Candy 2004 - A Healthier Health System

7/29/2019 Candy 2004 - A Healthier Health System

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Towards a healthier health system -- Stuart Candy, NHSU -- August 2004 1

Towards a healthier health systemJoining up futures thinking and a holistic view ofhealth

By Stuart CandyA paper prepared for NHSU, LondonAugust 2004

IntroductionTowards a more holistic understanding of healthTowards a new way of running organisationsThe challengeThinking about the future

A deep challenge calls for a deep solutionJoining ideas together: holistic health and healthy organisationsWhere to from here?

Introduction

In Britain today, there is an enormous amount of concern about the NationalHealth Service and its ability to provide medical support to the millions ofindividuals who rely on it both for general health purposes as well as fortreatment when things go wrong. Newspaper headlines frequently feature

stories of the systems inadequacies and idiosyncrasies, and many of us haveour own tales drawn from first-hand experience. Of course, it should come asno surprise that such a system attracts criticism, it being so large andimportant to the whole population particularly as the proportion of agedpersons increases. Criticism is not only inevitable, but it is also to some extenta necessary part of a healthy health service. Any organisation founded on ademocratic service ethic must accept the role of informed criticism to keep itrelevant, efficient and honest. But there is a need to go further and deeper inthis process of reflection, to revisit the foundation principles and structures ofsuch systems from time to time, however complex and uncomfortable thatmay be, to look past the facts and figures of hospital beds and waiting lists,

and ask whether the basics themselves are right, or if not, how they might beimproved.

In this article some very broad themes are laid out and drawn together. Dueto the breadth of terrain and limitations of space, it is impossible to exploreeach in depth, or to offer detailed empirical support in every area.

Accordingly, this paper does not aim to prove a thesis, but rather to extend aninvitation to the reader: to think about health, and the systems that support itin Britain and other developed Western countries, in a somewhat different

way from the ordinary. If by the end you have had pause to reflect on some ofthe major challenges at the heart of the health system, then the main aim will

have been satisfied. Perhaps some will care to critique or elaborate aspects ofthe argument tentatively offered here. It is broadening the terms of debate


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around the health system which is identified as the most important task fornow, and to this end the paper is addressed.

The starting point for this exploration is a consideration of the way in whichour understanding of health is becoming wider. A second theme is a similar

change around the conception of organisations, in how they are understood,structured and led, in order to be most effective at doing what they do. Thethird step is to examine the value of looking at these questions with a strategicfutures orientation. It is suggested that all three of these processes are under

way, and that they resonate with each other. But to acknowledge and connectthese trends, and follow them towards their logical conclusion, entails amonumental task. We need to be prepared to reexamine the basis of ourhealth system, and try to imagine one founded on a different way of thinking.This is the invitation, and a challenge to us all, but especially to an audience ofhealth practitioners, administrators and educators.

Towards a more holistic understanding of health

It is becoming increasingly apparent in the Western medical establishmentthat the phenomenon of health is a great deal more complex than the scientific

biomedical paradigm has generally allowed us to realise. Being truly healthyis not about merely ensuring that the body is free of ailments and discomfort,

but actively exercising ones body and mind, being engaged, stimulated andhappy about life in general. If health is more than bodily well-being, thenmedicine, hospitals and treatments are just the first of a vast fleet of factors

with a bearing upon the futures of health. More and more of us nowunderstand health as not merely a question of repairing individuals medical

problems as they occur; we are seeing how individuals can be served byfocusing on prevention of problems at a systematic level. The risingpopularity of so-called alternative and complementary treatments thereforemay be testimony not only to the growing cultural diversity of the Britishpopulation, but perhaps also to a growing dissatisfaction with the tunnel

vision of a narrow biomedical view of health, illness and medical treatment.

Health in public discourse is traditionally understood, or at leastadministered, quite narrowly. As a field of policy, it lies alongside education,the environment, and other areas of governmental responsibility, as if they

were separable ideas rather than interdependent aspects of life. Health is in

fact still generally understood in majority culture as a question of medicineand treatment. This is the model of health around which Britains NationalHealth Service was conceived in the wake of the Second World War.Prominent futures thinker and writer Ziauddin Sardar has commented on thecultural basis of the NHS. He writes:1

We understand medicine as modern Western medicine, which assumes therewas nothing before the arrival of modern, scientific medicine; diseases,sickness, ill health and premature death were the norm before the emergence ofthe modern scientific miracle. It is therefore necessary to make a special effortto remind ourselves that what we call modern medicine is as old and venerable

as 60 years, beginning with the development of penicillin.


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The basis of the NHS is a view of medicine and the body which comes from aWestern European philosophy and way of knowing. For some centuries therational, Cartesian tradition has been teaching us to accept, for instance, thenotion that body and mind are divided, although it appears we may have ledourselves astray in this regard,2 and it is interesting that we persist in speaking

of and treating mental health as a basically separable domain from bodilywell-being. Yet our medical tradition is gradually awakening to the fact thathuman health has spiritual and emotional dimensions as well as the physical,

bodily ones. The elementary, but very profound, psychosomatic phenomenonof the placebo effect is one sign of the power of the mind and emotional state

behind bodily health, which cannot be ignored.

Human health is a global ecology, embedded in and dependent upon the stateof the planet as a whole and how we treat it. Linguistic, cultural, medical andpolitical conventions may make this easy to overlook on a day-to-day basis,

but it is a scientific fact which fits with our emerging understandings and

experience of an increasingly globalised world. Recent health scandals aremerely the tip of an iceberg, a dawning realisation slowly being assimilatedinto our cultures understanding, of the convolutedness and fragility of oursystems of food production and distribution: mad cow disease, foot-and-mouth, and the genetically modified organisms debate are three majorexamples.

Health can clearly not be realistically pursued on a purely medical, case-by-case basis, as can be seen by examining the collective or community contextfor individuals decisions. In a bestselling self-help book on weight loss, DrDean Ornish highlights how overeating in America is partly attributable to

social changes which have left more people lonely and dissatisfied with theirlives.3

[A] hundred years ago more people in this country had a sense of communityand connection. They were born, raised, lived, loved, worked, played and diedin the same place. They had the same neighbors and their children went tothe same schools. They attended the same churches and synagogues. Theyoften held the same job for many years, and people at work knew each other.They lived in communities in which people knew they needed each other.These social networks protect us from isolation, illness, and premature death.

