holistic health care

Holistic health care

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our future?

Themes

• Aim for person-centred healthcareNot patient-centred health care

• Actions & decisions depend upon way of thinking

• Person-centred healthcare depends upon having a holistic understanding of healthNo social admissions, bed-blocking

patients, difficult to discharge patientsBrought to you by

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 Brought to you by

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 yearsSudden 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 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 Brought to you by

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.”

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Common current assumptions

• Disease refers to disorder of organ within the bodyi.e. Disease is malfunction of part of whole

• All symptoms and illnesses are attributable to diseasei.e. A person with symptoms is ill and must

have an underlying disease within body

• All disease causes symptoms and illnessi.e. Sooner or later disease manifests itself

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Biomedical model of illness

• These assumptions are central to the biomedical model of illnessIll-defined; no standard definitionCurrent dominant model

• Basis of model is the scientific method:Reductionist approach; identify single

causesFocus on pathology/disease within the

body as primary cause of illnessBrought to you by

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 Brought to you by

Biomedical model

• Has been very successful over 100+ years

• Socially very importantDetermines political policies

• Organisation of bureaucracy (e.g. CRS etc)• Allocation of resources / basis of payment

Guides most people’s actions & decisionsLeads to ‘sick role’

• Lack of responsibility for illness• Allowed to avoid social duties Brought to you by

Main assumptions are false

• Disease 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 Brought to you by

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 wholeBrought to you by

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 Brought to you by

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 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 - 2

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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 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

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There is an alternative model

• Biopsychosocial 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 Brought to you by

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World Health Organisation’s Inter-national Classification of Impair-ments, Disabilities and

Handicaps• WHO ICIDH - developed in 1970s

Published first in 1980

• Put forward as a classification systemlike ICD, to complement ICDfor all consequences of disease

• Impairment, disability, handicap

• Did not acknowledge environmentBrought to you by

WHO International Classification of

Functioning• Revised 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) activity• handicap -> (restriction on) participation

added global concept of ‘functioning’Brought to you by

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

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Organ (pathology)

WHO ICF Description of illness

Four Levels

Three Contexts

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Organ (pathology)


Four Levels

Three Contexts

Person (impairment)

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Organ (pathology)


Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

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Organ (pathology)


Four Levels

Three Contexts

Person (impairment)


Person in societySocial position (Participation) Brought to you by

Organ (pathology)


Four Levels

Three Contexts

Person (impairment)


Person in societySocial position (Participation)

Personal

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Organ (pathology)


Four Levels

Three Contexts

Person (impairment)



Personal

Physical

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Organ (pathology)


Four Levels

Three Contexts

Person (impairment)



Personal

Physical

Social

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Organ (pathology)

Traditional Model of illness

Four Levels

Three Contexts

Person (impairment)



Personal

Physical

Social

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Organ (pathology)

WHO ICF model of illness (1)

Four Levels

Three Contexts

Person (impairment)



Personal

Physical

Social

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Organ (pathology)


Four Levels

Three Contexts

Person (impairment)



Personal

Physical

Social

Well-Well-beingbeing

ChoiceChoice

Within body

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Organ (pathology)


Four Levels

Three Contexts

Person (impairment)



Personal

Physical

Social


ChoicChoicee

Within body

Body & physical environment

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Organ (pathology)


Four Levels

Three Contexts

Person (impairment)



Personal

Physical

Social


ChoicChoicee

Within body

Body & physical environment

Person and social environment Brought to you by

Organ (pathology)

Disease/diagnosis

WHO ICF Model of illness

Four Levels

Four Contexts

Body(impairment)

Symptoms/experiences

Person in environmentGoal-directed

behaviour Activities/disability

Person in societySocial position

Participation, social roles


ChoiceChoice

SocialFriends, colleagu

es

PhysicalClose & distant

PersonalAttitude, beliefs,

etcT

I

M

E

P E R S O N

WHO ICF & holistic healthcare

• Model suggests that a personHas 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)Brought to you by

WHO ICF model and illness

• Illness 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

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WHO ICF & NOC

• Brief discussion of how WHO ICF could be used to transform NOCClinicallyOrganisationally

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WHO ICF & holistic clinical care

• Use it to analyse clinical situationsIdentify all relevant factors related to

situation

• Use it to plan holistic clinical managementIntervene in as many factors as possible

• Directly• Liaise with others Brought to you by

Achieving holism clinically

• Key is to consider a person’s 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?

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“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.“

The importance of social roles

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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’”

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Holistic healthcare systems

• WHO ICF model can help organisation

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Impairment

Activities

Social roles

Expertise - condition

Expertise - locality

Focus changes over time- Level of illness- Context- Type of expertise needed

Acute phasePathology

Physical context

Social context

Time

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Specialist disease service

Specialist rehabilitation service

Locality rehabilitation service

General practice complete service

Self-management

Time course of a long-term condition, and service needs

Acute phase

Post-acute phase

Time

NOC?NOC?

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 activitiesClinical, planning, administration etc

• Develop seamless relationships withCommunity services and primary careSocial services (and others)

• Develop services centred on problemsOf people with relevant long-term

conditionsAcross 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 Brought to you by

1921 Wingfield Hospital - orthopaedic

1950 Nuffield Orthopaedic Centre

1992 Nuffield Orthopaedic Centre NHS Trust

2010Oxford Holistic Healthcare NHS Trust?

1872 Wingfield 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, UK

Tel: +44-(0)1865-737310Fax: +44-(0)1865-737309

email: [email protected] to you by

The WHO ICF model

Organ

Disease (actual pathology)

Whole body

Symptoms & signs experienced

Impairments of function implied

Personal context

experience, expectation, attitude, choice, belief, disease label

Social context

Expectations, attitudes, beliefs etc of others

Quality of life

Participation

Roles, patient’s interpretationRoles, others’ interpretation

Physical context

Objects, structures, bodies etc

Activities

Behaviour: goal-directed interaction with environment

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holistic health care

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