Nurturing Innovation through READ (Research, Education, Auditing and development)

1. Dr Barry White
Consultant Haematologist, St James’s
Hospital and former National
Director for National Clinical
Programmes

2. Ancient system of medicine
• Blood and other bodily fluid were regarded as
“humors” that had to remain in balance to maintain
health.
• Bloodletting was based on this ancient system and
was the most common medical practice for over 2000
years
• The purpose was to correct the imbalances of the
bodily fluids
• No real change in life expectancy over this period of
time

3. Locations for bloodletting
Field book of Medicine, Hand von Gersdoff, 1571

4. In 1799 George Washington (aged 65), the first U.S. president, died after having 3.75 liters of
blood removed from his body within a 10 hour period as treatment for a throat infection

5. Reductionism - “world is like a
machine composed of many smaller
parts and that it could be understood
by taking it apart and studying the
part..” Descartes

6. Holism
• A contrast to the reductionist approach is
holism or emergentism. Holism is the idea
that things can have properties (emergent
properties) as a whole that are not
explainable from the sum of their parts.
• “The whole is more than the sum of its parts”
- Aristole

7. Reductionism leads to dramatic
improvements in medicine in 20th
century
• Antibiotics
• Vaccinations
• Pharamceutical breakthrough across full
spectrum of illness (aspirin, statins, analgesia,
antihypertensives, immunosuppressants,
chemotherapy)
• Transfusion medicine
• Surgery, anaesthesia, ITU

8. Major improvements in health from
17th to 21st Century
• Life expectance 25 yrs to 80 yrs age
• Infant mortality 30-40% to 0.3%
• Child mortality before the age of 5 went from
70% to 0.4%
• Maternal mortality 3%to 0.03%

9. Has it all been good?
• Safety
– 100,000 deaths/yr in USA, 4% of hospital admissions
• Effectiveness
– 50% of patients with chronic diseases are on the right
treatment (thereafter 50-70% adherence)
•
•
•
•
•
Patient experience
Access
Equity
Cost
Clinician health

10. (i) Endemic reductionism
• Society driving endemic reductionism in healthcare – “super
specialitis”
–
–
–
–
Hospital doctors
Nurses
AHPs
GPSI
• Patient care is being reduced not just to systems but the actual
disease
• On average 17 consultants are managing the multi co-morbidity
patients that account for the majority of health spend
• While there are benefits probably driven by standardisation overall
it drives cost, risk, poor patient experience “I don’t want to be the
ball anymore”

11. (ii) Have we learnt the lessons of
improvement science?
• Focus is on science of discover
• Improvement science requires totally different
philosophy and methods

12. Improvement science
• “Every system is perfectly designed to get the
result it achieves” Batleson

13. Appreciation
for a System
Theory of
Knowledge
Learning from experience
PDSA for learning and
improvement
Profound
Knowledge
Psychology
e.g. motivation
Understanding
Variation and data

15. (iii) Definition of health and healing
“Health is a state of complete physical, mental
and social well-being and not merely the
absence of disease or infirmity”
Preamble to the Constitution of the World Health Organization which entered into force on 7
April 1948. The Definition has not been amended since 1948

16. Medicalisation of life
• If I am bereaved, does that mean I am unhealthy?
• 25% of teenagers suffering from mental health
problems! Is this a medical condition or part of
adolesence?
• Advances in technology have resulted in
investigation +/- treatment of many “illnesses”
e.g. early prostate cancer, non malignant breast
disease, imaging “incidentalomas”, coronary
heart disease

17. Expectations!
“I need something to make me feel
better”

18. (iv) Failure to address behavioural
factors
• The commonest condition in most specialties is
“functional”
• In addition biopsy provable diseases are primarily
driven by diet, exercise, alcohol and cigarettes
• Despite this, self management and self efficacy
training is peripheral activity
• The roof is leaking and we only seem to be able to
respond by debating whether we need more
people to to empty the water or whether they
need to worker faster

19. Solutions
• Generalist provides care; specialist role is to support generalist with
smaller amount of direct patient care with exceptions of proceedures
– Standardise with specialty support
– For rare diseases or rare complication of common diseases either direct care
by specialist or specialist supports generalist delivering care e.g Project Echo
• Implement science of improvement into healthcare
• Redefine health and healing – as integration of Descartes and Aristotle
• Redefine the role of the patient and clinician; switch expectations to
patient and support self care – you are what you choose
• Create new business model, metrics and incentives to support the above
• Improve awareness to achieve technical competence, deep insight and
compassion (doctors and patients)

