Developing Neighbourhoods – Community-Oriented Integrated Practice
Paul Thomas, in collaboration with the Journal of Holistic Healthcare & Primary Care Commissioning.
This blog can be seen as a video podcast at https://youtu.be/Hpn3WfZaRAQ
The UK government’s plan to develop out-of-hospital care through Neighbourhoods presents an opportunity for high-quality, low-cost care – through collaboration between health workers, care workers and everyday citizens. Achieving this at scale requires Community-Oriented Integrated Practice (COIP) – thinking and acting, in all parts of the system, to stimulate and facilitate collaboration for health and care.
There is a science to COIP. It sets familiar ‘top down’ control within processes of collaborative learning and coordinated change, that habitually, routinely, build trusted relationships across boundaries. ‘Vertically’ it facilitates communication between specialist & generalist practitioners, patients & Carers, to manage diseases. ‘Horizontally’, it builds multidisciplinary teams and local communities for health and care. For 40 years, COIN (Community-Oriented Integration Network) has been exploring this science, and how to practically apply it.
Practice means doing AND thinking. Behaviours and mindsets change over time (and need to change) in response to reflection on: a) Personal experience, b) What others say, and c) What text-books say. It is a learning process.
Community-oriented integration means coming together at local level. It can mean coming together with pre-defined outcomes – like railway lines. It can mean coming together in ways that allow creative things to happen – like a learning set where participants share experiences. Checkland calls these different kinds of integration hard and soft systems – ‘hard’ is pre-made, linear, predictable; ‘soft’ is co-created, non-linear, unpredictable. Both are needed. They reflect different ways of thinking. The need for both linear and co-creative ways of thinking is obvious – we need the Science AND the Art of Medicine, Quantitative AND Qualitative Research, Disciplined AND Creative Students. Not so obvious is how to integrate these very different understandings of the world, and how they can inform policy.
Integrating hard and soft ways of thinking challenges existing practice. The 1978 Alma Ata Declaration, signed by 134 countries, agreed that Health is everyone’s business, but, as John MacDonald points out, it doesn’t happen, because doctors have traditionally been trained in an engineering science. Doctors use ‘Hard’ thinking to estabish diagnoses. ‘Soft’ thinking is subordinate – used to deliver hard message in a soft way.
Better than considering ‘Soft’ thinking to be subordinate to ‘Hard’ thinking is to see that they provide different insights into everyday human, personal interaction, as we develop our life stories. The image below shows how to use both. Cycles of collaborative reflection and coordinated action allow people to repeatedly go under ‘umbrellas’ (shared developmental spaces) where they share personal experiences, listen to different kinds of evidence, and negotiate coordinated next steps. Over time this binds people together – comm-unity. It incrementally transforms the way people think – our cultures; our mindsets; our behaviours.
We all naturally go under ‘umbrellas’ of one kind or another. Every time we go on holiday, we do it. Neighbourhoods can highlight that this is a natural and desirable process. It helps those involved to understand and trust the processes whereby ‘I’ becomes ‘We’. For example, continuity of care can be a sequence of ‘umbrellas’ where a patient and doctor repeatedly meet to listen to each other, reflect on options and agree next steps. Team meetings can be a sequence of ‘umbrellas’ when those involved learn from and with each other, and agree shared plans. Friendships and partnerships of all kinds need sequences of umbrellas to sustain their relationships.
Neighbourhoods must find hopeful areas to try this, appropriate to their contexts; and develop skills and teams to make it work. They can point to theory, and success in other places. They can evaluate the effect of local collaboration on cost and quality.
The Spring 2024 Issue of the Journal of Holistic Healthcare (JHH) includes several papers that point to a successful approach. For example, Nigel Crisp (former NHS Chief Executive and author of Health is made at home; hospitals are for repairs) describes three successful national policies; he also highlights the difficult tension between “people attempting to see the whole picture & working together towards complex and related aims, and a transactional, consumerist approach to health”.
Future blogs will say more about reconciling these difficult tensions.
Further Resources:
COIN. www.youtube.com/@coin1562
Peter Checkland. Systems Thinking. Systems Practice
John MacDonald. Primary Health Care, Medicine In Its Place
Nigel Crisp. Policies to support compassionate communities (p5-8) https://bhma.org/product/many-ways-of-knowing/
Nigel Crisp. Health is made at home; hospitals are for repairs.