Public Health: In The Right Place?
There is a German compound noun – schwellenangst – which means anxiety when crossing a threshold. Many of us develop a nasty case of it when entering a medical premises, whether it be a GP’s surgery or a hospital. Our blood pressure, as we await the summons, “the doctor will see you now,” routinely rises because we’re more stressed than at home where we call the shots. Within a medical environment our life is not in our hands but theirs. One study even showed that blood pressure is higher when taken by a doctor than a nurse. Doctors make patients more nervous. They even have a name for it – “white coat hypertension.”
An anxiety about crossing a GP’s threshold has only been there for a few generations. It was not that long ago that the family doctor, when needed, arrived with his (and it was almost uniformly his) black bag. He would most likely have been pretty familiar with members of the family and their health and wellbeing issues. He could see the conditions in which they were living. He knew their ins and outs, their secrets. There was a continuity of and maybe a more rounded, “holistic” approach to care. He saw the whole picture. Health and associated longevity expectations – which maybe were more modest 75 years ago – were managed.
Home is where we should feel safe, relaxed, happy to be there – in an ideal world where our wellbeing is maximised. Places where we go when ill, either the GP’s surgery or hospital, can bring bad news. And, at their worst, they are “factories of the sick” processing us through as if we are passed down a production line.
Healthcare has changed. In the cause of productivity and efficiency most patients – at least pre-COVID – attended a GP surgery and waited in line among the dog-eared magazines, institutional pale-blue-painted walls, Formica and wailing newborns, awaiting immunisation. The wait is often quite long. That angst or anxiety rises as the wait increases. They are rarely places one would choose to “hang out”, to dwell for long. It’s in and out asap with or without the remedy of a chemist’s prescription.
The NHS has endured a tumultuous year with COVID and the pandemic isn’t over yet. Despite widespread predictions that hospitals would be unable to cope with the first wave, they did. And they appear to be coping thus far with the second wave also. There has been far less attention paid to primary care. Many GPs’ surgeries and health centres have been closed to patients who have had perforce to become accustomed to phone or sometimes video conference consultations. COVID-19 has created a ‘burning platform’, and massively accelerated the move to telemedicine in primary care, although numerous practical and ethical issues remain, not least in how to bridge the digital divide.
When COVID has gone or, at least, been controlled by a combination of vaccination and immunity, the challenges associated with public health and primary care will still be there as they were in 2019 and before.
The expansion and technical complexity of modern hospital specialties mean that although 90% of patient contact in the UK occurs in general practice, it receives less than 9% of NHS funding. Good general practice and primary care saves the NHS a fortune by doing things hospitals cannot do – knowing patients better; caring for them in their own homes; managing uncertainty; gauging when and when not to push for a diagnosis and a referral up the line.
In November 2020 during the second national lockdown, Jericho Chambers convened a series of five roundtable conversations: “Public Health: In the Right Place?” The pun was intentional, suggesting an examination of where physically the processes of primary health care is carried out – in what sort of bricks and mortar surgeries – and also where it sits on the continuum of medicine and wellbeing dating back many thousands of years.
The online discussions were attended by a wide cross-section of individuals: architects, doctors from primary and tertiary care, experts in social care, policymakers, including an MP, Danny Kruger, who was the current PM’s Political Secretary in 2019 and has a particular interest in civil society. He has just produced a report: Levelling-up our Communities: Proposals for a new Social Covenant.
The conversations were supported by Assura plc which develops, invests in and manages a portfolio of 570 primary care medical centres across the UK. “If we have one mission,” said Claire Rick, Assura’s Head of Public Affairs, “it is to try to create places – buildings and exterior environments – which move forward from the sense of a patient waiting for something to happen to them.”
Designing A Healthier Future
This was exemplified by Olivia Chapple, an ex-GP who now runs the charity Horatio’s Garden, a national organisation which creates and nurtures beautiful gardens in NHS spinal injury centres to support everyone affected by spinal injury. It attempts to grow thriving communities to support patients, their families and friends facing long stays in NHS hospitals.
“Clinicians aren’t designers and are working under intense pressure to perform their clinical day job, so it’s understandable that they are often not familiar with the realm of possibility of design,” said Olivia. “I don’t think the NHS values great design enough – it really doesn’t have to cost more and the benefits to everyone are vast”. Horatio’s Garden has shown what an impact natural spaces can have in the heart of the otherwise austere clinical environment. The reaction of one patient to the charity’s work: “The first time I went into the garden I was overwhelmed with tears and a sense of relief and excitement that there was somewhere to go other than the ward.”
