Seeing the Challenges as They Are
Gosh, is it February already?
2019 is zooming by. But in the slipstream of the zoom, three articles have reminded me that if we’re going to bridge health and community we need to see the challenges as they are.
The first article did an excellent job of putting into words a worry that I expressed to colleagues at the end of last year – that much of the work informed by the ‘social determinants of health’ is actually to overcome the social circumstances that get in the way of health care efficiency.
In other words, the concept is being leveraged to aid corporate, not social, ends.
Castrucci and Auerbach make this point with great diplomacy in their excellent post on the Health Affairs blog. They remind us that the 2008 definition of the social determinants of health “prioritizes a broad, community-wide focus on the underlying social and economic conditions in which people live, rather than the immediate needs of any one individual”. They illustrate how health care leaders conflate ‘social’ and individual’ by examining a speech by Alex Azar, the Secretary of the US’ Health and Human Services. Although Azar frames his speech with the social determinants of health, he provides examples that act at the individual level.
This conflation, they argue, is getting in the way: “it becomes more difficult for us to engage meaningfully with community partners, who will struggle to differentiate between these complementary but different approaches.”
The second article comes from England. The leaders of its National Health Service (NHS) recently secured themselves a huge funding increase. In their post-hoc justification – the so-called NHS Long Term Plan – they, argue Bleakley, Smith and Taylor, seem to have forgotten that we are all going to die. End-of-life care is only mentioned in the Long Term Plan in a short paragraph on enabling people to have more control over their care, something that NHS England apparently likes because it’ll “reduce avoidable emergency admissions”.
As Bleakley, Smith and Taylor comment, it appears that NHS England’s primary concern when it comes to dying is that it not be “inconvenient for the efficiency of hospitals”.
But death is changing. In our ageing societies, “people endure slow deaths of frailty, often with dementia” say the authors. It’s also increasing: “the total number of deaths in England and Wales has increased by more than 10% in 6 years as the population grows and ages and is expected to increase by another 10% by 2030”. With the number of people aged 85 years or older in the UK set to increase from 1·5 million to 2 million between 2015 and 2025 that’s a lot of slow deaths to prepare for.
As the authors ask, as more and more of us die slowly, often in care homes, how will it affect our families, friends, and communities? I don’t know but it’s clear to me that considering these challenges need to be part of how we think about the future of care. It’s rather amazing that NHS England’s leaders don’t seem to have thought about this.
As is often the case, the English are myopic compared to their neighbors in Scotland, Wales and Northern Ireland. This came into sharp focus [sic] for me as I slowly worked my way through the third article (although it’s more a short book), Wellbeing and Devolution: Reframing the role of government in Scotland, Wales and Northern Ireland.
Over the last couple of decades, the governments of Scotland, Wales and Northern Ireland have been given more power by the UK government (ie power has been devolved) and they’ve taken the opportunity to ask themselves what government is for. Although their starting points and journeys were significantly different, they’ve each ended up with the broad idea of facilitating societal wellbeing.
I’ve always been reserved about the idea of ‘wellbeing’; it makes me think of people with privilege doing yoga and swapping quinoa recipes (nothing wrong with that, of course, but health care isn’t really failing that demographic). But the author makes it clear that societal wellbeing is fundamentally different to wellbeing; the former is about living well together, while the latter is just about an individual living well. The article/book examines societal wellbeing as a proxy for social progress.
What struck me was how the elements of ‘societal wellbeing’ were similar to what we list as the social determinants of health. I guess that should have been obvious. If a society isn’t well, one of its impacts is likely to be on people’s health. But it felt to me that the term – societal wellbeing – offered an escape from the individualizing of the social determinants of health that Castrucci and Auerbach worry about. Sometimes you just need a different set of words to shift focus.
Interestingly, though, the NHS in Scotland seems resistant to the shift. The article/book describes how it continues to operate within its own performance framework seeing bio-medical health as the ultimate aim rather than a contribution to something bigger (societal wellbeing). Perversely, it likely uses elements of societal wellbeing, dressed as the social determinants of health, to continue to justify its isolationist approach.
These three articles have reminded me of the core challenge to bridging health and community. I call it healthcare-centricity. Individualizing the social determinants, only considering the growing rates of slow deaths from the perspective of emergency admissions, and refusing to truly see health as a contributor to societal wellbeing are all symptoms of this core challenge.
Dr Pritpal S Tamber MBChB
Creating Health Collaborative (International)
Bridging Health & Community, USA
Beyond Systems, UK