A sense of community and connection can directly address and help heal theemotional and physical pain of isolation. [] People who feel socially isolatedhave two to five times the incidence of disease and premature death due to allcauses as those who feel a sense of community and connection.

This analysis, which relates directly to the hotly debated obesity epidemic,goes a step beyond the preoccupation with what people are eating, to ask whyare people eating the things they eat, in the way they do? There are layers ofexplanation here, and a holistic understanding of health considers theseunderlying factors as essential.

There are encouraging signs in Britain that the reductionist biomedical view ofhealth is now being tempered by a broader, more holistic view, even at theheart of the medical establishment. In the June 2004 document The NHS

Improvement Plan: Putting People at the Heart of Public Services, several


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references are made, notably in Chapter 4, to transforming the NHS from asickness service to a health service.4 Increasing public attention is beingdevoted to lifestyle choices which affect health, such as reducing smoking andthe incidence of obesity. This is a step in the right direction from theperspective of those who regard supporting health as a question of nurturing

an ecology of human and other elements, rather than as an exercise introubleshooting illnesses, case by case.

If our idea of health is growing to include prevention as well as cure, this is apromising development, but it is neither a radical nor completetransformation. We remain a long way from implementing this holisticunderstanding of health, and confronting its consequences head on. Indeed itcan be argued that at base the focus on sickness remains, but the emphasis issimply moving further back in the causal chain; in other words, stoppingpeople from crossing the threshold where they cannot properly function

without medical assistance. This is certainly a part of maintaining good

health, but who really believes that its the whole story? If health consists inmore than the treatment of disease, it is also surely more than prevention.The absence of physical malady remains the focus, and a rather uninspiringcriterion of health.

A broad view is also necessary broad in the geographic sense. In contrast, theFebruary 2004 report by Derek Wanless, entitled Securing Good Health forthe Whole Population (also known simply as the Wanless Report) notes thatits predecessor document Securing Our Future Health was based on firstcatching up, and then keeping up with other developed countries, which hadmoved ahead of us over recent decades.5 National competition as a

motivation for providing a functioning health service is a rather curious idea,appearing to imply that the aim of an English health system is simply toensure that the English enjoy better health than everyone else. Even if this

were possible, which is open to doubt, this approach speaks of a view of healthnot as a value in itself, but as a consumer good, and the health agenda ofgovernment begins to bear an alarming resemblance to the corporation that

vies with its competitors to make better widgets. Health issues and servicesneed to be understood as being geographically broader in reach than the areas

which governments have a mandate to rule. Ultimately the health of those inEngland the composition of which is changing all the time is tied to thehealth of its neighbours, near and far. An approach to health that stops at the

border would be highly vulnerable to a single virus from outside the controlarea, which in view of the massive amount of traffic to and from all corners ofthe globe, for migration, business and leisure purposes, is not at all difficult toimagine. (Take for example SARS, which is clearly not just a problem for thecountries where it first broke out, but a problem for us all to face.) Higher

walls are not a viable solution here; but broader horizons may well be part ofit.

Therefore, the process may be gradual, and qualified by anomalies belongingto a disappearing era, but science is reaching toward a more holisticunderstanding of health, and the health system and popular conceptions arefollowing suit. This broadened understanding of health is clearly reinforced inother areas, as people think about the world and approach problems they


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encounter within it in the light of an increasing awareness of theinterconnectedness of individuals and the issues they face. As ElisabetSahtouris has observed, First and foremost, we must recognize globalizationas a biological process something that is happening to a natural livingsystem we call humanity.6 Such relatively recent intellectual developments as

the study of ecology and systems theory have provided powerful newperspectives on the world, which look simultaneously to the wholes of thingsas well as the parts, and the links between them. The Gaia hypothesis,proposed by James Lovelock in a highly influential 1979 book, proposed a

view of the world as a self-regulating planetary ecosystem.7 In recent years, aheightened awareness of the globalisation process in regard to economics andcommunications, and the understanding of networks that is both demandedand enabled by those technological drivers, have helped to reinforce theapplication of interconnected, systemic thinking to social phenomena.

The next section shall examine how these impulses are echoed by the changes

in our understanding of organisations, where a similar awakening appears tobe underway.

Towards a new way of running organisations

Every organisation faces challenges posed by change both within and without.In any given domain, these challenges seem to grow more numerous, complexand rapid even as we watch. In an industrial era dominated by mechanisticlogic, it seemed sensible to see people as cogs in an organisational machine.The constituent parts, individuals, were basically replaceable, and valued lessfor their personal attributes than for their role narrowly defined in

keeping the whole operation running smoothly. However, the fact thatorganisations now face constant change to which they must adapt in order tosurvive, has brought a corresponding change in our understanding of whatthey are and how they behave. Instead of seeing organisations as being likemachines, robotic devices whose purposes and methods are fixed and stable,

we have begun to see how they operate as communities; as organisms. Wehave started to incorporate complex biological and social factors into ourunderstanding of peoples collective endeavours, and the mechanisticcorporate entity is now all but extinct.

This shift has obviously begun to affect how organisations are managed and

led. A less mechanistic, more biological model and metaphor suggests thatsuccess is not a question of self-contained function as for a machine. Instead,success is closely connected with the environment in which the organisationoperates, and can be seen as the product of a good fit between an organisationand its environment. This fit is achieved and maintained through a sort oforganisational evolution. Learning is essential to organisational evolution, the

way adaptation genetic and behavioural is the key to survival in thenatural world. In human affairs, the key to this type of evolution oradaptation is not genetic but memetic; cultural. Responsiveness to change isthe common element, and in a word, it is accomplished through learning. Togain new insights and understandings, and to produce new patterns of

behaviour on a sustained and organisation-wide basis, all depend uponlearning taking place continually. What kind of learning is necessary will


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accordingly vary with the goals and contexts of organisations. The learningskills which enable adaptability are the key to an organisation remaining

viable over time. However, with fewer competitive pressures in public sectororganisations, this trend appears to be proceeding much more slowly therethan among than their private sector counterparts.