This sort of approach was echoed by Dame Laura Lee, CEO of Maggies, a revolutionary set of drop-in centres for anyone affected by cancer. When people arrive at a Maggie’s centre they don’t see a waiting room, or perspex protective dividers separating patients from receptionists – they frequently see a kitchen table around which people talk.
"I think we now have such a great opportunity for the NHS to change its outlook from being factories of the sick"
Dame Laura Lee
“I think we now have such a great opportunity for the NHS to change its outlook from being factories of the sick,” said Laura. “COVID and the need for distancing must not be allowed to dictate design in the future. There will always be a need for face-to-face human contact. Digital will have an important role to play but it isn’t without its problems. I should be able to leave feeling better than when I arrived – more in control, more empowered, less hopeless, less alone. Our philosophy is for people who come to Maggies to be active participants, not passive recipients.”
Ab Rogers is a designer and son of one of the most celebrated architects the UK has produced in the last half-century. Ab has worked within the NHS on a number of projects and described a process that, while tough going, was nevertheless hugely important and rewarding. “Design isn’t a luxury. It’s a necessity,” he said. ”I’ve seen so many environments that simply aren’t fit for purpose and desperately require de-institutionalisation. And it’s often not helped by a procurement process that is far too complex.” Rogers and a number of others spoke of battles fought with the forces of infection control, fire, health and safety with the estates and facilities staff. “There are far too many rules that, when you look into them, aren’t clear in their origin and purpose.”David Powell who has long experience of managing projects in the NHS including the Velindre Cancer Centre in Cardiff and at Alder Hey in Liverpool agreed: “People are very nervous about change, doing something differently. They have an instinctive fall-back to the tried and tested. You can get pushed around a lot, forced to comply. Maybe the initial driver of innovation does not have to come from the NHS but outside. Necessity can be the mother of invention.”
Much comes down to risk aversion. After all, the Hippocratic oath states: “above all, do no ill.” It is the snake oil salesmen of unproven remedies and treatment who aren’t mindful of potential harm. The status quo can be attractive if it’s working but many felt that it wasn’t and that not adapting, especially as digital becomes an even more potent force in healthcare, is not an option.
However, without freedom to try, to experiment how can things ever be improved? The author Margaret Heffernan made the important point about what she called “structural determinism”. “If we get the structure right, all good will follow. But you can’t think your way to the perfect structure. You have to try stuff. Without freedom, people will never take responsibility. That said if you wish to devise systems that suit people, those within the system have to be part of devising it.”The possibility of co-produced insurgency experiments framed by a set of principles attracted many.
New Networks vs. Old Hierarchies of Power in Health
This is after all how the organisation Buurtzorg was devised in Holland in the first place – the word means neighbourhood care in Dutch. In the UK, where it is a relatively new player and attracting much interest, its Managing Director is Brendan Martin. The 13-year-old not-for-profit is a network of over 14,000 nurses and care workers organised into smaller autonomous teams of up to 12 members who work together to meet their patients’ needs. There are no bosses or leaders. Within each neighbourhood, the independent teams of nurses are responsible for the complete care delivery to their 40-60 patients. These nurse teams have complete autonomy to carry out their work as they see fit – no targets, no allocated time slots per patient, no tick box care. It is the reverse of a controlling, top-down process. It is adaptive according to need.
The twelve are wholly responsible for the wellbeing of their patients and they share patient solutions, results and experiences with one another. A specialized digital platform facilitates this communication, linking not only nurses within a team but also to other nurses in the wider network. The ground rule is that nurses spend 61% of their time in direct contact with the people they support. There are no expensive managerial layers and bureaucratic processes of the sort that the organisation’s founder Jos de Blok was part of and rebelled against when he worked as an MD for a traditional care supplier.” It’s fair to say Buurtzorg probably frightens the life out of the average NHS middle manager. If management philosophy ranges from tight to loose, Buurtzorg practitioners operate under a loose rein.
"The examples of many of our primary care networks in the UK are a disappointment".
Brendan Martin, Managing Director, Buurtzorg Britain & Ireland
As Brendan Martin said: "The examples of many of our primary care networks in the UK are a disappointment. It’s not about whether the power should be redistributed and shared but how? How can communities themselves manifest that power and that must start with the relationship between professionals and the people they serve. How that relationship develops in the next phase of what needs to be a national conversation".
This concern for broader human wellbeing and not just symptom-treating is not new. Although there is a move towards ‘super surgeries’, treatment centres, intermediate care and polyclinics, healthcare design remains a process of evolution rather than revolution. Eighty five years ago, one pioneering initiative in London were the forerunners of many of today’s ‘innovations’. Good design played a central role in the ethos and the function of the project.
