A radical shift in health is surely what we desire for ourselves, our families, workplaces, communities and country.
To achieve this will require a radical shift in the way that health is delivered.
We are weary of changes in healthcare systems. In countries around the world, they are introduced every few years, with good intentions, only to lead to new systems which are more complex, more expensive, less efficient and achieve less in health outcomes. Exactly the opposite of the advances we see in technology, which grow exponentially and get better and cheaper.
We are losing the battle against chronic diseases and must do things differently.
We don’t need system change; we need meta-system change – we need to change the system beyond the system.
Why meta-system change? Let me explain:
Here in New Zealand, a recent major review of the health and disability sector found, unsurprisingly, that it wasn’t working.
Within the recommendations for the change came the underpinning principle that future healthcare delivery must shift from disease management to disease prevention and focus on the health of whānau (families), communities and population health.
Surely, no one would disagree.
The comprehensive report of the review hardly mentions doctors at all. Certainly not in terms of providing solutions.
Why does this matter?
Well, I’m not just sticking up for my mates, because I am a doctor!
It matters because healthcare systems are built around what doctors do – if doctors diagnose and treat disease, then that is what the system is set up to deliver.
But our medical students and new doctors are being taught that health is so much more than that.
The system is not set up to allow our new doctors to do what they are being trained to do.
The government’s response to the review is for a quite dramatic move in New Zealand terms, from 20 separate district health boards (DHB’s) to one overarching body, Health New Zealand, modelled on the UK’s NHS.
Modelled on the UK’s NHS. Which even before COVID was crumbling, with doctors burnt-out and leaving in droves. With the Royal College of General Practitioners (UK) calling for a new future for GP’s and their patients.
Are we staring at déjà vu all over again? The government’s motivation for change is sound. The risk is to repeat the same pattern. Now is the time for innovation and creation. The solution must meet the health needs of the population and the people who care for them.
Here in New Zealand, at any point in time, 50% of doctors are experiencing symptoms of burnout. 50%.
Rural communities and DHB’s struggle to recruit and retain doctors. We only need to look to
the UK to see what the next level of doctor despondency might look like, and it’s not pretty.
What is health?
I ask people this question often. I get an incredibly wide range of answers, ranging from, “Everything working correctly” to “Having the energy to play with my children and still have quality time with my partner”.
“Everything working correctly”. That’s what I was taught as a medical student 40 years ago. ‘Health is the absence of disease’ is no longer enough. This definition is not helping us, and it creates a false impression of what doctors do.
A GP I spoke to this week said, “The problem is that patients expect me to fix them”.
Here in one sentence is the explanation for why the current system doesn’t work and why doctors are burning out in pandemic proportions: healthcare systems around the world are predicated on the false belief that doctors fix patients.
They don’t. Doctors enable people to create the circumstances to heal themselves.
For doctors, this isn’t a crisis of care, it’s a crisis of responsibility. There is an unwritten collusion within the system that doctors take responsibility for people’s health. Doctors are very caring people. They take this responsibility to heart, often to the detriment of themselves and their families.
There is a new definition of health: Health is the ability to adapt and self-manage in the face of life’s challenges.
The work of Sir Michael Marmot on the direct relationship between control and our health leads me to conclude that this definition can be simplified: Health is the ability to control our lives.
Health is the ability to control our lives. This is an empowerment concept. With power comes responsibility, and therefore the need to take responsibility for our own health.
I presented this concept to a group of New Zealand doctors recently. Afterwards, one of them, Māori Paediatrician Dr Danny de Lore, came up to me and said, “I’ve had a realisation. This is exactly what Māori are seeking for their own health. It’s a key principle of the Treaty of Waitangi – Tino Rangatiratanga: The ability and power to be in control of your future. The ultimate goal.”
Surely, we agreed, this is the ultimate goal for all of us. He said, “I’m going to use that in my practice: Health is the ability to control our lives. Health is Tino Rangatiratanga.”
I have spent my 40 years in medicine working in a system which everyone knows no longer meets the needs of the people it serves, or the doctors and other healthcare professionals, in fact everyone who works in the system.
In my book, Positive Medicine: Disrupting the Future of Medical Practice, I describe my very personal journey through ill health to positive health, through realisations that lots of people are saying what I’m saying and that the solutions are readily available. What is required is simple and affordable. What will be needed is a new worldview, a change in the understanding of how the system works. Also, a system that sees the whole person, not a disease.
The book describes how the concept of the Māori model of health, Te Whare Tapa Whā, is a more appropriate way of seeing whole person health, and how it can be incorporated into medical practice.
Please, if nothing else, read the Epilogue, which is freely accessible at PositiveMedicine.com Now is the time for a radical shift in health.
This call only reflects what many doctors have said to me. I believe I speak for many people. (And remember, doctors are people too).
Metasystem change will require a shift in the social contract between doctors and patients: From doctors fix patients, to doctors partner with people to help them take control of their life and become experts in their own health.
We have enough evidence to know intuitively that evolution in health doesn’t work.
It is time for health system revolution: For doctors and patients to rise up and say, we want a system that truly works for us.
Dr David Beaumont
I presented this manifesto for comment to Sir Mason Durie, who first described Te Whare Tapa Whā. His email response to me was as follows:
David Nga mihi.
The Manifesto sends a strong message to doctors. I was remined of Hui Whakaoranga 1984 when a number of health agencies attended the first national Maori Health Conference – sponsored by the DoH. I presented the Whare Tapa Wha model. The model had emerged after my concerns about what was standard psychiatric practice in those days. The whole attention then was to understand the mind and accompanying emotions. For many Maori patients it was all a bit off-key. It did not take long to conclude that the mind and the body were inseparable, that there was a spiritual dimension that gave both hope and resolve, and that whanau involvement was critical. It did not mean that clinical realities should be avoided or ignored, but it did give emphasis to the need for a wider framework that was more attuned to mauri ora (flourishing), than to a fixation on diagnosis alone. Since the Hui Whakaoranga there has been a shift, at least by Maori services towards a more outward and rounded-looking approach.
So a fundamental shift by doctors, as the Manifesto promotes, will be timely. It does not mean ignoring clinical realities, but neither ignoring other things that may be more relevant in day to day lives.
Hope it is well received. Kia maia