Holistic health care: our future?

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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 [phone]
• Fax [phone]
• email derick.wade_at_ntlworld.com

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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

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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

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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

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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

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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)

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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

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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

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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

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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 peoples actions decisions
• Leads to sick role
• Lack of responsibility for illness
• Allowed to avoid social duties

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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

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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

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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

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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).

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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

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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)

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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?Id81
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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

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Holistic healthcare conclusion - 2

• Health (and illness) is comprised of various
  hierarchical systems.
• 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

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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

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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

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World Health Organisations 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

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WHO International Classification of Functioning

• Revised ICIDH gt 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 -gt (limitation in) activity
• handicap -gt (restriction on) participation
• added global concept of functioning

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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 20043291398-1401

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WHO ICF Description of illness
Four Levels
Three Contexts
Organ (pathology)
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WHO ICF Description of illness
Four Levels
Three Contexts
Organ (pathology)
Person (impairment)
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WHO ICF Description of illness
Four Levels
Three Contexts
Organ (pathology)
Person (impairment)
Person in environment Behaviour (activities)
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WHO ICF Description of illness
Four Levels
Three Contexts
Organ (pathology)
Person (impairment)
Person in environment Behaviour (activities)
Person in society Social position (Participation)
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WHO ICF Description of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Person in environment Behaviour (activities)
Person in society Social position (Participation)
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WHO ICF Description of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Person in society Social position (Participation)
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WHO ICF Description of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
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Traditional Model of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
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WHO ICF model of illness (1)
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
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WHO ICF model of illness (2)
Four Levels
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)
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WHO ICF model of illness (3)
Four Levels
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)
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WHO ICF model of illness (4)
Four Levels
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
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WHO ICF Model of illness
Four Levels
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
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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)

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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

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WHO ICF NOC

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

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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

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Achieving holism clinically

• Key is to consider a persons 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?

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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)
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Changing rolesan 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

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Holistic healthcare systems

• WHO ICF model can help organisation

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• 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
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Acute phase
Time course of a long-term condition, and service
needs
Post-acute phase
Specialist disease service
NOCv
NOCv
Specialist rehabilitation service
Locality rehabilitation service
NOC?
General practice complete service
Self-management
Time
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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 not disease management
• Across all boundaries

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Therefore the NOC should

• 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

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Summary

• 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

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1872 Wingfield Hospital - fever
1921 Wingfield Hospital - orthopaedic
1950 Nuffield Orthopaedic Centre
1992 Nuffield Orthopaedic Centre NHS Trust
2010 Oxford Holistic Healthcare NHS Trust?
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Holistic health careIt is our only future!

• Dr Derick T Wade,
• Professor in Neurological Rehabilitation,
• Oxford Centre for Enablement,
• Windmill Road, OXFORD OX3 7LD, UK
• Tel [phone]
• Fax [phone]
• email derick.wade_at_ntlworld.com

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The WHO ICF model
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, patients interpretation Roles, others
interpretation
Behaviour goal-directed interaction with
environment