The Pioneer Health Centre in Peckham, designed by the engineer Owen Williams, opened in 1935 as the home of the Peckham Experiment, a project led by George Scott Williamson and Innes Pearce. Williamson and Pearce, a husband and wife team, focused on preventative rather than curative healthcare, exploring the relationship between people’s social and physical environment and their state of health. This was the harbinger of today’s healthy living centres and the Department of Health’s Choosing Activity initiative. It had all the ingredients of what is today known as “social prescribing.”
The concept design was to create an environment in which people would infect each other with wellbeing. The result was a beautiful club, boasting an enormous swimming pool, a gym, boxing rings, a dance hall, a library, a creche with “room for perambulators” and a cafeteria serving “compost grown” – organic in today’s language – food, produced at the centre’s own farm a few miles away in Bromley. Local families could join for 6d a week, thereby ensuring they felt like members rather than recipients of charity. And they joined in their hundreds.
It’s a long way from Peckham to Austin, Texas and, if one is honest, it is rarely to the United States that one goes to seek inspiration for the creation of an ideal health system. However, the first discussion was joined by Stacey Chang from the University of Texas who formerly worked as Head of Healthcare at the consultancy IDEO, and Dr David Ring, Associate Dean for Comprehensive Care and Professor of Surgery and Psychiatry at Dell Medical School.
As Margaret Heffernan writes in her book Uncharted, at Dell they are attempting an experiment in “interpersonal medicine” which recognises that there is more to medicine than data and statistics and the next big leap will be in making medicine more human. “The big overarching hypothesis at Dell is this: if you change the power relationship in medicine by putting the patient in charge – not the doctor, nor the infrastructure, nor the technology salesmen or the insurance companies – you will get better, more affordable and more sustainable outcomes. It’s a big bet, expressed and explored through hundreds of experiments because there’s no other way to find out.”Stacey Chang explained what they were trying to achieve: "This complex system we refer to as healthcare is really a large interwoven web of human relationships: between people who provide care and people who receive care, between people and informal caregivers. Anything we design should hold those relationships at the centre, because that’s where value is actually exchanged".“It was the UK that devised the basic designs for healthcare but modern disease is very different from the way it was 100 years ago, when it was the after-effects of war, of acute trauma and, ironically, infectious pandemics that dictated how things should be organised.
Modern disease is more chronic – diabetes, hypertension. Health now is not largely solved in clinics. Health and wellbeing are created and solved at home or at work.“So tech can be an enabler not a panacea. You might well do better consulting a doctor from your own home remotely. That’s the modern equivalent of the old house call with the black bag. (That black bag rarely contained tools that solved very much.) They treated appropriately to context – it helped that they often knew the family concerned from involvement in community. You have to differentiate between access and service.”
Finding Health & Happiness: Closer to Home
Those modern, chronic conditions are frequently suffered more greatly by the poor. Research on socio-economic inequalities in health in the UK has a long history. Health outcomes generally worsened with greater socioeconomic disadvantage and this is very much on the minds of Britons with the promised process of “levelling up” for those left behind – not just the traditionally vulnerable and a new generation of carers but also the homeless, the jobless and the digitally dis-enfranchised. For the medic to travel out to meet patients is what happens at the MASH (Manchester Action on Street Health) project for which Verity Comely volunteers. It even visits female sex workers in massage parlours to offer judgement-free advice on risks, drugs and alcohol. It goes to where it's needed and has counselled 880 women in the last year.
Stacey Chang’s colleague Dr Ring added: “In musculoskeletal specialty care, I find that most of the diagnoses are simple, the key health advance is a correct understanding of the problem and an evolution of one’s inner narrative to adapt to the temporary or permanent change in your body, and flexibility in thinking and evolving one’s inner narrative are key. Most ‘health’ happens in your life, not in hospital.” Few surgeons anywhere in the world talk much about “inner narrative.”He continues: “I find those are similar features across most forms of specialty care. A physical space will be utilized by a small subset of people that need hands on technical care, or people that need a community to support them in their rethinking and accommodating their conditions. We can design the space for that subset. Building a space for people treating cancer would have a different approach, but a general surgery will be mostly about healthy habits of activity, intake, mindset, and circumstances. Half of GP-reported symptoms have no discreet pathology. I also believe that tech can actually increase compassion in healthcare – it levels the hierarchy. It can be far easier to ask important questions from your own home.”
