Holistic health care: our future?Dr Derick T Wade,Professor in Neurological Rehabilitation,Oxford Centre for Enablement,Windmill Road, OXFORD OX3 7LD, UKTel: +44-(0)1865-737310Fax: +44-(0)1865-737309email: derick.wade@ntlworld.com

ThemesAim for person-centred healthcareNot patient-centred health careActions & decisions depend upon way of thinkingPerson-centred healthcare depends upon having a holistic understanding of healthNo social admissions, bed-blocking patients, difficult to discharge patients

Nuffield Orthopaedic Centre1872 - 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 workshops1921 - officially orthopaedic (WW I)1933 Wingfield-Morris Orthopaedic hospital1948 joined NHS1950 - renamed Nuffield Orthopaedic Centre1991 - became NOC NHS Trust

Three puzzlesWhy 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 yearsSudden jump at 20 years and falls again at 21

What causes functional illness?People who experience symptoms (and disability) but have no disease to account for/explain their illnessForm 20% of all new out-patients in all clinicsExample 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

To answer these puzzlesNeed 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)

Common current assumptionsDisease refers to disorder of organ within the bodyi.e. Disease is malfunction of part of wholeAll symptoms and illnesses are attributable to diseasei.e. A person with symptoms is ill and must have an underlying disease within bodyAll disease causes symptoms and illnessi.e. Sooner or later disease manifests itself

Biomedical model of illnessThese assumptions are central to the biomedical model of illnessIll-defined; no standard definitionCurrent dominant modelBasis of model is the scientific method:Reductionist approach; identify single causesFocus on pathology/disease within the body as primary cause of illness

Biomedical modelIncorporates other important assumptions:Patient is passive:A victim of disease, andA recipient of treatmentMental phenomena are separate domain unrelated to physical phenomena (Cartesian dualism)physical symptoms/signs are not caused by mental processes

Biomedical modelHas been very successful over 100+ yearsSocially very importantDetermines political policiesOrganisation of bureaucracy (e.g. CRS etc)Allocation of resources / basis of paymentGuides most peoples actions & decisionsLeads to sick roleLack of responsibility for illnessAllowed to avoid social duties

Main assumptions are falseDisease without symptoms is commonScreening programmes based on this5% of 70 year old people may have silent cerebral infarction.Symptoms (i.e. Experiences considered outside normal) are very commonDaily occurrenceTwo life-threatening symptoms each six weeks

ConclusionThe current biomedical model:Is incompleteE.g. not explain functional illness or lead to treatmentIs unable to resolve modern problemsPayment by results tariff not able to workMajor determinants of cost are social and disabilityIncorporates a mereological fallacyThe fallacy of attributing to parts of an animal attributes that are properties of the whole

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.

FromSpeech by Rt Hon John Reid MP, Secretary of State for Health, 11th March 2004:Managing new realities - integrating the care landscape

HolismThe 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).

HolismConcept led on to General Systems Theory (Ludwig von Bertalanffy, 1971)Concepts of:System being more than the sum of its partsHierarchical and interacting organisationsand hence to:Complexity, and Chaos Theories etcStressing importance of non-linear relationshipsMinor change in one factor may have major effect elsewhere

Holistic medicineHolistic 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)

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.Holistic Medicine - 2American Holistic Medical Associationhttp://ahha.org/articles.asp?Id=81

Holistic healthcare: conclusion - 1The concept has mutated to encompass and even exclusively represent alternative health care:Often said to be an approachOften focused on spiritual careAlways difficult to specify

Holistic healthcare: conclusion - 2Health (and illness) is comprised of various hierarchical systems.A person (ill or healthy):encompasses several componentsSpirit, mind, body etclives within a contextPast, personality, social milieulives in a certain way, their life styleHave their own goals, expectations etc

Achieving holistic healthcareTo achieve holistic healthcare effectively requiresa model of illness that is holistic, givinga systematic and comprehensive approachto all domains of health andto all domains influencing health

Biomedical model is not holistic

There is an alternative modelBiopsychosocial medicine1977, Engel (building on sociology etc)Systems approach to illnessPsychiatry and chronic back pain

At same time World Health Organisation was developing a new classification of consequences of disease

World Health Organisations Inter-national Classification of Impair-ments, Disabilities and HandicapsWHO ICIDH - developed in 1970sPublished first in 1980Put forward as a classification systemlike ICD, to complement ICDfor all consequences of diseaseImpairment, disability, handicapDid not acknowledge environment

WHO International Classification of FunctioningRevised 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) activityhandicap -> (restriction on) participationadded global concept of functioning

Adapted WHO ICF modelBasic WHO ICF model is incomplete:No mention of quality of lifeNo 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

Organ (pathology)WHO ICF Description of illnessFour LevelsThree Contexts

Organ (pathology)WHO ICF Description of illnessFour LevelsThree ContextsPerson (impairment)

Organ (pathology)WHO ICF Description of illnessFour LevelsThree ContextsPerson (impairment)Person in environmentBehaviour (activities)

Organ (pathology)WHO ICF Description of illnessFour LevelsThree ContextsPerson (impairment)Person in environmentBehaviour (activities)Person in societySocial position (Participation)

