The intellectual clarity and ambition of the Creating Health Collaborative’s Eleven Principles for Creating Health is freeing, and my short answer is, ‘Yes, where do I sign?’. If my longer response is a little more argumentative it is because the best compliment I can pay is to be provoked.
As a Senior Associate of Innovation Unit, I have spent years working to develop ‘radically different, better, lower-cost public services’, mainly in England, often in health care. This work includes People-Powered Health, harnessing the potential of peer support and self-help. So the principles trigger my memories of that work, included the committed clinicians and leaders we engaged.
In England, innovating in health means trying to change the National Health Service, a tax-funded system that is part of the nation’s DNA but prone to initiative after initiative that mostly succeed in turning its staff into sceptics. So, when I imagine drawing on the Collaborative’s principles, I imagine pitching to the NHS-based sceptic. Eleven Principles is not written to convert the sceptic so how would I pitch it to a sceptical doctor?
I imagine this doctor hurrying to meet me. Before we are sat down, she may say, “l have spent this morning saving lives and I don’t have time to be here, really, so this better be good. Then I need to get back to the real world”. There is much to de-construct here: what is health? what is ‘unreal’ about a chat with a non-clinician? how thoughtful are we about what we ‘have time for’? But I won’t ask those things. I will state my business quickly and practically, to get in to the conversation.
I need two things to convert my sceptic – a clear critique and a vision that is inclusive and inspiring.
The critique needs to grab the doctor’s attention. I think my critique says that doctors are incredible, but can sometimes care too much, and help too little. That they can be blinkered to others’ abilities and perspectives, the downsides of drugs and devices, and the taboo of death. As a result, people can choose to lead lives that they understand to be less healthy rather than miss out on things they profoundly value.
However, I will feel anxious in sharing that critique.
The alternative is to propose a separate, ‘social’ model of health, one that considers cultural, economic, and environmental factors rather than just disease. But I know how toothless that will seem to the doctor that has spent the morning “saving lives”. The pastiche of this is of someone in a white coat shouting, “I have the cure for cancer”, and their colleague replying, “Meh, I’m of the social model”. Every time we suggest that we are talking about something else, not disease and medicine, we lose our audience. It is tempting to argue that we need a ‘new language’ for creating health. We don’t – we need to speak plainly about what’s wrong and needs to change.
After my critique, I need to cheer them up with some kind of inclusive and inspiring vision. As a movement, we need a story in which doctors can see a richer version of their own vocation. We need to describe how a more open approach to health can create the support and space in which doctors can thrive and evolve into a better version of themselves. And as soon as possible, we need to show, not tell; to engage doctors in prototypical work, helping them feel the difference co-creation can make, enabling them to want to take some ownership.
Having made the vision inclusive we need to ensure it’s inspiring – but not dauntingly heroic. Many clinicians perform exceptionally because of their ability to focus and follow rules. They root out ambiguity and risk, and ignore extraneous details. That makes working with people to construct and pursue idiosyncratic notions of health exceptionally challenging. It may be tempting to blame these clinicians for being conservative, for holding progress back, but, at least from where I sit, we need a ‘big tent’ strategy, not a ‘pick sides’ one. This inclusive work is essential.
To ‘create health’ we need to take seriously the loyalty citizens and clinicians feel towards their existing health system, and health as it is traditionally understood. They will likely ignore us if we do not address them directly and plainly, and help them get excited about our vision. But if we can show how health and health systems might be dramatically better, we can create something very special, not just at the margins but in the mainstream.