Reflections on a Thought for the Day

DRAFT

Reflections on a Thought for the Day.

On Friday 4th July 2014 at approximately 7.50am on BBC Radio 4, Vishvapani (1) delivered his Thought for the Day to over seven million listeners (2). In just under three minutes he managed to explain the key ‘big-picture’ problems faced by the health services of all ‘developed’ countries and succinctly summarized the solutions promoted by the British Holistic Medical Association and by this journal.In this article I will develop, and hopefully illuminate, each key message, using my own life and experience. The sections will begin with the words used by Vishvapani in his broadcast.

The limitations of curative medicine

“A doctor friend told me recently that as a medical student he’d expected he’d go into the community and cure people. But when he became a GP he learned how many problems medicine couldn’t solve. His patients had to live with them as chronic illnesses.”

I remember when the first H-2 receptor antagonist was released to the market in 1976 for treating peptic ulcers by reducing stomach acid secretion. I was on my general practitioner (GP) training scheme in Bath, Somerset. Before that I had been a specialistregistrar in general medicine and gastroenterology in Surrey where a significant part of the work concerned peptic ulcers, mostly duodenal. Many patients ended up with surgery – cutting the vagus nerve or repairing the perforated intestinal wall. There wasn’t much else we could offer and some patients died from acute haemorrhage or peritonitis.When the new drug appeared, itwas hailed as a triumph of pharmaceutical research led by Smith, Kline and French (now GlaxoSmithKline). It seemed like a miracle cure. The drug, cimetidine (trade name ‘Tagamet’) soon made much of the surgery disappear into the history books.

However, as the years went by we all noticed that the trickle of non-respondingpatients was turning into a stream and then a torrent. Some had ulcers, some didn’t. Then in around 1990, right on cue, AstraZeneca delivered the next miracle drug: the proton-pump inhibiter (PPI), omeprazole. This drugradically reduces acid secretion to nearly zero, making cimetidine (by then off patent andavailable over the counter) seem little better than antacid mixtures. What had happened? How had the once miracle drug, cimetidine, lost its potency?Had the human tolerance of discomfort been reset at a lower level? There are still fewer operations but plenty of patients with dyspepsia, plenty of patients with life-threatening haemorrhage, and lots of money made by pharmaceutical companies. Certainly, the drugs-for-acid approach has not cured the people of their stomach troubles nor healed them of their deeper travails.It has lured them into more therapy.

Health and Social Care Services overwhelmed

“We’ve heard recently about the growing challenges for health and care services as more of us live longer and develop long-term physical conditions like diabetes and arthritis; or mental ones like depression and dementia. The test for politicians is how public services can manage rising demand on finite resources.”

The challenges to health and care services are not new. During the 1990s we GPs were faced with steadily increasing workload and long waiting lists for hospital care.The politicians’ story at the time described the NHS as a dinosaur – the last of the giant nationalized industries, inefficient and overdue for modernization. The denouement of this storywas the creation by theThatcher and Major governments of the ‘internal market’ within the NHS (or at least the beginnings of it) and also the pitching of GP practices against one another to get the best deal for their patients. This latterwas ‘GP fundholding’. It failed but it set the long term political agenda.

Like most GPs at that time, I did not understand why we were overwhelmed butI knew that competition was not the right answer, andthat government was not tackling the right problems. I was distraught. As Tony Blair took office in 1997 I took sabbatical leave and started the long process of acquiring knowledge and understanding. I returned after five months full of optimism and ideas. My growing understanding told me that the problems lay not so much in the NHS (though it was far from perfect), but rather in society and communities. So I was dismayed when in 2000 the New Labour government set aboutdeveloping the fledgling internal competitive market. The ‘customers’ for this market would be GPs. Sick people were effectively the raw materials to be processed. Commodifying healthcare into packages required complex bureaucracy. However, waiting times did reduce but at the cost of huge expenditure and the diversion of doctors’ and nurses’ attentioneven further away from patients and towards computers, logistics management and cost effectiveness. With impeccable corporate logic, the present government pushed this process still furtherwith leaner management and theopening of NHS services to commercial corporations.

But still the poor wait. The latest story is the one repeated by Vishvapani:excess demand is because people are living longer with long term conditions. This is only partly true. People are living longer: modern healthcare is good at keeping people alive. However, people are getting serious illnesses (long term conditions – LTCs) at a younger age – especially diabetes, mental health problems and addictions – and hence living longer with them. However, those who manage to avoid these problems can expect to live independent and productive lives into their 70s and 80s and consume resources only in extreme old age and in their last illness – as was the case before, but perhaps 10 years later (3).Dementia is a particular worry. I will mention this later.

