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: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: [email protected]

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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 : +44-(0)1865-737310 Fax : +44-(0)1865-737309 email : [email protected]. Themes. Aim for person -centred healthcare - PowerPoint PPT Presentation

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Page 1: Holistic health care: our future?

Holistic health care: our 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]

Page 2: Holistic health care: our future?

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 healthNo social admissions, bed-blocking

patients, difficult to discharge patients

Page 3: Holistic health care: our future?

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

Page 4: Holistic health care: our future?

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

Page 5: Holistic health care: our future?

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

Page 6: Holistic health care: our future?

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)

Page 7: Holistic health care: our future?

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 illness

i.e. Sooner or later disease manifests itself

Page 8: Holistic health care: our future?

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 illness

Page 9: Holistic health care: our future?

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

Page 10: Holistic health care: our future?

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 people’s actions & decisionsLeads to ‘sick role’

• Lack of responsibility for illness• Allowed to avoid social duties

Page 11: Holistic health care: our future?

Main assumptions are false• Disease without symptoms is common

Screening 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

Page 12: Holistic health care: our future?

Conclusion• The current biomedical model:

Is incomplete• E.g. not explain functional illness or lead to

treatmentIs 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

Page 13: Holistic health care: our future?

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

Page 14: Holistic health care: our future?

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).

Page 15: Holistic health care: our future?
Page 16: Holistic health care: our future?

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

Page 17: Holistic health care: our future?

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)

Page 18: Holistic health care: our future?

“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

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

Page 19: Holistic health care: our future?

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

Page 20: Holistic health care: our future?

Holistic healthcare: conclusion - 2

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

• A person (ill or healthy):encompasses several ‘components’

• Spirit, mind, body etclives within a context

• Past, personality, social milieulives in a certain way, their ‘life style’

• Have their own goals, expectations etc

Page 21: Holistic health care: our future?

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

Page 22: Holistic health care: our future?

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

Page 23: Holistic health care: our future?
Page 24: Holistic health care: our future?

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 environment

Page 25: Holistic health care: our future?

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’

Page 26: Holistic health care: our future?

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 2004;329:1398-1401

Page 27: Holistic health care: our future?

Organ (pathology)

WHO ICF Description of illness

Four Levels

Three Contexts

Page 28: Holistic health care: our future?

Organ (pathology)

WHO ICF Description of illness

Four Levels

Three Contexts

Person (impairment)

Page 29: Holistic health care: our future?

Organ (pathology)

WHO ICF Description of illness

Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Page 30: Holistic health care: our future?

Organ (pathology)

WHO ICF Description of illness

Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Page 31: Holistic health care: our future?

Organ (pathology)

WHO ICF Description of illness

Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Personal

Page 32: Holistic health care: our future?

Organ (pathology)

WHO ICF Description of illness

Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Personal

Physical

Page 33: Holistic health care: our future?

Organ (pathology)

WHO ICF Description of illness

Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Personal

Physical

Social

Page 34: Holistic health care: our future?

Organ (pathology)

Traditional Model of illness

Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Personal

Physical

Social

Page 35: Holistic health care: our future?

Organ (pathology)

WHO ICF model of illness (1)

Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Personal

Physical

Social

Page 36: Holistic health care: our future?

Organ (pathology)

WHO ICF model of illness (2)

Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Personal

Physical

Social

Well-Well-beingbeing

ChoiceChoice

Within body

Page 37: Holistic health care: our future?

Organ (pathology)

WHO ICF model of illness (3)

Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Personal

Physical

Social

Well-Well-beingbeing

ChoicChoicee

Within body

Body & physical environment

Page 38: Holistic health care: our future?

Organ (pathology)

WHO ICF model of illness (4)

Four Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Personal

Physical

Social

Well-Well-beingbeing

ChoicChoicee

Within body

Body & physical environment

Person and social environment

Page 39: Holistic health care: our future?

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

Well-Well-beingbeing

ChoiceChoice

SocialFriends, colleagu

es

PhysicalClose & distant

PersonalAttitude, beliefs,

etc TIME

P E R S O N

Page 40: Holistic health care: our future?

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 environmentActs as a conscious social being

• Has goals , makes choices, experiences spirituality

• Interacts with other people (social context)

Page 41: Holistic health care: our future?

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

Page 42: Holistic health care: our future?

WHO ICF & NOC• Brief discussion of how WHO ICF

could be used to transform NOCClinicallyOrganisationally

Page 43: Holistic health care: our future?

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

Page 44: Holistic health care: our future?

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?

Page 45: Holistic health care: our future?

“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

Page 46: Holistic health care: our future?

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

Page 47: Holistic health care: our future?

Holistic healthcare systems• WHO ICF model can help

organisation

Page 48: Holistic health care: our future?

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

Page 49: Holistic health care: our future?

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?

Page 50: Holistic health care: our future?

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

Page 51: Holistic health care: our future?

Therefore the NOC should• Embrace WHO ICF in all its activities

Clinical, planning, administration etc• Develop seamless relationships with

Community services and primary careSocial services (and others)

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

conditionsAcross their lifetime

Page 52: Holistic health care: our future?

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

Page 53: Holistic health care: our future?

1921 Wingfield Hospital - orthopaedic

1950 Nuffield Orthopaedic Centre

1992 Nuffield Orthopaedic Centre NHS Trust

2010Oxford Holistic Healthcare NHS Trust?

1872 Wingfield Hospital - fever

Page 54: Holistic health care: our future?

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]

Page 55: Holistic health care: our future?

The WHO ICF model

Organ

Disease (actual pathology)

Whole bodySymptoms & signs experiencedImpairments of function implied

Personal contextexperience, expectation, attitude, choice, belief, disease

label Social contextExpectations, attitudes, beliefs

etc of others

Quality of life

ParticipationRoles, patient’s interpretationRoles, others’ interpretation

Physical contextObjects, structures, bodies etc

ActivitiesBehaviour: goal-directed

interaction with environment

T I M ET I M E