Leadership in this context is less about maintaining control and more aboutcreating conditions for semi-autonomous development of organisations andindividuals within them. No longer do we seek to create a perfect machinefrom the perfect components, because once-and-for-all perfection is no longerideal: Gone is the need for an autocratic leader who makes every decision,then establishes rules and regulations for carrying them out. Instead, allparties within the organisation need to operate in a culture that is open toand encourages innovation and change, provided they base all decisions onsound, agreed-upon core principles and vision.8

A large body of literature has grown around the concept of the learningorganisation (popularised by Peter Senge9) which refers to a corporateculture that values and enables continuous improvement. This has beenintensively discussed and theorised in light of the imperative for constantadaptation to survive and thrive in fast-changing times. What is intriguing,however, is that this idea has been enthusiastically embraced for reasons notdirectly or obviously related to learning. The online discussion groupLearning-org features a collage of reasons collected from various peoplefor their advocacy and support of the learning organisation concept.10

Although many note the competitive and business advantages conferred bythe approach, just as many people make mention of passion for learning,

spirit, humanity, improvement of peoples working lives, and similar factors.The participatory and creative aspects of the learning organisation, it seems,are welcomed as an antidote to the weaknesses of the traditional alternative,

what might conveniently be described as a mechanistic organisation.

The enormous popularity of the learning organisation idea exemplifies a shiftin thinking, away from viewing people as instrumental to the ends of theorganisation and its management, and towards holism, with the interestsincluding the interior lives (intellectual, emotional, spiritual) of people

working and living within it. Indeed, in management and organisationaltheory literature, there is an abundance of alternative organisational models

floating around which have been devised to fill this gap in the traditionalconception, seizing this latent or hoped-for dimension of the learningorganisation to take it further: the ecological organisation11, the consciousorganisation12, the living organisation13, the inquiring organisation14, andmost appropriately in the health context, the healing organisation15.

This last idea, the healing organisation (an idea to which we shall return) isconceived by futurist Sohail Inayatullah as the missing other half of thelearning organisation. It attempts to engage with the crisis of thepostmodern employee, concerning what is lacking in the mechanisticorganisation, and also in the learning organisation, which deals largely withthe intellectual dimension. For workers, being a part of this would meanhaving meaning in their lives and working in organizations that sustain life,


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heal self, others, and the planet the emotional dimension of working andliving.16 This model, like the others mentioned, proposes a new type oforganisation to which we might aspire to belong, whose endeavours wouldtake account of human dimensions unknown to or unwelcome in themechanistic organisation.

There are resemblances between the changes occurring in the way health isviewed, and the way organisations are understood and managed. The oldorganisational management model and the biomedical paradigm of healthspring from the same mechanistic understanding of the world. There is theexpert doctor who examines, diagnoses and prescribes treatment for bodilyills; and there is the expert manager whose leadership is based on engineeringcorrect solutions. In both cases power is highly concentrated in the hands ofone party, while the other (patient or employee) submits. The success orotherwise of the intervention depends almost entirely on the subtlety,sensitivity, knowledge and good fortune of the individual concerned, since the

actual contribution of the patient or employee is in this way of thinking largelydisregarded.

The more holistic and organic understandings of health, and of whatorganisations (including communities and governments) are all about, arereaching towards the same fundamental insights. They are redressing animbalance inherent to a rational worldview that has long denied, in the publicsphere at least, a place for the spiritual and emotional dimensions ofexperience. Inayatullah writes:

For those who study macrohistory, the grand patterns of change, this is not

surprising. Modernity has brought the nation-state, stunning technology,material progress but the pendulum has shifted so far toward sensatecivilization that it would be surprising if the spiritual as a foundationalcivilizational perspective did not return.17

Related processes can be seen elsewhere in the arena of public debate, I think,in the emergence of the corporate social responsibility movement, theglobalisation protests which in recent years have highlighted concern over thedeleterious effects of businesses seen as acting exclusively in the interest ofprofit, and the success of ethical investment funds and companies withsocially and environmentally aware agendas, such as Fair Trade and the Body

Shop. The recognition of the interconnectedness of problems is beginning toappear even in very traditional and conservative domains, such asparliamentary politics. The idea of providing joined up solutions for joinedup problems which has characterised the idiom of Britains Labourgovernment18 appears to draw on this perspective, albeit in a way that is so farlargely confined to political rhetoric.

The elements and ramifications of this gradual shift comprise far too large atopic to be discussed properly here. However, if this is a plausiblecharacterisation of how a change in worldview may presently be underway, itcontains a great challenge for us all.


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The challenge

The British healthcare system is over half a century old, over which periodmost of the change in mindset discussed so far in this paper has come about.Ziauddin Sardar has pointed out how worldview is embedded in social

institutions, including health systems:

How we enjoy life, what we think of our bodies and how we treat them, how weshape our environmentall this is governed by our worldview. [] There isthus a direct relationship between worldview and health. By promoting certainlife-styles and producing an environment within which these life-styles canflourish, worldviews determine the state of health of individuals and societies.But worldviews also form the matrix of health care systems.19

What basis is there, then, for believing that a healthcare system rooted in theworldview of another era can be changed modestly and incrementally toarrive, fully functioning, in a different one altogether? Its not unlike trying toride a bicycle across a lake with the ill-founded confidence that there wont beany problems because it worked so well on the road.

We can see that systems spring from the worldviews which underpin them.But most of the efforts to reform the NHS have nothing to do with this deeperunderstanding of what health is: they miss the point entirely, and to thatextent leave entrenched ideas that we know to be increasingly outmoded andirrelevant. In terms of how we understand our bodies (health) and ourcollective endeavours (organisations), our worldview is changing quite quickly but the system is not.

Meanwhile, our society is unwell. A health system that focuses on illness,whether prevention or cure, misses the point if it fails to address its context,namely a culture which values the growth of economic activity above all else.Somewhere in our past, the ideal of becoming healthy, wealthy and wise thattriumvirate of perennial values became hopelessly lopsided. Health and

wisdom fell by the wayside. Unhealthy behaviours are unlikely to changeunless we work on their root causes, and rethinking the health system arounda positive commitment to health, personal and collective, bodily and spiritual,is a way to deal with root causes. Thats the challenge.

