A tweet from Jonathan Tomlinson caught my eye a couple of weeks ago. It had the hashtags #nuka and #humanisinghealth attached to it.
“Community ownership of heath services in Alaska- 40% drop in A&E and 20% drop in GP attendance btw 1997 and 2007 #humanisinghealth #nuka”
It got my interest. As a Canadian with Inuit and First Nations relatives (by marriage) how they go about things is always of interest to me. A conversation ensued between a few of us, including Dr Margaret Hannah, deputy director of Public Heath in Fife, the author of the book referred to in the tweets: Humanising Healthcare – Patterns of Hope for a System under Strain.
Knowing a little bit about the community, cultural and geographic differences between a northern North American town and the cultural and physical compactness and yet churn of the UK population, I had difficulty getting my head around how Margaret, Jonathan and others though Nuka could translate into the NHS. Native populations are less mobile, their towns more isolated, and family still plays a strong part in the community. By contrast in the UK we have a mobile population, a loss of the extended family, and a lack of community continuity. So I bought the book to find out.
The first impression on opening it was one of caring and compassion. It is hard to put it into works, but I think it was the illustrations that did it for me. They came across as warm and caring.
The book is split into three sections: The Contemporary Challenge which looks at the past and how the NHS and medicine came to where it is today; The Response, looking at how we are dealing with it now; and Another Way is Possible, looking at different healthcare systems that Margaret has come across and one that she was involved in setting up.
The first two sections of the book were good and sound. Most of the people involved in health and social care, be it at the bottom as patients or further up as practitioners, would recognise the scene as set out. There were a few things that did make me go ‘ah’ where Margaret showed a different aspect, but there were no great surprises.
It was the third section that got exciting. It was here I got my pen out and scribbled in the margins, crying ‘yes’. Margaret showed that Nuka could indeed work in the UK.
The first chapter of the third section looks at the South Central Foundation healthcare system in Alaska. Margaret sets out the historical setting for the development of SCF, then goes on to describe how it actually works. This is were things started to fall into place for me.
One of the first examples that hit me was the use of a ‘talking room’ where the consultation takes place, and an adjacent examination room if that is required. Much of the consultation work takes place over the phone, and if you need to see a doctor in person the interview can take between ten and forty minutes.
This reminded me of my sole practice GP in Toronto in the early 1980s. You spoke to him or his wife to explain the situation, so only if an appointment was needed did you go in to the surgery. That meant that there was no waiting to see the doctor when you arrived. His office was comfortable and homely despite the large oak desk between patient and doctor. I never saw this as a problem as I always find it easier to make eye contact when sitting opposite someone rather than beside them. But then we didn’t have big computer screens between us in those days, it was all on paper.
Patient notes were in open shelves behind the patient, and if he hadn’t already found your notes before you arrived, the patient would fetch them down off the shelf. And maybe it was just the informality of the Canadians but patients and doctors were on a first name bases which helped foster the feeling of trust and cooperative care. We were in this together. There was an examination room behind, but I rarely went into it.
As Margaret said on twitter: “We’re not so much innovating or inventing, rather re-discovering what has been forgotten.”
She goes on to show examples of how this style of healthcare has been used in small areas. One such example that was highlighted on a BBC 4 documentary about health before the NHS was the Peckham Project. I can’t help but think that the original Sure Start Local Programmes before they were taken over under the Labour government and turned into Sure Start Centres would have been similar. Perhaps a more recent and closer to home example would be my local hospital Tetbury Hospital Trust. When the NHS tried to close it down local people got together, set up a trust and bought the hospital.
However both Peckham and Sure Start lost their way, and I am not sure how Tetbury Hospital as a private trust fits in with keeping the NHS publicly owned. I was still unsure of how Nuka could translate to UK communities. As Margaret says:
“With a small investment in catalytic funding – and learning – and a smart policy framework to support it, everything could be different. It just requires the political will to set in place enabling conditions for the kind of innovation this book advocates rather than implicitly crowding it out in favour of approaches that are more familiar, effective up to a point, necessary but not sufficient and that offer only false hope for the future.”
But where is that political will? How can patients whose voice so often seems to be lost, help those few people that have this type of vision implement a new way of doing things?
It was the final chapter Creating the Future where everything fell into place for me. Margaret tells of the Fife Shine story, a ‘programme designed to help older people live longer and more fulfilling lives in their own homes and to enable earlier discharge from hospital…’ In essence there was a shift from the normal routine assessment to a grown up conversation between the elderly being discharged from hospital and their families, and staff assessing their needs at home. What started with occupational therapists soon spilled into small social enterprise and volunteer involvement, and a greater satisfaction for both staff and patients, once they were able to find their place in this new way of working.
I was immediately reminded of the difficult problems facing those parents with young adult children who have learning difficulties or Autism, as so eloquently highlighted by Mark Neary and Sara Siobhan. Maybe instead of waiting for the change to come from the top down, we could work from the bottom up and start to make these changes ourselves. By all accounts everyone is happier with this way of working, from the patients and their families who are at the centre, to the administrators, clinicians and other support staff.
It will take a change in culture, in practice and in ourselves. I will leave the last word to Margaret herself, “But the prize is great: to restore effectiveness in a healthcare system that remains accessible to all, free at the point of delivery, meeting contemporary patterns of illness and as part of an integrated approach that sustains healthy, fulfilled lives. And all that at a fraction of the current cost.”