While the NHS is promised another £20 billion (which is still not enough, “health people” say), I listen every day on the radio to teachers, police, prison officers, social workers, local government councillors, community builders, lawyers, and others saying that their systems are on the point of collapse because of underfunding. How has it happened that “health” has become so dominant? I don’t have a complete answer, but my search leads me back to the thinking of my friend Pritpal S Tamber, who argues on his website that “Our approach to health is unsustainable…[and that]… healthcare needs to reconceive its relationship with the communities it serves. To do this, it must adopt an inclusive, participatory, and responsive approach.”
Pritt makes his case more clearly and in much greater depth than I can manage, but I tried recently after one of our many conversations to summarise his argument. Here’s my attempt. The start of the argument is familiar to me, but it evolves into something unfamiliar and disturbing—but which, nevertheless, I think is right.
- Health is not produced by hospitals and the health system. [This is indisputable, but not widely understood, and, as I’ve observed before, conversations about health quickly become about healthcare. We have mixed in our minds two entities that are different categories.]
- Social determinants (wealth, housing, education, middle-class power, etc) are the main determinant of health. Perhaps the most important determinant is “agency,” which philosophers and social scientists define as “the capacity to act.” [This too is indisputable, but Pritt qualifies what I wrote: “We have to remember that “social determinants” is the language of the health system, the powerful. I increasingly use “social circumstances” to intentionally force people to think about what it means and not default to some stock understanding of “social determinants”.]
- Health has been “expropriated” (Ivan Illich’s word) by the health system, which has wealth, power, knowledge, and methods and crucially “defines” what is health and how it should be measured.
- Some people funding and running healthcare systems recognise the impotence of the systems when it comes to health as opposed to treating sickness and the capacity of health systems to swallow resources while producing ever less “value.”
- They look for alternatives, and “communities,” particularly those of powerless people, the people with the poorest health, look like a good place to try to do better.
- So they try starting “community schemes.” They are not sure how to do it and often fail, but sometimes they succeed at least for a while—as in Mississippi, and Bromley-By-Bow. [Pritt points out that many, probably most, of the people starting community schemes are not from health, but more readily than health people understand the health consequences of social circumstances.]
- If they succeed, then they attract the attention of “public health professionals,” people who are really just agents of the healthcare system and who pedal the biomedical model, the idea that health is individual and measured mainly though biological metrics.
- With their power and their methods (agents of their power) they take over and either declare the scheme a failure (no reduction in hospital admissions or in blood pressure) or with their middle-class power destroy or disempower the scheme [They either, writes Pritt, use their knowledge and power to assume control, as Michel Foucault argues, or decide they know better, get involved, and hence rob communities of their agency—the one thing that was fundamental to their health and to them addressing the many issues they face.]
- A way to fight back might be to use their methods (statistics, qualitative methods, science, etc) to both deepen understanding of what makes community schemes flourish and provide evidence of their flourishing. [Perhaps, writes Pritt, but we who are doctors have to remember that there are many methods outside of health that already have legitimacy in this space. They’re just not well-known in health, and in our arrogance we tend to poo poo them. That’s usually because we consider them “soft,” although what they really are is “appropriate” to complex systems, which is what communities are.]
- But the fight back is doomed to fail because the power, the hegemony, of the “heath people” will prevail. The “health people” will arrive with their computers, statistics, journals, theories, knowledge, and inability to think beyond the biomedical model and take over. Middle class, university-based systems will dominate, as they always do.
Richard Smith was the editor of The BMJ until 2004.