As with its stratified medical professions the NHS used to have a securely established hierarchy of organisations. District Health Authorities came under Regional Health Authorities. General hospitals were higher than community or cottage hospitals but lower than their University Hospital counterparts. These hosted the main specialist clinical disciplines and their NHS education and research facilities. The prevailing concepts were those of bureaucracy, institution and profession: all large scale, leaving the small businesses of general practice and pharmacy on the bottom rungs of the NHS ladder.
Although still often a psychological reality for NHS staff, this organisational pecking order and its supporting concepts clearly apply far less than they once did in a modernised world that is increasingly characterised by the hybrid forms of multi-disciplinary clinical commissioning groups, integrated care trusts and central regulators. The concept of ‘health system’ has replaced terminologies rooted in the notion of health care as an environment populated by fixed point physical constructions and providers. The health system now increasingly embraces non-NHS agencies, and indeed the national Public Health research programme commissioned from Southampton explicitly excludes the funding of studies of NHS developments. And as the term ‘system’ itself moves on to become closer to the notion of holistic health ‘movements’ so the informal dimensions of systems are becoming recognised as increasingly important, alongside the formal attributes of administrative procedure, clinical and corporate governance and health management structures. And with this emerging concept come the new emphasis on Wellbeing and its defining organisational concept: ‘networks’.
Communities of Health Practice
The popular demand is for more NHS funding to be spent on its traditional formal agencies - acute hospitals; specialist surgery; accident and emergency departments and so on. Political decision makers struggle and sometimes despair; going much further beyond 40% of GDP on public expenditure is simply not sustainable. The investment has to come from elsewhere if there is to be a viable answer to escalating demand, especially from the ever growing number of older people and their long term ailments. Can the informal elements of the health system supply some solutions? Wellbeing shopping and service outlets are visibly advancing in the High Street. New immigrants often secure a toe hold in the economy with low cost offers of alternative therapies and complementary care. Personal trainers abound, as do the likes of nutritionists and arts practitioners now often produced by independent sector vocational training colleges and institutes, undercutting high fee charging public universities. Local authorities support their businesses in pursuit of both dynamic service based economies and expressions of their novel public health roles. Putting all these developments into a single trend suggests that new communities of health practice could be just around the corner.
Retirees to the rescue
With such new communities of practice will come many questions about the status quo; not least in relation to what should go into the offer from general medical practices in the future and where their surgeries should be located. On a more universal level the questions arising from an expansion in emergent informal networks of wellbeing will clearly be most pertinent in relation to older people. Given increased longevity and long term conditions, the response of retirees to the changing landscape is crucial. It may even decide the future viability of the NHS. The Holy Grail for central policymakers is a burgeoning informal wellbeing sector of networks socially constructed around the values of Sport and Exercise on the one hand and Soul and Mindfulness on the other: together they could relieve a substantial burden from the NHS.
Or they could add to the pressures. (Pilates can injure backs as well as ‘heal’ them after all.) So how can and should older people select their spiritual gurus and personal trainers; their choirs and cycling routes; their café meeting points and deli stores; their menu of therapists and their essential recipes and reading, becomes vital to identify and understand. Who, where and how are such networks of wellbeing mediated? Which promote health comprehensively from collective acts of prevention and rehabilitation to constant community based palliative care? When should statutory authorities, including the NHS, contribute without becoming counterproductive? When do faith and science come together to validate the networks with evidence?
Perhaps of these the last is both the most important but also the most difficult question. What is apparent is that the new Networks of Wellbeing as informal dimensions in more holistic health systems require research, and quickly.
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About the author
Geoffrey Meads is Professor of Health Sciences Research in the Health and Wellbeing Research Group at the University of Winchester. His main research interests are international developments in primary health care, with recent publications covering global innovations in community governance and frontline Wellness practices.