Heroes Not Zombies

As part of the NHS’s 60th anniversary celebrations, Donald Berwick, President of the US organisation, the Institute for Healthcare Improvement, made a speech at one of the specially organised conferences. I’ve always been impressed by his writing and his speeches. I first encountered them when I read “Crossing the Quality Chasm” – the book which introduced me to the concept of “complex adaptive systems”, and I thoroughly enjoyed his “Escape Fire” ( a collection of ten of his annual addresses ).

His speech, in praise of the NHS, compared it very favourably to the state of health care in the US. In summary, he said this –

You could have had the American plan. You could have been spending 17% of your gross domestic product and making health care unaffordable as a human right instead of spending 9% and guaranteeing it as a human right. You could have kept your system in fragments and encouraged supply driven demand, instead of making tough choices and planning your supply. You could have made hospitals and specialists, not general practice, your mainstay. You could have obscured accountability, or left it to the invisible hand of the market. You could have a giant insurance industry of claims, rules, and paper pushing instead of using your tax base to provide a single route of finance. You could have protected the wealthy and the well instead of recognising that sick people tend to be poorer and that poor people tend to be sicker, and that any healthcare funding plan that is just must redistribute wealth. Britain, you chose well. As troubled as you may believe the NHS to be, as uncertain its future, as controversial its plans, as negative its press, as contentious its politics, please behold the mess that a less ambitious nation could have chosen.

He then went on to make ten suggestions for improvement. The first, I think was the most important and one that most health care systems haven’t even begun to implement on any significant scale –

Put the patient at the absolute centre of your system of care—In its most authentic form, this rule feels very risky to both professionals and managers, especially at first. It means the active presence of patients, families, and communities in the design, management, assessment, and improvement of care. It means total transparency. It means that patients have their own medical records and that restricted visiting hours are eliminated. It means, “Nothing about me without me.”

Apart from that he recommended strenghtening the Primary Care and Community aspects of the service, stopping the habit of more and more “reforms”, a strong plea NOT to pursue a market-led direction (ie I suspect, to do more like the Scottish NHS than the English one), and paying attention to the training and integration of the diverse employees of the NHS. Finally, he recommended aiming at health itself, not just health care.

He is astute enough to know that “great health care, technically delimited, cannot alone produce great health”. Of course it would be nice if the NHS was structured around trying to improve the health of its users, but the real big changes in health as such will be achieved through political means and societal changes, not health care ones.

I just read Professor Richard Wilkinson’s “The Impact of Inequality” (ISBN-13: 978-1-59558-121-1). I first read Wilkinson’s work on the impact of inequality on health in the BMJ back in the early 1990s. I found his research remarkable and disturbing at the same time. Essentially what he was highlighting was that in developed countries absolute income levels were not a determinant of health. Instead, what seemed to cause the greatest harm was the size of the gap between rich and poor. In other words, income inequality within a society impacts on many parameters of health, from infant mortality to life expectancy and many disease rates in between. This was a bit puzzling. We mostly believe that poverty, of the kind where your basic material needs of food, water and sanitation are not met, is indeed deadly, but that relative poverty ie the extent to which people feel poor compared to others in society could be deadly? How could that be? Was it true?

Well, over a decade has passed and dozens of more studies have shown the link between inequality and health. In “The Impact of Inequality”, Wilkinson sets out the case very clearly and then provides an explanation for the findings. In a nutshell, he shows that psychosocial stress has an enormous impact on health, and that the key element underpinning this stress is how we think others perceive us. Shame is a strong social force. We feel it when we are not respected, when we are judged to be inferior or to have failed, when we told we are just not “good enough” or when we are dismissed as irrelevant. Social status is the root of much of this shame in all societies, but especially in unequal societies which have strong hierarchies based on dominance and competition. The biological mechanism for this stress is the body’s inflammatory response. When experiencing stress, the human organism activates cellular and hormonal systems to increase defences and prepare the subject for “fight or flight” as a fundamental survival mechanism. Years of such inner responses produces an “allostatic load” – a fairly new measure for the accumulated inflammatory activity. A high allostatic load is associated with an enormous range of chronic diseases.

Let me just cite one example. In societies where there is great economic inequality, blood cholesterol levels are higher than those in more equal societies. These high lipid levels are part of the body’s inflammatory response. The reductionist, technological, “fix” for this is to prescribe statins for more and more people for greater and greater proportions of their lives. This isn’t exactly a matter of stable doors and bolted horses but even if the statins do what they say on the tin, the problem just shifts elsewhere. Unequal societies experience lower life expectancy, particularly in those who live in the poorest strata. If they don’t die early from heart disease, they die early from something else. The answer, if we take on board what Wilkinson shows us, is political. It’s about creating more humane, more caring, more “affiliative” societies by tackling the fundamental issue of inequality.