20. Awareness
Patient
• Recognise and respond to
the psychological and social
factors at play
• Develop the skills needed to
self care and to understand
the meaning of health and
healing
• Understand their own
limitations and distractions
• Self compassion
Clinician
• Recognise and respond to the
physical, psychological and
social factors at play and how
variaitons will impact patient
• Understand their own
limitations and distractions
• Act with technical competence
and insight
• Deeper meaning to their work
and life
• Compassionate to self and
others

21. Thank you

23. Health and healing
• Healing and health is the ability to reconcile all
aspects of the self (physical, psychological and
social) – “to be in balance” - even in the
setting of aging, incurable illness (social,
psychological or physical) and pending death.
• To understand- we our what we choose

24. “I need something to make me feel
better”

25. Expectations

26. Awareness
• The central pillar is the self aware clinician and the self
aware patient
• Awareness in patient and clinician
• Insight and prediction regarding physiological,
psychological and social dimensions as well as deeper
issues relating to who we are and meaning to life for
self and the patient
• Taken far enough awareness will strike the spring of
compassion
• Ultimate goal of a Full aware clinician and patient will
find their true nature which is compassion (for self and
others)

27. Health and healing
• What is the difference between healing and curing?
• Healing – transcending suffering, illness and ultimately
death beyond cure alone
• The patient needs to, in the majority of cases, take
responsibility for being the primary treater. As such
the clinician becomes as much teacher as treater.
• We are what we choose?
• We need to prescribe training in self care and self
efficacy

28. • Domains of healthcare
• Why problems
– Reductionism vol and standardisation
– Definition of health generating demand, and
unrealistic expectation on doctor and projection
– QI and systems of healthcare
– Holistic arpproacj

29. • Most criticism of the WHO definition concerns the absoluteness of
the word “complete” in relation to wellbeing. The first problem is
that it unintentionally contributes to the medicalisation of society.
The requirement for complete health “would leave most of us
unhealthy most of the time.”4 It therefore supports the tendencies
of the medical technology and drug industries, in association with
professional organisations, to redefine diseases, expanding the
scope of the healthcare system. New screening technologies detect
abnormalities at levels that might never cause illness and
pharmaceutical companies produce drugs for “conditions” not
previously defined as health problems. Thresholds for intervention
tend to be lowered—for example, with blood pressure, lipids, and
sugar. The persistent emphasis on complete physical wellbeing …

30. Bloodletting didn’t work!
• In the 1830s, Pierre Charles Alexandre Louis
convincingly argued against the perceived effectiveness
of phlebotomy for the treatment of pneumonia and
fever. Ironically, with the gradual decline of
bloodletting there was an increase of other dangerous
and ineffective treatments, such as the use of
electricity, elixirs and potions. These medications
gained popularity for the same reason that
bloodletting had in earlier times: it sometimes worked
as a placebo. Because the patients believed that
receiving electric shock therapy would heal their illness,
the psychological factor may have been enough to
actually make them feel better.

31. Health and healing
• Expectation that “healthcare providers” job is to
make you “healthy” i.e. complete physical,
mental and social well-being
• This is unachievable and is not consistent with
our experience of human existence which is one
of suffering (even the suffering of emptiness if
nothing is wrong), aging, illness and death
• Leads to projection (doctors fault not mine) ,
litigation and burnout

32. Reductionism
• Though the idea of reductionism has existed
since the ancient Greeks, René Descartes, a 17th
century French philosopher and scientist and
father of modern philosophy was the first to
formally state the concept.
• He stated that the world was like a machine
composed of many smaller parts and that it could
be understood by taking is apart and studying the
part before learning how they all fit into the
whole.

33. Evidence based medicine finally
identifies bloodletting as harmful
• However not without a fight
• Sir William Osler still recommended it in 1923,
Principles and Practice of Medicine
• “Many of those who have practiced blood letting were
careful and shrewd mean….it seems scarcely possible
that such men should have been utterly mistaken in
assigning advantages to this powerful means of
modifying vital actions. Imprimis non nicere, like all
proverbial morality is a maxim oftener used to justify
the coward than to guide the conscientious”, A fair trial
for bloodletting, BMJ 1871

34. Increase in lve

37. Current problem
• Definition of health
• Awareness as to the respective roles of the
clinician and the patient

40. “I need something to make me feel
better”

41. Model for Improvement
Aims
Measures
Ideas
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
The Improvement Guide, API
Plan
Study
Do