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Aligning the 3 Domains of Health and Wellbeing
The NHS is at crisis point. Incredibly dedicated staff are working harder and harder to deliver services to people to support their health and wellbeing. But they are burning out and the system is failing to deliver to its potential. Is it time to seriously consider and implement a different approach that aligns people and communities with their struggling health care providers?
This blog proposes a model that aligns what I consider the main domains of a health creating system. I am naturally drawn to positive approaches that create the conditions for good health, or “Salutogenesis” as Antonovsky termed it. My narrative accompanies a driver diagram (figure 1). This encourages people to look upstream of these 3 Domains to consider what contributes to them, informing how we could implement a health creating system in our society. I encourage you to keep thinking upstream.
This paper is built on my experience as a GP leader, PCN clinical director, and developed through discussion with other thought leaders with professional and lived experience. I outline my ideas not as a finished piece (can it ever be?) but to provoke further thought and action.
The essential aspect of describing this is so that we can be mindful of the relative value of the whole system, and ensure appropriate attention is paid to all 3 areas. It is also important that they work synergistically so each domain is pursued in a way that enhances the other 2.
It is important to recognise the need to work compassionately across boundaries. There is huge value in each domain, but the tendency of professionals dedicated to each one can be to become defensive about their area of expertise, and to advocate for their area at the expense of the other essential domains. Professor Michael West offers consistent research in the benefits of shared purpose, common goals, and a spirit of mutual support across organisational and discipline boundaries to achieve best outcomes for people we serve[1]
Public health research consistently emphasises the value of these 3 domains, although different studies attribute differing emphasis on the relative contribution to health and wellbeing[2]. At the individual person or community level the relative importance of each domain is likely very personal depending on the specific prevailing conditions, and context. There can be other factors such as individual genetic constitution or macro environment. These are much harder to influence, so I focus on the 3 areas where I think we can have meaningful influence in the short to medium term.
Medical interventions
As GPs we are well versed in this pillar, we have spent most of our lives working in this area. There is huge value here. Medical science and practice have evolved significantly over the last 70 years, as the NHS itself was born and has matured. Our growing understanding of physiology, pharmacology, anatomy, and pathology, amongst other medical related fields, has been phenomenal. We can restore hip function by replacing the joint, re-pace the heart with electrical pacing systems, and treat cancer with a range of chemical, radiological and surgical options. Infections and injuries that where once fatal, are now routinely treated with great success. Science is even starting to venture into the capability to manipulate the underlying genetic blueprint in a therapeutic interventions.
This area of healthcare is very well matured in terms of processes and resources. There are well established training and development programs for staff, clinicians, managers, administration. The financial and estates infrastructure is well established, and consistently maintained. Research is robust and a there is a strong evidence base to draw on to guide practice.
This has all lead to strong trust in, and reliance on, these medical interventions to assure us of good health. When we develop symptoms, we seek out a medical diagnosis and fix.
Whilst Medical interventions have made tremendous progress in treating acute illness, it has been less successful in preventing and treating long term conditions. We recognise the importance of high-quality medical interventions to treat acute conditions in creating ongoing good health. However, we also recognise the limitations of relying on these interventions entirely to deliver a whole system of high performing health creation.
Activation of People and Communities
It is being increasingly recognised that for established health care practices to work best, people in receipt of care need to be fully involved. Evidence tells us this is best achieved when people are recognised and treated as equal partners in their care. This was illustrated in the economic review by Sir Derek Wanless where he described the financial benefits of a ‘fully engaged population’[3]. This has been matched by the work of Professor Sir Michael Marmot whose research repeatedly confirms the central importance of people themselves, being in control and taking a lead role in managing their health.
It is also clearly recognised that people don’t operate in isolated individual units. We are social beings, whose health outcomes are very much influenced by the people around us who support us emotionally, socially, and physically.
This people and community activation approach forms the basis of the personalised care aspect of the NHS 10-year plan and is the cornerstone of many of the most successful and innovative health systems from the Nuka system in NW America, to Canterbury New Zealand, to Frome in Somerset.
The evidence base to underpin this thinking, has multiple dimensions with roots in Social Science, Self Determination Theory, Behaviour Change, Education, and Economics amongst others. It has more recently been confirmed in the context of health. The case for this Domain is beyond doubt in my mind. However, the evidence base for how to do deliver this Domain is far less developed than the Medical Intervention Domain, and subsequently the roles and processes are less mature. In a similar way public perception of how to participate in, and the value they attach to this, is lagging.
An Enabling Environment
People and communities usual exist in discreet places and spaces. Some of these are geographical, some organisational, or even virtual. Nevertheless, the context of people and communities is crucial to health outcomes. Work on wider determinants of health, housing, social connections, quality of work, and income all strongly influence opportunity to be healthy and live well. So too does access to the basics of life, good food, clean air, safe and appealing places to exercise or just live, green and blue spaces.
The life enhancing ingredients of the worlds ‘Blue Zones’ have been well documented and illustrate how the cultural and environmental conditions have a strong influence on longevity and quality of life.
Like the activation pillar, the case is well made, but the methods to influence this pillar are less well developed. However, community development skills and practices are developing fast. The results of deliberate and consistent approaches, like Asset Based Community Development[4], show us the value of applying evidence-based techniques. But as Cormac Russell writes, community development can not go faster than the ‘speed of trust’, and it takes time to build trust and connections in communities.
I write this summary as a call to action. I hope that in recognising the benefits of each Domain and how to maximise their impact we can stimulate a whole system approach. Perhaps contrary to public perception, the evidence probably leans towards the activation and enablement Domains as being more influential than the intervention pillar. However, if for the sake of argument, we assume that each contributes an equal 33% contribution to health creation, we can see how important it is to invest and support the highest possible performance of each Domain. Just like a student answering only 1/3 of an exam paper, no matter how perfectly you perform in that 1/3 it is only ever possible to achieve 1/3 of the marks.
Reflecting on how stressful and overwhelming the current medical service feel to the staff working in them, we wonder if the over reliance on this pillar is perpetuating an expectation of outcomes that are impossible to achieve through focus on only 1/3 of the system.
In my opinion modern health creation requires a balanced and systematic approach to maximising the benefits of each Domain. Policy and organisations should support their staff to have the time and facilities to pursue a co-ordinated implementation of all 3. We already have tremendous examples to build on from across the health, social and voluntary sectors. Further collaboration and building on these assets offers huge potential for a better health and wellbeing for all of us.
[2] https://www.kingsfund.org.uk/sites/default/files/2018-11/A%20vision%20for%20population%20health%20online%20version.pdf
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