Indeed, the emergence of a multicultural, pluralistic society raises theobligation to accept and engage other worldviews, including other culturessystems of medicine, as equal partners. Currently, as Sardar points out, non-

Western medicines are still marginalised and labelled alternative,complementary and traditional systems. Non-Western traditions (Islamic,Chinese, Ayurvedic) are generally way ahead of Western scientific medicine intheir recognition of the complex processes involved in illness, and their non-physical aspects. He continues:

As traditions, the diversity of systems of medicine can learn from each other,interact with each other, and cooperate with each other. Medicine then becomes

a model of how a multicultural society operates as an ongoing dialogue of valuesamong citizens sharing equal responsibility for improving the well-being ofsociety.


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This ability to consider divergent ways of looking at health and medicinerequires the same kind of effort to critique our cultural biases at arms length.But where, practically, does all this leave us? What tools do we have at our

disposal to meet such a challenge, and how can we be sure that thisfundamental rethink is a good idea? The approach offered by futures studiesto this problem will be considered in the light of earlier analysis, and apossible way forward sketched out.

Thinking about the future

People often have a very vague sense of their futures, both individually andcollectively. It is nothing new to remark that our experience of life and thepace of change itself are quickening, and it is clear that increasingly rapidchange is highly challenging to our sense of order and stability. As a result it

is not uncommon to encounter the view that the future is beyond anyonescontrol or knowledge: que sera, sera. In this fatalistic view, the future isregarded in much the same way as some have described history just onedamn thing after another, to be weathered as best one can. Another attitude,perhaps more optimistic but no less mistaken, is to hope that the stubbornuncertainties of the future can be overcome with clairvoyant techniques eitherlow-tech (the crystal-balls-and-tea-leaves variety) or high-tech (such ascomputer modelling). Yet both the blind hope for the best attitude and thefollies of prediction leave much to be desired as ways to deal with uncertainty.First, outside of a few very confined areas (such as meteorology) predictiondemonstrably does not work as a strategy of future orientation; the more

complex and further out in time the domain in question, the more obvious thisbecomes. Second, in both approaches the issue is taken to be what willhappen, which implies that there is a future which is certain, in advance, andcannot be changed or influenced for the good. They are two different ways ofthinking, in that one says the future cant be known, while the other insists itcan. However, at one level they share the mistaken assumption that the futureis fixed.

An alternative stance is seen in the academic pursuit of futures studies, whichis committed to anticipating and articulating a range of potential futures(hence the plural). It is accepted that the way things unfold is in some regards

essentially unpredictable, at a highly detailed level for example, and in large-scale discontinuities which could occur at any time (wild cards) butfutures meets the challenge of producing useful information about thepatterns, forms and causes of change processes. This emerges in the shape of

possible, probable and preferable futures. Futures studies is about learningto live with uncertainty, and can help us to turn our minds from the faitaccompli to the yet-to-be. It reveals in the unpredictable an opportunity totake action, through making use of the multiple possibilities which are theobverse of unpredictability. It also helps to manage apparently intractableproblems by alleviating short-termism, the reflex of perceiving things in anurgent, immediate timeframe. As one futurist thinker has remarked, Thereare problems that are impossible if you think about them in two-year terms

which everyone does but theyre easy if you think in fifty-year terms.20


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Futures studies is thus an empowering domain concerned with increasingunderstanding and improving the wisdom of choices, and its underlying goalis to help identify how concrete outcomes canbe constructively influenced viathoughtful intervention. One definition describes it as:21

A transdisciplinary, systems-science based approach to analyzing patterns ofchange in the past; identifying trends of change in the present; andextrapolating alternative scenarios of possible change in the future, in order tohelp people create the futures they most desire.

How is it used though?

The September 2001 publication by what is now the Prime Ministers StrategyUnit provides an outline of some of the most common tools used by futuriststo explore possible, probable and preferable futures. These include Delphi

surveys (involving an iterative process of expert consultation on future issues),qualitative and quantitative trend analysis, scenario planning and analysis,and visioning exercises.22

The tools provided by futures studies can be applied to many differentproblems at almost any level. Another report from the same organisation,dealing with best practice in futures, states: The turbulence which strategicfutures work seeks to master can be about any sort of organisation orexternal change, whether market conditions or a newly elected mandate.23

Whether the context is an automobile company attempting to improve itsgrasp on changes in the market for its products, a national government

seeking to formulate a new policy on smoking in public places, or a universityadministration hoping to reform its curriculum to meet the emerging learningneeds of undergraduates, futures techniques can be put into play.

This is important because the use of futures tools does not dictate an agenda.In my view, the adoption of a strategic forward view is naturally conducive to

values such as sustainability, ecological protection, and accountability; thesebecome more apparent the further into the future one is working. Historian oftechnology Paul Saffo has said, The first thing you learn in forecasting is thelonger view you take, the more is in your self-interest. Seemingly altruisticacts are not altruistic if you take a long enough view. In the long run saving

yourself means saving the whole world.24

However, these are meta-tools forapproaching the understanding of change and can be used to advance virtuallyany agenda; and the most common applications are indeed shorter term andquite instrumental.

Futures techniques have been adopted at various times in the discussion ofBritish health issues. For example, the technique of scenario building, one ofthe most popular techniques in the futurists methodological repertoire, iscentral to the Wanless Report. One writer neatly sums up its purpose: Youdont plan for a single certain future but rather for multiple possible futures,each based on a different theory of whats really going on.25 Scenarios instil

flexibility towards the future and exemplify a commitment to the notion of


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multiple possible outcomes, and in principle, strategic intervention can helpto nudge affairs towards the most desirable of those possible outcomes.

The Wanless Report discusses the steps necessary to achieve a fully engagedhealth scenario for 2022, which is articulated in the 2001 interim report,

Securing Our Future Health: Taking a Long-Term View and nominated as apreferred future.26 The other two, less attractive scenarios of the healthlandscape twenty years hence are labelled slow uptake and solid progress.This is a good example of the conventional use of a futures method toilluminate (not eliminate!) uncertainty about how things might unfold.

The preferred, fully engaged scenario refers to a population of individualsfully engaged with the responsibilities involved in looking after their ownhealth, driven by the provision of health information. Consequently, in thishypothetical 2022, there has been a sharp decline in health risk factors such assmoking and obesity, and other benefits including decreased acute ill health

among the elderly and higher overall life expectancy. This provides a vision towork towards, and it is a picture of the existing system working better than itcurrently does.