"Why spend upwards of 10% of your space making people unhappy? Waiting rooms allow you to fail"
Stacey Chang, Founding and Executive Director, Design Institute for Health, University of Texas
At the Dell hospital one of their many experiments is no waiting rooms. “Why spend upwards of 10% of your space making people unhappy? Waiting rooms allow you to fail” says Stacey Chang. Patients wait in consultation rooms and medical staff come to them.
Treasures, Transitions, Experiments, Insurgencies
If anything is to change then we are reliant on our political leaders to enact that change, especially in a nation, like the UK, where so much health and care is not bought by consumers but provided by the state from the cradle to the grave.
"It would concern me if the deification of the NHS meant we consolidated problems rather than encouraging and applauding beneficial changes"
Danny Kruger, Member of Parliament for Devizes
A political angle was important here. In a year when the Leviathan that is the NHS has been in the spotlight “Our” NHS is an even more unimpeachable treasure than it was in 2019. As Danny Kruger, the MP for Devizes, warned “It would concern me if the deification of the NHS meant we consolidated problems rather than encouraging and applauding beneficial changes.” It will be a brave Chancellor that denies it what it requests on the money front in the next years to come.
Kruger continued, “I’m encouraged by the nimble innovation that has occurred during the last year when the central controls had to be loosened. The NHS should be more like the care system – plural and community based. There are three questions that arise: firstly, collective impact and how you coordinate a nationally incentivised structure; secondly, when it comes to ‘patient power’ is it appropriate to ask an individual to pull together a fragmented system on his or her behalf – how, for example, can an at-risk child be expected to do that; and thirdly, the role of the broker and patient advocates. Do we need another systems change or a bottom-up guerrilla warfare that might change cultures for the better so that the old and unnecessary structures fall away with time? Is it to be quiet or noisy?”
"Mental Health and Wellbeing is a foundational challenge of 21st-century economy and society, as Public Health was to the industrial revolutions"
Indy Johar, Co-Founder, 00 and Dark Matter Laboratories
The most broad-ranging and radical contribution came from Indy Johar, a qualified architect and co-founder of Dark Matter Labs. “Mental Health and Wellbeing is a foundational challenge of 21st-century economy and society, as Public Health was to the industrial revolutions,” he said. “Most of our illness comes from a lack of environmental justice.”
This is moving towards a philosophy where “treatment is a sign of failure” and “your life in your hands.” It would be not just an NHS but an education, transport, communities, Home Office eco-system, where serve and support takes over from command and control.Taking his lead from the systems in Scandinavia (powered by tech platforms such as NyBy and others) and especially Stockholm, Sweden Indy asked, “The debate in the UK is stuck in services and redesign of services and we’re not making the case for deeper structural changes. Health isn’t and shouldn’t be seen as a cost. It’s a foundational investment for the future economy.” For Indy, a patient-centric approach is an “old political argument.” It is far more of an “we are all in this together” approach.
Roland Sinker is Chief Executive of Cambridge University Hospitals NHS Foundation Trust (CUH) but also, since 2018, the accountable officer role for integrated care system partners in Cambridgeshire and Peterborough, who between them serve a population of 1 million people with a health and social care spend of £1.5 billion. He is very much on the sharp end of health provision from the ground up to the consultant cardiac surgeon. He has to deliver.
“We should be putting huge amounts of energy now into enabling the right people to have the right sorts of conversations. There is a tension between tight and loose when it comes to action. The idea I’m going to tell neurologist how to do his or her job is ridiculous. At the end of the day, a lot of people need joints replacing or are struggling with diabetes. That takes medicine and systems and process and uses ecosystems to sort out. How do I in my job to empower 11,000 in my hospitals and 5,000 outside not just to do their jobs but to reimagine how they can work together to keep people well? And I am optimistic. Ultimately, it’s true that these themes include exploring how to get human beings, citizens front and centre in our thinking – before they even become patients.”
Jonathan Murphy the CEO of Assura concluded: “We started out thinking where is the patient in all this – building on Brendan Martin’s comments enabling communities to come together to provide the services they need? If we can build community health and wellness centres that put the patient in charge and place them at the start we will make massive progress. This is an inspirational objective for us. It won’t be easy but it’s worth shooting for. So, how do we get these new eco-systems and insurgency experiments going?”
Everyone has to start somewhere. The Peckham Experiment closed in 1950 as it was felt it innovative methods didn’t fit in with the universal vision of the newly formed NHS. A new version, perhaps making use of technology advances, is now called for. After all, Big Tech could step up and pay its growing debt to civil society beyond just selling the worried well Fitbits and associated paraphernalia: an incentive centred on social value rather than pure shareholder profit. MedTech, too, requires a shot in the arm after the well-documented problems of test, track and trace.Whole systems thinking – and a radical re-set – can bring together the best-of-the-best: new tech platforms and networks for social good; inspirational, as well as aspirational, design, that takes medicine closer to the home; local interventions that better balance the compassion of third sector actors with the financial muscle of the state – and liberate many communities (the poor, the vulnerable, the homeless, the disabled, the digitally disenfranchised) from “forgotten” status. Free-at-the-point-of-delivery, cradle-to-grave patient care is a cherished and protected ambition: but it is better delivered through new 21st century ecosystems than by excessive managerialism or last-century institutional thinking.
