Archive for June, 2013



Where do you think I took this photo? I love the colours in this, and it got me wondering what we see in a photograph which gives us a sense of the context of a shot. What is there about the architecture, the signs, the symbols the fashion, the design, the people, which helps us to know where a photograph has been taken.

It also got me wondering about memory and imagination. What memories does this image evoke for you? What does it stir in your imagination?

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Don Berwick, recently appointed to head up the post-Mid-Staffs Review, was the person who introduced me in 2001 to the concept of “complex adaptive systems” in Appendix B of “Crossing the Quality Chasm“.

I happened to be diving into the writings of the French philosopher, GIles Deleuze, at the time, and somehow this “CAS” concept fell right into place with Deleuze’s philosophy of rhizomes and of becoming…..so much so that in 2007, when I started this blog, I chose the subtitle “becoming not being….”

I know the American Republicans really don’t like him, but I’ve enjoyed a lot of what he has had to say, and when he praised the NHS at its 60th anniversary he said (amongst other things) this

First, put the patient at the center – at the absolute center of your system of care. Put the patient at the center for everything that you do.  In its most helpful and authentic form, this rule is bold; it is subversive.  It feels very risky to both professionals and managers, especially at first.  It is not focus groups or surveys or token representation.  It is the active presence of patients, families, and communities in the design, management, assessment, and improvement of care, itself.  It means customizing care literally to the level of the individual.  It means asking, “How would you like this done?” It means equipping every patient for self-care as much as each wants.  It means total transparency – broad daylight.  It means that patients have their own medical records, and that restricted visiting hours are eliminated.  It means, “Nothing about me without me.”  It means that we who offer health care stop acting like hosts to patients and families, and start acting like guests in their lives.  For professionals made anxious by this extreme image, let me simply remind you how you probably begin every encounter when you are following your best instincts; you ask, “How can I help you?” and then you fall silent and you listen.

People throw around the words “patient centred” and “consultation” like mantras these days, but sadly, its often lip service. It’s NOT difficult to practice the way Don Berwick recommends. Check out his questions in that paragraph –

How would you like this done?


How can I help you?

When did a health care professional last ask you those questions? Do you feel treated as an individual? With your values, your beliefs and your wishes being held as CENTRAL? Do you feel treated as a guest in the lives of NHS staff? OR do you feel YOU are the host, and they are the guests in YOUR life?

Let me say again – this is NOT difficult. The doctor, the nurse, the physio, are there to help you. They are there to listen and there to help you find a better way to cope with these symptoms, or address this disease, or whatever has led you to seek them out (a desire for better health I expect)

Don Berwick is revisiting this ethic in his new post and saying that he can be confident that the NHS can be more made safe because

“One of the most important guarantors of continuing excellence in the NHS is the ability to include and invite and listen to the wisdom of patients, families, carers and communities”

There’s still way too much of the attitude that “we” (the “experts”) know best, and “you” the patients, families, carers and communities should just get on with swallowing the “evidence based” tablets we prescribe.

“nothing about me without me”

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I noticed this. I noticed it partly because of its colour, and partly because of its shape. A lot because of its shape. This is what we do. We notice patterns. We recognise patterns. Patterns kick off a train of associations in our memories and our imagination.  I noticed the shape of a heart. Then I held it in my hand. Not grasping, but holding lightly. I held it in my hand and I wondered about the little veins in the petal, and how they looked like the creases in my palm. And I wondered about the intricacy of the petal, and the intricacy of my hand. And I was amazed yet again how the universe creates such beautiful complexity, such uniqueness, filled with connections, intricate echoes of the past, continuously evolving through today. And I photographed it with my iPhone. And I shared it. This is what we do. This is us becoming more human every day……noticing, reflecting, sharing.

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The Mayo Clinic claims that 70% of Americans are taking at least one prescription drug.

More than half of these are taking at least two different drugs.

20% are taking five or more prescription drugs.