Turning to another example; rather than using scenarios, the Kings Fundreport The Future of the NHS published in January 2002 simply discussesthree major problems identified for urgent attention within the service over-politicisation, excessive centralisation, and lack of responsiveness. It isinteresting that a document which explicitly seeks to provide a framework fordebate about the future of the NHS does not make the framework of the NHSitself part of the debate. It deals with political and structural concerns of the

NHS as a bureaucracy, which are of course extremely important challenges,but they are less to do with addressing underlying health issues, and more todo with oiling an ailing juggernaut. Both examples illustrate a typical futureorientation, which unfortunately engages less deeply with the underlying illsof the health service than they might.

There is in fact a specialised area of futures practice called health futures,which represents the application of various futures tools to the arenas ofhealth and health care.27 Health futures imports a broad conception ofhealth, and there is a valuable distinction to be made between this and thenarrower domain dealing with the technologies and structures of Western

medicine:28

Medical futurism deals with the institutions and professions that comprise whatis sometimes referred to as the medical-industrial complex Health futurism alsoencompasses the subject of healthy public policy, exploring what policies might

be developed if health were a prime determinant of official decision making. Thevalue of health futures stems largely from its ability to take people beyond theirmistaken preoccupation with medical care, to an examination of the realdeterminants of future health. It also serves to focus our attention on human andecological ends rather than on the economic and technological means thatdominate medical futurism.

Perhaps this can help us to restate the problem: for a long time we have seenhealth as being about medicine, and the health system about curing illness. A


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purely technological and institutional approach to the issues is too narrow toget to what health is really all about, although much of the work that appearsto be about the futures of health is in fact caught up in the narrower medicalconception of health.

This shows how, notwithstanding the incorporation of a futures orientationand techniques it is possible for foundational questions and assumptions toremain more or less untouched. Neither future orientation generally, nor theuse of futures tools specifically guarantees that the approach being taken, orthe goals guiding the process are the best or most desirable that they could be.The point is, although in Britain we are looking at and thinking about thefuture(s) of certain aspects of health, this does not mean that in each case weare addressing the real underlying problem. There is however a possibility and a powerful but latent need to use futures to engage in a fundamentalreconsideration of what health is, and how it could be dealt with differently,from a governmental and organisational point of view.

A deep challenge calls for a deep solution

Futures is not a monolithic or undifferentiated enterprise, and it is vital todistinguish between different kinds of futures work, from the purelyfacilitative at one end of the spectrum, to quite visionary and transformative

work at the other end; the latter challenging both the existing agenda and theunderlying assumptions on which it is based. It is this which I suggest isneeded to make a real difference to the health system, but it is the former

which tends to prevail for the time being. Futures studies can in fact be put toits most powerful use not merely as a way to carry out current agendas more

effectively, but as a way to re-conceptualise and transform those agendas.The transformation at issue here has profound implications for both thehealth system and the organisational and governmental context of which it ispart.

Richard Slaughter, probably the key theorist in academic futures today, haswritten extensively of the need for critical futures which deal with thefundamental assumptions and priorities in our culture.

The best (ie. most positively useful) critique operates self-consciously out ofthese deeper layers of Critical Futures work. That is, the writer or speaker

functions as a human agent who is fully conscious of his/her immersion in, anddebt to, particular sets of cultural resources. [] Futures work that avoids thisengagement may function as a diversion, as entertainment, but is otherwiselargely without value. It misses the main game and is not to be taken seriously.

This deeper approach to designing futures may help us more effectively toapproach the task of reforming institutional and governmental efforts toembed health in society.

Lets take an example. There is a futures technique available which helps toclarify this point, called Causal Layered Analysis.29 This approach identifies

four layers, which are qualitatively different and describe problems, and theirsolutions, as being located at these different levels. The first layer, and the


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most obvious at first glance, is the litany, which consists of quantitativetrends and problems, often in news reports, appearing as a sequence ofdiscontinuous concerns. Beneath this is the layer of social causes, includingeconomic, cultural, political and historical factors. The third layer is describedas structures and the discourse or worldview which supports them. The fourth,

and deepest layer that can be subjected to analysis, is that of metaphor or myth,which deals with deep stories and collective archetypes: in other words, thevery basis of culture. It is the deeper layers that we must consider in identifyingwhats awry in the present circumstances.

If a changing view of health is part of a changing worldview, then incrementaladjustments to a system founded in the old view are unlikely to suffice.Systems theory, on which futures is partly based, can offer a direct insight into

why change in this case must occur at the foundations. Donella Meadows, oneof the authors of The Club of Romes 1972 report The Limits to Growth, once

wrote a short introduction to the levels at which one can intervene in a system.

The least effective level of intervention is labelled numbers, or in systemsparlance, parameters.30

The amount of land we set aside for conservation. The minimum wage. Howmuch we spend on AIDS research or Stealth bombers. The service charge the

bank extracts from your account. All these are numbers, adjustments tofaucets. So, by the way, is firing people and getting new ones. Putting differenthands on the faucets may change the rate at which they turn, but if they're thesame old faucets, plumbed into the same system, turned according to thesame information and rules and goals, the system isn't going to change much.[] Numbers are last on my list of leverage points. Diddling with details,arranging the deck chairs on the Titanic. Probably ninety-five percent of ourattention goes to numbers, but there's not a lot of power in them.theyRARELY CHANGE BEHAVIOR.

Funding levels, managerial changes, incidence of administrative error,distribution of staff and other resources: they are not the stuff of real change.

And yet these are the usual preoccupations of health reform.

Several levels further up, we find the goals of the system, which is aconsiderably larger leverage point. It could be argued that adopting the goalof people taking greater care of their own health needs, described in thepreferred Wanless scenario, represents a change at this level. But it leaves themost significant leverage point: the mindset or paradigm out of which thesystem arises:31

The shared idea in the minds of society, the great unstated assumptionsunstated because unnecessary to state; everyone knows themconstitute thatsociety's deepest set of beliefs about how the world works. [] Paradigms arethe sources of systems. From them come goals, information flows, feedbacks,stocks, flows.