So what sort of ‘challenge’ does this healthy post-war generation present to society exactly? We baby-boomers have enjoyed free healthcare and free educationsince childhood. Far from being a burden to society we can be an asset, and by seeing through the politicians’ convenient stories,become a necessary thorn in their side. In the case of healthcare, we have perhaps a 10-year window to do our work in uncovering the real causes of the increased demand from the suffering millions and in setting in motionthe sustainable solutions described in Vishvapani’s broadcast.

We need more self-care and resilience

“But as well as what the state provides, it’s also a challenge for us as individuals and as a society. Individually, the challenge is that, if we live longer while feeling sicker, we need to learn to manage better with pain and difficulty. My GP friend commented that many of us regard our bodies as if they were cars. When something goes wrong we take them in to be fixed; and if the doctor can’t fix the problem we’re shocked. When I’ve worked with people with chronic pain using mindfulness, I’ve seen that learning to calm our minds and acknowledge the reality of our condition can make a big difference. Pain and disability needn’t mean you can no longer live a meaningful and even an enjoyable life, but it’s not easy and we need help to become more resilient.”

In 1965 when I was 17, I attended an interview at The Middlesex Hospital Medical School. It was fun. I got talking with a consultant surgeonabout Austin 7 cars – my consuming interest at that time.Like all of my things, I took it apart and put it back together. They offered me a place!

There is an obvious parallel between servicing cars and healthcare. But my own interest in car mechanics seemed to have no connection with my interest in health and illness. It had another purpose in my life.I began to understand this only recentlyafter reading a fascinating book, ‘The Case for Working with Your Hands’ by Matthew Crawford (4). Part motorcycle mechanic and part philosopher, Crawford unpicks and beautifully displays the formative and healing connection between the hands, the heart and the collective soul of humanity. The key, he writes, is ‘individual agency’. I now recognize this in my youthful passion for engines and axles. Working with the unyielding, sharp-edged reality of steel, I was testing myself against the external world – the stuff that is not me. The cold, the grazed knuckles, the bits of rust in my eyes, the exhilaration when it worked, the public ignominy when it didn’t; it was all mine. Success and failure were mine. I was forging my identity and my resilience.I was unknowingly preparing myself for a long, hard and immensely rewarding career in medicine.Other formative interests followed:playing a musical instrument, creating a wildlife garden. They each fed the deep needs we all share: to strive to make a difference through hard-won knowledge and skills,to connect with uncompromising nature andto share our struggle with others.

Crawford agues that the seemingly elusive cause of our modern lack of resilience and much of our misery is the learned helplessness of consumer culture. Many have argued this before: Erich Fromm (5), Christopher Lasch (6), Tony Judt (7). Retail therapy does not meet our deep needs. It leaves us unsatisfied, restless and prone to addictions and ill health. Crawford argues that it is the exercise of our agency in making, mending, using skills that creates wellbeing and health. My childhood toys could easily be taken apart andreassembled. It is no accident that this is now seldom possible. It is not durability and repair but novelty and disposal that are built into the complexity and design.I tolerate the computer I am now usingonly for what it enables me to do. But if the people bought only what they needed,the economy would collapse.That’s why politicians are blind to the ill-effects of consumerism.

So, of course, people treat their body as a complex consumer commodity unsuitable for home repair. They take little care of it and cart it to the NHS when it doesn’t work. That is what our culture has trained us to do. The culture not only generates illness fundamentally through lack of true agency, it fails to equip us with the motivation and skills to care for ourselves.

Building Community

“The collective challenge is that looking after more people in the community means that the community itself needs to be stronger. Many of us already respond as carers or through the voluntary sector. But at a time when society is becoming more fragmented and we feel less natural connection with our neighbours, we need to cherish a vision of life that looks beyond our personal interests and struggles.”

I practised as a GP in the South West of England for 32 years, almost all in one town.I became increasingly aware that most of the problems the patients brought to me reflected what went on in their lives. There is now strong evidence that mostLTCs that weigh on the NHS are socially determined illnesses (8). This includes many forms of cancer, coronary heart disease, stroke and dementia. The common problems of broken families, work stress, unhealthy lifestyle, loneliness are not the whole cause, but they are major factors, and change here would have a big effect not only in terms of disease prevalence, but also caring for those affected.

Lots of things drive families and social groups apartgeographically, economically and socially, fragmenting communities andexaggerating the divide between the rich and the poor. Lurking at the core of this is thecompetition for status inherent in consumerism because, of course, competition entails winners and losers.The prevalence of illness and social dysfunction, including domestic violence and abuse, closely tracks income inequality. In unequal societies all income groups are affected, though the poor suffer most (9). This often leaves the very old, the sick and the very poor to be cared for by the state.This is not sustainable.