Organ (pathology)WHO ICF Description of illnessFour LevelsThree ContextsPerson (impairment)Person in environmentBehaviour (activities)Person in societySocial position (Participation)Personal

Organ (pathology)WHO ICF Description of illnessFour LevelsThree ContextsPerson (impairment)Person in environmentBehaviour (activities)Person in societySocial position (Participation)PersonalPhysical

Organ (pathology)WHO ICF Description of illnessFour LevelsThree ContextsPerson (impairment)Person in environmentBehaviour (activities)Person in societySocial position (Participation)PersonalPhysicalSocial

Organ (pathology)Traditional Model of illnessFour LevelsThree ContextsPerson (impairment)Person in environmentBehaviour (activities)Person in societySocial position (Participation)PersonalPhysicalSocial

Organ (pathology)WHO ICF model of illness (1)Four LevelsThree ContextsPerson (impairment)Person in environmentBehaviour (activities)Person in societySocial position (Participation)PersonalPhysicalSocial

Organ (pathology)WHO ICF model of illness (2)Four LevelsThree ContextsPerson (impairment)Person in environmentBehaviour (activities)Person in societySocial position (Participation)PersonalPhysicalSocialWell-beingChoiceWithin body

Organ (pathology)WHO ICF model of illness (3)Four LevelsThree ContextsPerson (impairment)Person in environmentBehaviour (activities)Person in societySocial position (Participation)PersonalPhysicalSocialWell-beingChoiceWithin bodyBody & physical environment

Organ (pathology)WHO ICF model of illness (4)Four LevelsThree ContextsPerson (impairment)Person in environmentBehaviour (activities)Person in societySocial position (Participation)PersonalPhysicalSocialWell-beingChoiceWithin bodyBody & physical environmentPerson and social environment

Organ (pathology)Disease/diagnosisWHO ICF Model of illnessFour LevelsFour ContextsBody(impairment)Symptoms/experiencesPerson in environmentGoal-directed behaviour Activities/disabilityPerson in societySocial position Participation, social rolesWell-beingChoiceSocialFriends, colleaguesPhysicalClose & distantPersonalAttitude, beliefs, etcTIMEP E R S O N

WHO ICF & holistic healthcareModel suggests that a personHas a body whichFunctions as a wholeExperiences, skills etcHas subsystemsOrgans, Interacts with physical environmentActs as a conscious social beingHas goals , makes choices, experiences spiritualityInteracts with other people (social context)

WHO ICF model and illnessIllness arises when the system of:Person within their contextFails 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

WHO ICF & NOCBrief discussion of how WHO ICF could be used to transform NOCClinicallyOrganisationally

WHO ICF & holistic clinical careUse it to analyse clinical situationsIdentify all relevant factors related to situation

Use it to plan holistic clinical managementIntervene in as many factors as possibleDirectlyLiaise with others

Achieving holism clinicallyKey is to consider a persons social role functioningWhat roles do they have or aspire to?What roles could they achieve?Do they have any roles at all, other than patient?

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)

The importance of social roles

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

Holistic healthcare systemsWHO ICF model can help organisation

ImpairmentActivitiesSocial rolesExpertise - conditionExpertise - localityFocus changes over time Level of illness Context Type of expertise neededAcute phasePathologyPhysical contextSocial contextTime

Specialist disease serviceSpecialist rehabilitation serviceLocality rehabilitation serviceGeneral practice complete serviceSelf-managementTime course of a long-term condition, and service needsAcute phasePost-acute phaseTimeNOC?

Holistic healthcare requires:Use of a holistic model of illness to:Analyse clinical situationsUnderstand multi-factorial causation of illnessPlan healthcare interventionsMulti-factorial, not simply disease-focusedOrganise services and notes etcAround different levelsBe basis of commissioning and fundingCondition management not disease managementAcross all boundaries

Therefore the NOC shouldEmbrace WHO ICF in all its activitiesClinical, planning, administration etcDevelop seamless relationships withCommunity services and primary careSocial services (and others)Develop services centred on problemsOf people with relevant long-term conditionsAcross their lifetime

SummaryHolistic healthcare requires a comprehensive, coherent model of illnessThe expanded World Health Organisation International Classification of Functioning biopsychsocial model is holisticThe Nuffield Orthopaedic Centre should join the Community Health Organisation to become the first healthcare organisation to use this model fully

1921Wingfield Hospital - orthopaedic1950Nuffield Orthopaedic Centre1992Nuffield Orthopaedic Centre NHS Trust2010Oxford Holistic Healthcare NHS Trust?1872Wingfield Hospital - fever

Holistic health careIt is our only future!Dr Derick T Wade,Professor in Neurological Rehabilitation,Oxford Centre for Enablement,Windmill Road, OXFORD OX3 7LD, UKTel: +44-(0)1865-737310Fax: +44-(0)1865-737309email: derick.wade@ntlworld.com

The WHO ICF modelOrganDisease (actual pathology)Whole bodySymptoms & signs experiencedImpairments of function impliedPersonal contextexperience, expectation, attitude, choice, belief, disease label Social contextExpectations, attitudes, beliefs etc of othersQuality of lifeParticipationRoles, patients interpretationRoles, others interpretationPhysical contextObjects, structures, bodies etcActivitiesBehaviour: goal-directed interaction with environmentT I M E

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