtzorg, Shared Lives, Somerset Cares – we know the models and we need to fund them and support these new cultures to spread.

The third reason we cannot go on is Poverty – health is rooted in poverty and inequality – and the gaps between us are now chasms. Jamie assumed that Joe is old – in fact he is the same age as me, but his life chances have been very different and his body – his toe-nails, tell the score.

Today our health services are designed in such a way, that they not only fail to address inequalities, they in fact create them.  The porters, the cleaners, the carers – the thousands of workers on which the health service depend are paid a minimum wage or less.  This is not only unjust, it creates ill health.

These are injustices of race and gender which were designed into our health services and must now be changed.

‘Your body is tolerated, your value is economic’

‘I’m just a number’

‘If anything happens to me, it won’t be long until they find another’

These are just some of the shocking statements made by Black and Brown nurses in the film Exposed in which health workers tell their story of the pandemic. If you have not seen it, I urge you to do so because when we think of the pivot, we have to think about systems that take care of everyone, to address the legacies of injustice – to do anything else is not only exploitative, it is like pouring water into a leaky bucket, liking hunting for buffalo that are now extinct.

What can we do?

Everything is possible.  Just as in the time of Plenty Coups – new ways of caring and supporting health are all around us.  Despite the oppressive conditions and exhaustion, the health service is full of extraordinary individuals and you are leaders – you can ditch all the speak about pathways, improvement and transformation – you can lead in a different way – one which will release the abundant resource that is actually around you.

Here is how you could pivot

  • Tell a new story

Just as Kate found a new way to live and to flourish, by re-weaving a new story about her life, so we can the same – do not under estimate the power of a story in which we can see our lives reflected.

Don’t talk about fixing the NHS, don’t run focus groups or participation exercises around how to improve your services.  Start outside the system, where people are and create a story about what health means and looks like in your place.

This has to be a baggy story – it’s not a management document – it’s a tale that resonates that can bring together everyone in your system that is creating health – the dinner ladies with new ideas, the parish priest, the small group of local podiatrists that do want to cut toe-nails, nurses, doctor’s receptionists, a clinician with different ideas – find them and weave your story.

  • Organise horizontally – build a coalition of the willing

Today the health service is an industrial, vertical system with power and resource concentrated at the top. This made sense in the era in which it was designed but it does not make sense today.

Today we need to think horizontally – to form new bonds between institutions, professionals, the community.  Don’t spend time trying to convince others at the top of the system, connect horizontally to the energy that already exists in the places you lead.

All the new models I have talked about are dependent on new relationships between clinicians, public workers in the broadest sense, and the community.

  • Create Possibility

Fund everyone that is bringing your story to light.

The new Integrated Care Boards have the power to do this.  Use it.

Don’t have innovation pilots.  Do as the founders of our systems did – have a clear strategy to switch resource – to Wellogram, to those who want to create independent Buurtzorg models, to the Birgit Valla’s that are prepared to throw out the rules and invent something new, copy the work of Connie Jurgens, take a risk on the framework.

I just want to say a word about risk. Today it is risk models that prevent change – they work against possibility because the more we focus on managing risk the more we focus resources here, again diverting from the new and stifling possibility.

The thing about risk is that the models only work in conditions of certainty– but you are all operating in conditions of uncertainty – ageing, physical and mental illness – these are uncertain things – no amount of data, modelling and talk of managing risk will help.

A reliance on data driven modelling leads large organisations in particular to make decisions on the basis of what is easiest to justify rather than what is the right thing to do’.  These are not my words but those of Mervyn King the former Governor of the Bank of England and John Kay a leading orthodox economist.  I really recommend their book Radical Uncertainty for those of you trying to convince colleagues that risk-based models are the problem. These two establishment figures recommend ditching statistical models in favour of narrative – stories, and they emphasise the role of our humanity and intuition, rather than data in good decision making.  They understand this is a moment of paradigm change.

  • Take care of everyone

If I had to sum up my own book Radical Help and my work in one line – it would be this – ‘take care of everyone’.  People are your precious resource.  In our systems I think it is critical that we do not distinguish between those who are doing the work – clinicians, receptionists and so on – and those who are in the community and need support to create health.

We have to grow capability in every part of our system and just as Aimée has to allow Kate to feel attended to, before she can make change – so it is for everyone in the system.  If you are afraid that you will be blamed for trying something new, if you are so over-worked that you cannot listen to your instincts, if you are so badly paid that most of the time you are doing calculations in your head about your rent and your heating, then you cannot be part of a healthy system.

If you are a leader here today don’t pretend your systems can cope – listen and be honest with the people you lead.  They have already shown you under the pressure of the pandemic how they can pivot – so ask them what you should do together – this would be Radical Health.

Talk delivered at the NHS Confederation June 16, 2022