But there are hopeful signs. For instance, ‘social prescribing’enables practitioners to ‘refer’ suitable patients to community involvement rather than to a medical intervention (10). It coaxes and supports people in venturing out of their often shrunken and fearful world to rediscover some of the natural connections they have lost. In a more connected and trusting community, with high social capital, we not only smile in the street and care for the weakest, we also look ‘beyond our personal interests and struggles’ and this creates a virtuous cycle of wellbeing and health for everyone.

My current consuming interest is to enable this to happen on a wide scale. It is challenging because most people do not see the link between their problems and their need for connection.There are different routes toward change but, in the end, we need moreconcern with ‘bigger-than-self’ problems – where it is not obviously in a person’s immediate self-interest to invest time and energy. The motivation for this needs to be more ‘intrinsic’ than ‘extrinsic’. That is, things we do because we believe they are right, rather than because they bring us status in the eyes of others (11). Gratification is only slightly delayed and it’s much deeper!

Role of religious and spiritual traditions

Among others, religious and spiritual traditions have much to offer here. People often think that Buddhism, for example, focuses on self-development. In fact, it’s about overcoming selfishness, and a central focus of Buddhist life is what we call sangha: the community of those who live by the same values. My involvement in Buddhist sanghas has taught me that a healthy community needs constant attention. We foster it throughout our lives by connecting with other people and by giving our time and our friendship. The care crisis isn’t going away and sooner or later it will affect us all. It’s time for the discussion to move beyond politics and to start exploring what it means for our own lives.

All the world’s major religious traditions offer rules for living that help us to respect one another and our environment. Even in countries where most people do not profess faith or practise religious rituals, our secular traditions, laws and practices have ancient religious and mythological origins. I am not a religious person but I can see that an exclusively materialist culture, in which individual advantage smothers the greater good, is doomed.If we are to nurture communities, we must finda secular answer to the question: ‘Why should I care?’ whichmight translate as: ‘Why should I not be selfish?’.

We are resourceful animals: resilient, adaptable, cooperative and artistic; but also vulnerable, violent, competitive, brutal, greedy and jealous. Above all though, we are clever. We are, in fact, a freak of nature. This is our challenge; this is why our communities need constant attention.Before the consumerist invasion in the 1950s and 60s our postwar mass culture of frugality and gratitude had ways of balancing our conflicted instincts. These were embedded in values carried through family stories, fairy tales, traditions and religious practice. Remnants of these remain not far below the surface of even the most hardened materialist or hedonist, along with theunfulfilled potential to replace the practices of compliance with those of vision and legacy (12).But currently there is a silence – the voice of complicity (13). McIntosh describes this as a form of hypnosis. He goes on: “We need to shake people out of a meek acceptance of the Powers-that-Be, out of the consensus trance zone and into the transformative fire of indignation.” (14) One helpful precaution I have taken for many years now is never to look at or listen to any form of advertisement.

By meeting people where they are, by listening, being kind, living by the standards we espouse, helping people to reframe their problems so that solutions will emerge, joining them with others who want the same changes, supporting them in making the changes they want to happen –then, if we do all this,our deeper cultural heritage will re-emerge. Above all, we must enable people to have a sense of belonging, and therefore of meaning. You could call this rediscovering spirituality, but I prefer Alastair McIntosh’s expression: the ‘opening of closed hearts’ (15).

TOTAL: 2654 words

References:

1. Vishvapani Blomfield is a teacher and writer on Buddhism and mindfulness.
2. Spijker J, MacInnes J, British Medical Journal doi:10.1136/bmj.f6598; also editorial at BMJ 2013;347:f6823
3. Crawford M, The Case for Working with Your Hands, London, Penguin 2009
4. Fromm E, The Sane Society, Abingdon, Taylor and Francis, 2001 (first publ 1955)
5. Lasch C, The Minimal Self – psychic survival in troubled timesLondon, Pan Books 1985
6. Judt T, Ill Fares the Land, Penguin, London 2011 (first publ 2010)
7. The Marmot Review, Fair society, Healthy Lives, [accessed 25-07-2014]
8. Wilkinson R, Pickett K, The Spirit Level – Why Equality is Better for Everyone London, Penguin 2010, p137
9. Social Prescribing in General Practice – adding meaning to medicine. Find at:
10. Common Cause – the case for working with our cultural values. This is an excellent analysis by Tom Crompton of values and motivation in public life. Find at:
11. McIntosh A, Rekindling Community Totnes, Green Books 2008, p93
12. McIntosh A, Soil and Soul London, Aurum Press 2004, p95
13. Ibid p140
14. Ibid ref11, p29.

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