Here are the top five, in order of frequency –

  1. Antibiotics
  2. Antidepressants
  3. Opiate painkillers
  4. Antihypertensives
  5. Vaccines

Prescription drug use has increased steadily in the U.S. for the past decade. The percentage of people who took at least one prescription drug in the past month increased from 44 percent in 1999-2000 to 48 percent in 2007-08. Spending on prescription drugs reached $250 billion in 2009 the year studied, and accounted for 12 percent of total personal health care expenditures. Drug-related spending is expected to continue to grow in the coming years, the researchers say.

So, here’s what I’m wondering. What is our working model for health care? What are we trying to achieve? Health? And if that’s our goal, how are we doing? Does this study indicate we are on the right road? Is this a sustainable direction? How do we pay for every more expensive health care of this type every year?

Oh, and isn’t it interesting that three of the top five are called “anti-” something? This suggests that our only hope is that health will emerge as a side-effect of these treatments…..they certainly aren’t designed to improve health directly.

And just in case you think antibiotics create health, have a look here.

If 7 out of 10 people in a population are taking drugs, are those drugs bringing them what they hope for?



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We tend to look right through windows. We look as if the window isn’t there. But as I look at these photos of windows, I wonder two things. First of all, how beautiful the window itself often is. Secondly, how does the window itself influence what we see as we look through it?


glasswaves glassspeckles stonewindow paperwindow templewindow

What are your favourite windows?
What does the world look like through your window?

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Less disease = more health

More health = less disease

Which of those two statements do you agree with?

Of course, neither equation is that simple. Sometimes bringing a disease under control, or removing a pathological lesion, results in a person’s health increasing. It’s true in most acute diseases. But it’s a bit more complex in chronic illness. Better managed diabetes allows the patient a better health experience, and controlled asthma does too, but those chronic diseases don’t go away and a person with any chronic disease isn’t likely to experience health as fully as someone who doesn’t have any such disease. Sometimes increasing health, resilience and wellbeing not only reduces limiting symptoms, but allows the innate self-healing capacity of human beings to work so well that the disease is removed completely. Other times, again in chronic situations, it results in greater wellbeing but not erradication of the disease.

The lack of simplicity reflects the fact we can’t put parts of life into unconnected boxes. There aren’t two, separate, complete states – disease and health. But they influence each other. They influence each other in unpredictable ways because human beings are complex adaptive systems, and such systems have distinct types of relationships between their parts – non-linear links. Non-linear links are typical of human feedback loops. And that’s a good description of the relationship between health and disease – they are bound together in non-linear negative feedback loops.

Most health care focuses on the first statement. We have a disease-focused, disease-management service, not a health service. Health, if it increases, does so as a kind of side-effect of the treatment. Yet, health is still the goal. Taking a health-making focus creates or enhances the conditions for reduction, or control, of disease. But that too may not be enough. The human ability to self-heal is not perfect, and not omnipotent. Management of a disease really can contribute to better health.

Why don’t we do that more?

Are we doing our best to help people to experience as much health as possible?

Not if we only focus on disease. Not if we only focus on health.

We need an integrated health service – where disease management AND health making are available to all patients.

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An article in the BMJ recently repeated the statement made several years ago by a researcher who works in the area of pharmacogenomics for GlaxoSKF, the drug company. He said

“The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people,” Dr Roses said. “I wouldn’t say that most drugs don’t work. I would say that most drugs work in 30 to 50 per cent of people. Drugs out there on the market work, but they don’t work in everybody.”

Whilst that observation caused a stir at the time, and is causing a stir again, now it’s been repeated, at the time it didn’t really surprise me. You don’t have to work as a GP for long to discover that there are no drugs which do what the manufacturers and researchers say they do for every single patient who you prescribe for. How many different BP pills does the doctor have to try sometimes to get hypertension under control? How many different painkillers? Different antidepressants, anticonvulsants, treatments for constipation, diarrhoea…..you name it. I really don’t know of any drug on the market which does what it claims to do for EVERY single patient who takes it. What did surprise me were the figures quoted – 90% of the drugs only work in 30 – 50% of the people!