It is this level which is in the process of changing: the basic view of whatconstitutes health. It is this level which is in greatest need of attention if our

health problems are going to improve.


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The key level of worldview, mindset or paradigm described by Meadows,loosely corresponds to the third and fourth levels of analysis in the CausalLayered Analysis model. These are the layers that need to be addressed tomake a real difference.

Joining ideas together: holistic health and healthy organisations

We have considered in turn three sets of ideas. The first is that the concept ofhealth in our society is coming to be regarded more holistically, and less in theinstrumental terms of biomedical science, technologies and techniques. Thesecond is that the conception of what organisations are, and what they do, has(like health) become less mechanistic and more organic in recent times. Thethird idea raised here is that futures studies can provide a valuable set of toolsin empowering todays decision-makers, but that to take up the challengeextended by changes in the other two areas, we must find transformative waysof taking action which go beyond merely facilitating existing agendas.

How do these three ideas come together? Each is a key aspect of the questionat hand. We are interested in improving the organisation infrastructure(including governance) that supports health for thefuture in Great Britain. I

believe that the trends in thinking about health and organisations are urgingus toward much greater changes than we have so far prepared ourselves for,and that preparing ourselves to undertake transformative futures work canhelp us to understand and design the deep changes required.

Health is at the centre of this whole topic, the conceptual foundation on whichall else rests. There is considerable evidence, which it has been possible to

consider only very briefly in this paper, that this understanding is undergoingan important change, and that consequently a thorough examination of howhealth is provided for may lead to some very significant reforms. There are

basically two reasons why health is key driver here. The first is because,holistically understood, almost everything has a bearing upon health. Thesecond is because of its paramount importance as a value in our lives, as anend in itself. Lets look at these in turn.

Firstly, health is distributed. The determinants of health can be seen as aseries of concentric circles, with the individuals personal profile of age, sexand hereditary factors in the centre, encircled by (moving outwards):32

- individual lifestyle factors;- social and community factors;- living and working conditions; and finally- general socioeconomic, cultural and environmental conditions.

If we face the fact that holistic health is not what the current system is allabout, then thats the level at which the current system needs to bereconstructed. Having accepted the range of factors bearing upon health, thenotion of a discrete health service itself begins to appear rather absurd. Suchan arrangement is inevitably a sickness service. On the other hand, if

virtually everything helps to determine health, then surely the conditions ofhealth need to be built into virtually everything. A holistic view, if trulyabsorbed into our way of doing things, would mean a transformation in


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necessary to change our concrete institutions and practices. What we can dois try to develop our organisations and modes of governance in accordance

with the holistic view of health. We can try to imagine a health system thatreflects and embodies this way of regarding health, which as we can now see,has many faces. Attaining it is not about maintaining a series of individuals

who arent sick, like a fleet of functioning vehicles. The group (collective,organisational, community, social) aspects of health need to be addressed.However it is important to note that, lest it be misunderstood, the tenor of thiscall is not entirely critical. Implied in the task of rigorously critiquing howthings are is the even more important job of imagining how they could bedone better. Critique and vision, then, are simply two sides of the same coin.

What kind of futures can we envision? If one way to begin to change things isthrough modification of organisations and their priorities, lets revisit thenotional organisations discussed earlier. Although, as suggested above, thereare certainly philosophical overlaps between the various ideas on offer, the

one which most clearly resonates with the task at hand is the healingorganisation. This (so far hypothetical) entity takes seriously that there is aninner dimension and external dimension to organizational efficacy.35 This isnot a concept that has been comprehensively expounded to date, but it helpsto crystallise the holistic conception of health as applied to the practical task ofrunning a company or other organisation.On this question, Ornish adds:36

[T]ransforming and transcending isolation is the essence of real healing. Eventhe word healderives from the same Indo-European root as to make wholeand to become holy. Social support is only one of many approaches that can

help you begin healing the pain of isolation.

Instead of healing organisations, we might talk about healthyorganisations, by analogy with the established movements for healthycommunities and healthy cities. What, we might wonder, would adistributed health system look like? It is in these ideas that some preferablefutures for our health system might be sought out.

The notion of a healthy community tries to meet the challenge of makinghealth the central idea, and distributing it throughout everything thecommunity does. One commentator, Joe Flower, describes the concept

particularly well:37

Somewhere, you've experienced it - a community that nurtures its members,that makes us all more than we were. But what makes a community healthy?

What builds health, it turns out, also builds community, safety, wealth, andfamilies. The health of a community grows from how many children peoplehave, in what kind of families, with how much money and education, from asense of choice, and from friends and family who give life meaning, from clean

water and air, and basic medicine, from families who eat well, are well housed,secure from crime, and not deranged by drugs or alcohol. Building a healthycommunity requires all the energy the community can muster, from everyone

who can make a difference - but it can be done. There are ways to do it. This

powerful idea has taken hold in over a thousand cities and towns around theworld. This is how to build a world that works.


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This is not merely an idea, but a movement towards empowerment of groupsof people and establishment of health on that basis the basis of community that has been in action for some time. The movement for healthycommunities, or in the urban context healthy cities, has gained particular

currency across Europe and North America since the mid-1980s. The WorldHealth Organizations European Health Cities program has now beenoperating for over 15 years:38

Health is everybody's business and most statutory and non-statutory sectorshave a role to play in health development. Modern public health calls forcomprehensive and systematic efforts that address health inequalities andurban poverty; the needs of vulnerable groups; the social, economic andenvironmental root causes of ill health and the positioning of healthconsiderations in the centre of economic, regeneration and urban developmentefforts.

It is tied to a recognition that the health of individuals and that of collectivesare directly related, and can be favourably influenced by appropriate action atthe local level. Such action emphasises but is by no means confined to localgovernment.

It is intriguing to note that an awareness of the role of urban environment inmaintaining health has been present for much longer than this. In 1875, theEnglish physician Benjamin Ward Richardson gave a presentation to theSocial Science Association meeting in Brighton, called Hygeia: City ofHealth.39 Richardsons conception of an ideally healthy city recognised andproposed to address directly the environmental aspects of health. Thequestions at issue were, in his words:

What are the conditions which lead to the pain and penalty of disease; what themeans for the removal of those conditions when they are discovered? What arethe most ready and convincing methods of making known to the uninformedthe facts: that many of the conditions are under our control; that neither mentalserenity nor mental development can exist with an unhealthy animalorganisation; that poverty is the shadow of disease, and wealth the shadow ofhealth?

