The evidence base of the future for health and care needs to integrate psychology, sociology, linguistics, neuroscience, computer science, artificial intelligence and philosophy, alongside traditional clinical practice taking into account culture, history and our environment.
Key to this is the understanding that although we can introduce processes and measurements for the predictable, when we are looking at human behaviour, complex dynamic systems and uncertainty, we can no longer use a process or an algorithm so our current model of health and social care needs to value skills such as experience, empathy, instinct and shared decision making.
From Dr Steve Sucklings blogs – https://themaslow.foundation/category/steves-thoughts/
I have been able to explore that we have four types of knowing;
- Procedural
- Prepositional (facts)
- Perspectival
- Participatory
In health, we have focused on policies, procedures and facts rather than wisdom considering life experience, reflection, active open mindedness and situational awareness to enable the balancing of view points, appreciate context and provide the aspiration to improve through mastery.
INSANITY – Doing the same thing over and over again and expecting different results. Albert Einstein
We discuss understanding our patients but have not recognised that our staff need the same support. We all move away from danger to safety and towards others and the need to belong, so understanding the principles of psychological safety and trauma informed practice underpins how we all respond as individuals, in teams, as organisations and systems.
When we are stressed and feel unsafe, we have tunnel vision, impaired memory and processing capabilities, with a survival response which leads to fight (aggression and defensiveness), flight (withdrawal), freeze and compliance.
When we are thriving and feel we belong, we can collaborate, innovate with creativity and insight and utilise our experience to best effect.
We appreciate that we work in constraints, both financial and of resources including staffing but we also need to understand how we build our own constraints. We should value aspiration and ambition. We need to discuss our feelings and emotions and how these interweave with our decisions.
Power dynamics are rarely discussed however are critical in appreciating decisions and feeling safe. Imbalances of power, naturally happen through roles, professional identity and cultures but if misunderstood can lead to individuals, teams and organisations that feel like bullies, often driven by their own insecurities.
So remember:
- Inclusion safety – means we are all valued, we appreciate and respect.
- Learner safety – enables us to experiment, fail and share our learning journey
- Participation safety – ensures that everyone is empowered to contribute
- Challenger safety – creates an environment where we can speak up and challenge the status quo.
For patients, we need to identify a new way of delivering personalised case which will take into account; clinical medicine, genomics, neural networks and biochemisty, understanding emotion, motivation, perception alongside sociology and the social determinants of health with an appreciation of power and equity alongside how and what interventions are delivered.
For organisations, it is critical that we understand patient safety and have high quality services but we need to move from fixed mindsets and goal orientated behaviours to growth mindsets and continuous improvement. Rather than fearing feedback and aspiring for approval, we need to understand mastery and activation and ‘being better than we were last year’.
We have recognised from The Francis Report about Mid Staffordshire NHS Foundation Trust to the latest Ockenden Report about Shrewsbury and Telford Hospital NHS Trust and their maternity services, that we have consistently delivered some areas of poor care. We have identified the importance of culture and that this is the bedrock of good practice, but we seem unable to move to a new way of working.
I would propose that attempting to systemise the unpredictable and not value uncertainty and the opportunities that this brings, will lead to the reinforcement of a failing system, in which people feel scared.
Our organisations have grown up in silos delivering care for single diseases and lack the structures, culture, systems, and routines needed to support a democratic, collaborative, and interdisciplinary approach to self-management in patients who have more than one chronic condition and live in a complex eco-system. We have not created holistic services which respond to the needs of patients.
Our partners have their own traditions, with significant differences between health, care and the voluntary sector which are not understood. Challenges such as accountabilities between multiple stakeholders and historic relationships also need to be considered in the new Integrated Care Systems.
Our regulators including the CQC, have tried to simplify the complex, basing its reviews on ‘fallible’ measures and creating an unintentional consequence of feeling that you are being bullied where you have no options but to follow their drumbeat of activities even where it is causing detriment to your organisation and staff.
Our strategic leaders, and politicians often implement new policies and transformation plans with a disconnect on how these will be delivered, with optimism bias, where the politicians can over estimate the benefits, and local leadership having the bias of negative framing believing that nothing will change the current position.
Greater levels of shared understanding would bridge these gaps across our health and care systems, from co-creation with patients, to a shared vision across strategic leaders.
Finally, we have forgotten the most improvement element which is the change over time. Snapshots are not helpful, although comparing trusts and organisations provides an opportunity for insight, I think the real measure is to see self-improvement removing the stress of being compared to others.
With a lens of new understanding, we can build on the foundations of EBM to form a new model of best practice which we have called Participation Centred Care where we merge personalised medicine and participation, organisational development and distributed wisdom and systems theories and philosophy with greater understanding of the totality of the statistical bell curve and celebrate our outliers narrative to inform our practice.