And yet, there are still those who claim there are only two kinds of treatments available – those which work, and those which don’t.

Life just isn’t like that.

But here’s another comment in that BMJ article which really grabbed me, and I don’t know why I didn’t see this so clearly before!

Pain relief is not normally distributed but usually bimodal,being either very good (above 50%) or poor (below 15%). Using averages is unhelpful and misleading, because “average” pain relief is actually experienced by few(if any)patients, and it tells us nothing about how many patients will experience clinically useful pain relief [BMJ 2013;346:f2690 doi: 10.1136/bmj.f2690]

What does this mean? “Bimodal”? Well, here’s another article, referred to in this BMJ article, pointing out the same problem –

Systematic reviews of regulatory trials often pool average data. In acute and chronic pain, however, underlying distributions are commonly not normal, tending to be U-shaped rather than bell-shaped, where the average describes few individuals [PAIN 149 (2010) 173–176]

When you look at the effect of a drug on a research population you don’t get drugs which work, and those which don’t. What you get is two distinct groups of patients – those who get a “good” result, and those who don’t.

By averaging out the results of the entire group, this reality is obscured.

Whilst these articles refer to painkillers, I believe this finding is likely to be found with pretty much any therapy you can think of. There will be a group who really get no benefit, AND a group which get significant benefit.

This is a common problem in health care – there are no average people. Every single person needs to be considered and treated as an individual. After all even the results from the group trials have been obscured by this averaging out.


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This tree is just bursting with potential. Every little seed could grow to become a whole tree. Could you tell what the tree will look like, just by looking at one of these seeds? Only if you have seen one of these seeds before and you recognise it, or if you see it in the context of the parent tree (as you can see in this photo). But even then, you can’t predict which seed will become a full tree, and which won’t. Nor can you tell EXACTLY what the particular grown tree will look like.

But what we do know, is that here is potential and possibility.

Life is like that. YOU are like that.

Bursting full of potential.

What are you becoming…..?

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I read Montaigne’s essay yesterday about “Liars” and it made me laugh out loud. I really enjoy Montaigne’s humility. It seems to me that he frequently wrote with a twinkle in his eye. In this essay he refers to his claim that he as a terrible memory. He says that others consider that an affliction of sorts, but he thinks it has advantages.

Firstly, he says that having a poor memory has saved him from being an ambitious person – “the defect being intolerable in those who take upon them public affairs”.

Secondly, he says it has saved him from deafening all his friends with his “babble”

I have observed in several of my intimate friends, who as their memories supply them with an entire and full view of things, begin their narrative so far back, and crowd it with so many impertinent circumstances, that though the story be good in itself, they make a shift to spoil it…for whilst they are seeking out a handsome period to conclude with, they go on at random, struggling about upon impertinent trivialities, as men staggering on weak legs.

…..old men who retain the memory of things past, and forget how often they have told them, are dangerous company; and I have known stories from the mouth of a man of very great quality, otherwise very pleasant in themselves, become very wearisome by being repeated a hundred times over and over again to the same people.

Thirdly, he says he is less likely to remember the injuries he has received (and therefore doesn’t hold grudges)


the places which I revisit, and the books I read over again, still smile upon me with fresh novelty.

And, finally, (getting to the title of the essay) he says that it has saved him from being a liar, because liars always forget the details of their lies and trip themselves up. Knowing he has a bad memory means he doesn’t trust himself to lie!


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What a beautiful shape! Here is one stem of a fern unfurling, unfolding, becoming. If I came back next week and photographed this exact fern, it would look very different. If I could take a photo every few minutes and view it as stop motion video it wouldn’t look so still. We would see it was constantly moving, restless, stretching, curling and uncurling, spreading its leaves in the sun.

This single fern is a wonderful example of how, if we want to really know an individual, we have to follow them through their unfolding. Single moments, isolated snapshots of existence only hint at the complexity, the movement, the development which is at the heart of all Life.

Becoming, not being…….

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