Substantially similar ideas are embodied in the healthy communities

movement, and indeed Wards paper served in part as inspiration for thatdevelopment.40 It is intriguing that nearly 130 years later, we are still

beginning to address the same questions about the environmental factorsbehind morbidity and mortality, and strategically building the broaderdeterminants of health into our societies and living spaces.

The notion of community health, as opposed to individual health, is an ideawhich offers great potential, but as Sahtouris suggests, this way of thinkinghas only recently become possible again:41

Words such as community and communal values were consciously or

unconsciously suppressed in our culture during the Cold War because of theirlinguistic similarity to communism. We have, in fact, suffered greatly from


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their absence. The big question is whether we can restore community andcommunal values to our globalization process before all is lost.

The notion of healthy communities is connected to this kind of thinking,encouraging people to solve their own health challenges locally, from the

grassroots up.

Where to from here?

It does not seem appropriate to offer a conclusion here: the thoughts offeredin this paper intentionally lead to further exploration rather than resolution.But in which direction?

Let us revisit the main points. I remarked at the outset of this article thatcriticism is a necessary part of a healthy health service. But at the levelat

which such criticism or reflection is pitched makes all the difference. To

complain about waiting lists, access to services, treatments, budgetsthis isone kind of criticism, and it is legitimate for people to feel hard done by whenthere is a failure to deliver in these areas. But these are the outputs of thesystem, the numbers we experience but they are not the source of the realproblems, as Meadows argument implies, and they will not therefore lead usto real solutions. They are part of a superficial litany of complaints relatingto the health system. A healthy health system must be understoodholistically, like health itself. We must be prepared to query and critique the

very foundations of the health system, and the way we think about it. This hasbeen the invitation offered here.

Our sense of what health means is gradually changing. The consequences forapproaching a holistic view of health, and one that accommodates differentcultural perspectives, are that we must bring our priorities and methods intoline with it. Real solutions are not going to come from doing slightlydifferently what were already doing, but from reframing the problem, whichis why looking at the future of the NHS offers little prospect fortransformativesolutions. Instead, we should accept that there is a central rolefor health in governmental priorities generally, and try to run ourorganisations in ways that acknowledge and give a place to the non-tangibleaspects of human experience. It has been suggested that building healthycommunities may serve as a focal point for a national system, helping to put

the embedded meaning of health into practice, beyond the provision ofmedical service and advice; this businesslike approach which leavesuntouched the key issues of isolation and social breakdown, and which treatshealth as a matter of individual, and mostly physiological, well-being.

Says American novelist Kurt Vonnegut, We are healthy only to the extent thatour ideas are humane.42 Our ideas about what organisations, communitiesand governments are there to do are, I venture, becoming more humane as weleave behind our crude, mechanistic understandings of both humanindividuals and groups. However, to date the soft technology of socialinfrastructure has changed much more slowly than the hard technological

change that demands so much attention and is frequently credited withdriving society towards its future. Ultimately, though, it is our ideas that


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matter, for our technology and our medical techniques serve and aresubordinate to them.

Rather than letting the gap between the principle of holistic and spiritualhealth and the practice of a biomedical health system grow any wider for in

this gap cynicism and disillusionment thrive it is time to look for ways to putour healthy, humane ideas into practice. Our system should be embedding theconditions of health across whole communities and societies. Is it too much toask a national health service to actively promote happiness, health, andspiritual growth?

To demand such major change instantly, yes it would be too much; but over alonger time horizon why not? But what would such a system look like? Nospecific proposal for the design of a holistic or distributed health system isoffered here. As Slaughter has written, critique is no longer merely anoption. It has become a necessity in a fundamentally compromised world.43

Envisioning something better is critiques constructive, and essential, otherhalf, and its the next step in which we all have a part to play.


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ENDNOTES

1 Ziauddin Sardar, Medicine and Multiculturalism,New Renaissance, vol. 11, no. 2, Summer 2002,

http://www.ru.org/sardar-112.htm .2 See Morris Berman, The Reenchantment of the World, Cornell University Press, Ithaca, 1981.3 Dean Ornish,Eat More, Weigh Less: Dr. Dean Ornish's Life Choice Program for Losing Weight SafelyWhile Eating Abundantly, Perennial Currents, 2000, pp.61-624 Derek Wanless,Securing Good Health for the Whole Population: Final Report, Department of Health(UK), London, February 2004, http://www.dh.gov.uk/assetRoot/04/08/45/22/04084522.pdf. TheWanless Report recommendations also note that A NHS capable of facilitating a fully engagedpopulation will need to shift its focus from a national sickness service, which treats disease, to a nationalhealth service which focuses on preventing it. (para 9.1, p. 183)5 Ibid, p. 36 Elisabet Sahtouris, The Biology of Globalization, adapted fromPerspectives in Business and SocialChange, 1997, http://www.ratical.org/LifeWeb/Articles/globalize.html .7 Lovelock, J. E., Gaia: A New Look at Life on Earth, Oxford University Press, Oxford, 1979.8 NCREL, Systems and Leadership, North Central Regional Educational Laboratory (NCREL, USA),

http://www.ncrel.org/engauge/framewk/sys/sysdef.htm .