Matthew GwytherPartner, Jericho Chambers
matthew.gwyther@jerichochambers.com
***
About The Project – What Next?
So far, over 155 experts and those with lived experience have contributed to the Public Health: In the Right Place? project, sponsored by Assura PLC (see list of participants below). The ambition is for this group to continue to meet in different formats, perhaps sometime in 2021, even in person. The thinking is on-going and Assura will integrate the insights and ideas into its development thinking. To borrow from the language of the zeitgeist, “insurgent experiments” (previously known as pilots) remain a moonshot ambition.The emerging themes, many of which are captured in the article above and integral to the shift away from “factories of the sick”, include:
Understanding the nature of the beast – why the NHS is not a monolith but a network of smaller organisations; and how to embrace it as such.
Addressing capacity shortfalls – the lack of front-end ability to design both the systems (and the buildings) we need.
Short- vs. long-termism – budgetary and planning. Building on Best Practice elsewhere
Why innovationis horizontal and local – across government, institutions and partners; explore new foundation economic models to capture this
Focus on localism – new, tech-enabled networks to support integration of authorities and services in a new care eco-system. Much more than a linear dependency on telemedicine.
Commitment to “Forgotten Communities” - Central to the whole programme is the urgent need to include carers; the homeless/ vulnerable; those living in poverty; minority ethnic groups; the geographically excluded; and the digitally di-enfranchised. Local authorities, charities and volunteering organisations and self-organising support networks all have critical future roles to play (see Localism point above).
Public Health as a campaigning issue of “environmental justice”. Building on the thought that “patient-centricity” might now be a tiring political argument. Thinking needs to go wider than and behind the individual patient and their symptoms, in search of a new societal eco-system, within a revised Social Contract.
Contributors to the Autumn 2020 Roundtable Conversations on Public Health, supported by Assura PLC:
Stacey Chang, Founding and Executive Director, Design Institute for Health, University of Texas
Dr Olivia Chapple, Co-Founder and Chair of Trustees, Horatio's Garden Charity
Dr Nav Chana, MBE, NAPC Clinical Director
Verity Comley, Commitment to Carers, Experience of Care, Nursing Directorate, NHS England and NHS Improvement
Bev Fitzsimons, Director, Point of Care Foundation
Louise Fowler, Non-Executive Director, Assura
Cathy Francis, Housing Delivery Director, Ministry of Housing, Communities & Local Government
Sharon Grant, Chair of the Board, Public Voice CIC
David Grayson CBE
Matthew Gwyther, Partner, Jericho Chambers
Lukas Hardt, Wellbeing Economy Alliance Scotland
Alison Haskins, Chief Executive, Halifax Opportunities Trust
Dr Margaret Heffernan, Leadership Thinker, Author, CEO
Neil Heslop OBE, Chief Executive, Charities Aid Foundation
Indy Johar, Co-Founder, 00 and Dark Matter Laboratories
Danny Kruger, Member of Parliament for Devizes
Dame Laura Lee DBE, CEO, Maggie’s
Sian Lockwood OBE, Chief Executive, Community Catalysts
Kamran Mallick, Chief Executive, Disability Rights UK
Brendan Martin, Managing Director, Buurtzorg Britain & Ireland
Sarah Mistry, CEO, British Geriatric Society
Jonathan Murphy, Chief Executive, Assura
Robert Phillips, Founder, Jericho Chambers
David Powell, Development Director, Velindre Cancer Centre
Rachel Power, CEO, Patients Association
Rebecca Pritchard, Director of Services, Crisis
Claire Rick, Head of Public Affairs, Assura
David Ring, MD PhD, Associate Dean for Comprehensive Care and Professor of Surgery and Psychiatry, Dell Medical School
Ab Rogers, Designer and Founder, Ab Rogers Design (ARD)
Andrew Russell, Growth Director, Nyby
Roland Sinker, Chief Executive, Cambridge University Hospitals NHS
Luca Tiratelli, Policy Researcher, New Local
Ed Wallis, Head of Policy and Public Affairs, Locality
Zehra Zaidi, Solicitor and Social Entrepreneur
