540 likes | 876 Views
Themes. Aim for person-centred healthcareNot patient-centred health careActions
E N D
1. 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: derick.wade@ntlworld.com
2. 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 health
No social admissions, bed-blocking patients, difficult to discharge patients
3. 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
4. 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 years
Sudden jump at 20 years and falls again at 21
5. What causes functional illness? People who experience symptoms (and disability) but have no disease to account for/explain their illness
Form 20% of all new out-patients in all clinics
Example 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
6. 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)
7. Common current assumptions Disease refers to disorder of organ within the body
i.e. Disease is malfunction of part of whole
All symptoms and illnesses are attributable to disease
i.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
8. Biomedical model of illness These assumptions are central to the biomedical model of illness
Ill-defined; no standard definition
Current dominant model
Basis of model is the scientific method:
Reductionist approach; identify single causes
Focus on pathology/disease within the body as primary cause of illness
9. 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
10. 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 peoples actions & decisions
Leads to sick role
Lack of responsibility for illness
Allowed to avoid social duties
11. Main assumptions are false Disease without symptoms is common
Screening programmes based on this
5% of 70 year old people may have silent cerebral infarction.
Symptoms (i.e. Experiences considered outside normal) are very common
Daily occurrence
Two life-threatening symptoms each six weeks
12. 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 whole
13. 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.
From
Speech by Rt Hon John Reid MP, Secretary of State for Health, 11th March 2004:
Managing new realities - integrating the care landscape
14. 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).
16. 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
17. 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)
19. 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
20. 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
21. Achieving holistic healthcare To achieve holistic healthcare effectively requires
a model of illness that is holistic, giving
a systematic and comprehensive approach
to all domains of health and
to all domains influencing health
Biomedical model is not holistic
22. There is an alternative model Biopsychosocial medicine
1977, Engel (building on sociology etc)
Systems approach to illness
Psychiatry and chronic back pain
At same time World Health Organisation was developing a new classification of consequences of disease
24. World Health Organisations Inter-national Classification of Impair-ments, Disabilities and Handicaps WHO ICIDH - developed in 1970s
Published first in 1980
Put forward as a classification system
like ICD, to complement ICD
for all consequences of disease
Impairment, disability, handicap
Did not acknowledge environment
25. 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
26. 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
40. WHO ICF & holistic healthcare Model suggests that a person
Has 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)
41. WHO ICF model and illness Illness arises when the system of:
Person within their context
Fails 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
42. WHO ICF & NOC Brief discussion of how WHO ICF could be used to transform NOC
Clinically
Organisationally
43. WHO ICF & holistic clinical care Use it to analyse clinical situations
Identify all relevant factors related to situation
Use it to plan holistic clinical management
Intervene in as many factors as possible
Directly
Liaise with others
44. Achieving holism clinically Key is to consider a persons social role functioning
What roles do they have or aspire to?
What roles could they achieve?
Do they have any roles at all, other than patient?
46. 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
47. Holistic healthcare systems WHO ICF model can help organisation
50. 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
51. Therefore the NOC should Embrace WHO ICF in all its activities
Clinical, planning, administration etc
Develop seamless relationships with
Community services and primary care
Social services (and others)
Develop services centred on problems
Of people with relevant long-term conditions
Across their lifetime
52. 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
54. 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)1865-737310
Fax: +44-(0)1865-737309
email: derick.wade@ntlworld.com