9 Peter M. Senge, The Fifth Discipline: The Art and Practice of the Learning Organization , DoubledayCurrency, New York, 1990.10 Learning-org, Why a Learning Organization?, http://world.std.com/~lo/WhyLO.html .11 NCREL, above, note 8.12 John Renesch, Conscious Organizations,Executive Excellence, vol. 19, issue 5, p. 19, May 2002;Richard Hames Creating the Conscious Organization: The Art of Intelligence-making for StrategicNavigation, http://www.saxton.com.au/saxton_db_data/files/Hames_Consciousorganisation.pdf.13 Leandro Herrero, The Living Organisation,Scrip Magazine, June 2002,http://www.thechalfontproject.com/services/pdfs/Organisational_Innovation/The_living_organisation.pdf; William A. Guillory, The Living Organization: Spirituality in the Workplace, InnovationsInternational, 2000.14 Henrik Herlau et al, Exformation and Preformation in the Age of Information: Designing InquiringOrganisations, paper for conference Risks and Challenges of the Network Society, 4-8 August 2003,Karlstad University, Sweden, http://www.cs.kau.se/IFIP-summerschool/preceedings/rasmussen.pdf.15 Sohail Inayatullah, The Learning and Healing Organization, article provided by author. See alsoThe Learning and Healing Organization in Questioning the Future: An Anticipatory Action LearningGuide for Transforming Organizations, Tamkang University Press, Taiwan, 2002.16 Ibid.17 Sohail Inayatullah, Spirituality as the Fourth Bottom Line,http://www.shapingtomorrow.com/media-centre/spirituality_as_4th_bottom_line__10_10_20031.doc .18 Gerald Wistow, Modernisation, the NHS Plan and Healthy Communities,Journal of Managementin Medicine, vol. 15, no. 5, 2001, pp. 334-351.19 Ziauddin Sardar, above, note 1.20 Danny Hillis, quoted in Stewart Brand, The Clock of the Long Now: Time and Responsibility,Phoenix, London, 2000, p. 157.21 This definition comes from a presentation by Wendy Schultz, Futures Studies: An Overview of BasicConcepts, 2003, http://www.infinitefutures.com/essays/prez/overview/index.htm . Since we all have a

stake in the future, and no single academic enterprise or perspective has a monopoly on it as a subject ofstudy, it is important to note that there are related fields of study with quite different names (such asstrategic foresight, and change management). Conversely, there are entirely different activities withsimilar names (for example, although futures studies is sometimes called futures for short, it hasnothing to do with the futures market in the financial sector). Futures studies has also been known asfuturology, a term now out of favour due to its pseudo-scientific connotations. As in any otherdomain, not all futures work reaches the rigorous standard that it ought to meet.22 Performance and Innovation Unit (UK),A Futuristss Toolbox: Methodologies in Futures Work,September 2001, http://www.number-10.gov.uk/su/toolbox.pdf.23 The Henley Centre, Understanding Best Practice in Strategic Futures Work: A Report for thePerformance and Innovation Unit, October 2001, http://www.number-10.gov.uk/su/understanding.pdf, p. 1.24 Quoted in Stewart Brand, above, note 20, p.122.25 Stewart Brand, above, note 20, p.118.26 Derek Wanless,Securing Our Future Health: Taking a Long-Term View: An Interim Report,

Department of Health (UK), November 2001, pp 39-40, http://www.hm-treasury.gov.uk/media//82EE3/chap3.pdf.27 Clement Bezold, The Future of Health Futures, Futures, vol. 27, no. 9/10, 1995, pp. 921-925; p. 921.


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28 Trevor Hancock and Martha Garrett, Beyond Medicine: Health Challenges and Strategies in the 21stCentury,Futures, vol. 27, no. 9/10, 1995, pp. 935-951; p. 936.29 Sohail Inayatullah, Causal Layered Analysis: Poststructuralism as Method,Futures, vol. 30, no. 9,1998, pp. 815-829.30 Donella H. Meadows, Places to Intervene in a System: Strategic Levers for Managing Change inHuman Systems, Whole Earth, Winter 1997. Capitals in original.31 Ibid.32 A diagram from Dahlgren and Whitehead,Policies and Strategies for Promoting Social Equity inHealth, 1991 is reproduced in Wanless, above, note 4, p. 25.33 Consider the proposed alternatives to Gross Domestic Product, such as the Genuine ProgressIndicator (GPI see http://www.redefiningprogress.org/projects/gpi/ ). This modifies GDP to takeaccount of economic activity that has negative consequences or is carried out purely in compensation forsocial ills. Joe Flower makes the following related point: A car crash is good for the economy -- bytraditional measurements. Ambulance companies make money from it, emergency medical technicianspick up overtime. So do healthcare workers, body-and-fender shops, car dealerships and the carcompanies, insurance adjusters, physical therapists, and psychotherapists. All these are counted bytraditional economic measures, and in those measures probably far outweigh the lost capital representedby any undepreciated value of the destroyed cars -- and may even outweigh the costs of the lost workhours and lowered lifetime productivity of the injured, and the hiring and training costs to replace thedead. What is not measured, what is not considered measurable in traditional economics, is the human

suffering. That is dismissed as an intangible. (Joe Flower, Healthy Economy, Healthy Communities,The WELL, 1997, http://www.well.com/user/bbear/hc_econ.html .)34 Sohail Inayatullah, above, note 15, emphasis added. Elsewhere, he discusses the notion of spiritualityas the fourth bottom line (above, note 17), inviting an interesting analogy between health andspirituality.35 Sohail Inayatullah, Spirit@Work New Zealand,http://www.mang.canterbury.ac.nz/people/nilakant/spirit/inayatullah.htm .36 Dean Ornish, above, note 3, p. 68.37 Joe Flower, Healthy Cities - Healthy Communities, The WELL, 1996,http://www.well.com/user/bbear/healthy_communities.html .38World Health Organization Regional Office for Europe, Healthy Cities and urban governance,http://www.who.dk/eprise/main/WHO/Progs/HCP/Home .39 Benjamin Ward Richardson,Hygeia, A City of Health, originally published 1876,http://www.blackmask.com/thatway/books153c/hyge.htm .According to the Dictionary of the Historyof Ideas; Hygeia, from whose name our word hygiene is derived, was one of the personifications ofAthena, the goddess of wisdom. (Environment, vol 2, p. 122, http://etext.lib.virginia.edu/cgi-local/DHI/dhiana.cgi?id=dv2-13.) See also Victor G. Rodwin, Urban Health: Is the City Infected?,Lecture at the Millennium Festival on Medicine and the Humanities, London, May 2000,http://www.nyu.edu/projects/rodwin/urbanhealth.html .40 Ibid.41 Elisabet Sahtouris, above, note 6.42 Kurt Vonnegut,Breakfast of Champions , Delacorte Press, New York, 1973. 43 Richard Slaughter, The Role of Critique in Futures Work,http://www.foresightinternational.com.au/07resources/Critique_in_Future_Studies.pdf.

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Candy 2004 - A Healthier Health System