Each year we ask returning Harkness Fellows to share their learning from their time as a fellow. Mary Docherty offers an interesting link between personal and professional learning, articulating something many of us felt as we looked back on home from across the Atlantic. Mary is a Consultant Liaison Psychiatrist at South London and Maudsley NHS Foundation Trust.
The task ‘to share my learning as a Harkness Fellow’ feels a difficult one. I have a suspicion that the learning from this year doesn’t reveal itself to you immediately but rather gently creeps up over time. Three areas of connected observations do however come to mind: What I learnt about myself, what leaving my organisation and role and looking elsewhere led me to observe about the NHS and, what I found out during my study of integrated care.
I grew up in the NHS, literally. I can trace the last 40 years of its history through childhood memories. Weekends answering the phone for my father’s GP Practice and evenings spent playing with Lloyd George envelopes waiting for the surgery to end. The Home Service health policy broadcasts would punctuate the relative tranquillity of the school run culminating in a near collision with a roundabout circa. 1989 as Ken Clarke delivered his White Paper. In a family of doctors, the rhythm of our family life and how we lived were regulated by collective responsibilities to the NHS. It is an organisation I equate to family, to community and I fully partake in our Nation’s collective fantasy that the NHS is an omnipotent and benevolent being who will look after you come what may.
My Harkness Fellowship occurred at a time when, yet again, we are trying to change the shape and form of NHS provision. We are attempting to heave this omnipotent being forward away from its focus on reactive acute care towards prevention, population health and tackling the social determinants of health. The plan to achieve this is through a process of integration, which requires boundaries to be broken down or dismantled, and then rebuilt and transformed with networks and partnerships.
Fountain House in New York offers its members who all live with serious mental illness access to a community, friendship, employment, mental health care and support to look after their physical health. It is a gold standard example of what can be achieved when services are designed for and by the people that use them, rather than according to pre-existing structures that demarcate between the biological, psychological and social aspects of health.
“Transformation” was a theme of my year away. Not only in my research into integrated mental, physical and social care provision, but also personally. Despite hope and desire for transformation I went to America and ‘took myself with me’. My general neuroses and mild introversion inevitably accompanied me across the Atlantic. As well as being a personal lesson in acceptance this observation impressed on me the need to temper our endemic desire and fantasy for radical health service transformation with two realities. Firstly, whatever health reform we pursue we will be bringing ourselves along with us and this needs consideration in any transformation plan. Secondly, we and our predecessors have created the systems, processes, boundaries, and behaviours that characterise our health service. They have evolved for reasons, good or bad, and dismantling them will not be easy.
A year outside of the NHS affords new eyes to look back in, particularly at the values and norms through which we operate. An anxiety provoking encounter with a subway advert for Mount Sinai’s neurosurgical department brought home the inherent difference between our respective health care systems. The advert’s instruction to ‘Choose Mount Sinai’ implied catastrophic consequences of not making this choice. America has a health system that makes you wholly accountable for your health. It falls down if you lack the resources to make such a choice.
While briefly reassured that the trusting dependency I have on the NHS was well placed, a later encounter with their medical system, this time as a patient, caused me to think again. I had instant access to my medical investigations, genuine choice over potential courses of action and the explicit message in my physician’s communication that I was in control and empowered. This approach to care held some attraction but perhaps not so to the less informed, resourced or well. Wherever our choice falls, between an omnipotent benevolent system and one founded on the principles of personal accountability, it will involve a sacrifice. These value related tensions between autonomy and dependency are familiar conflicts and are at the core of many of our health and care systems’ challenges.
Acknowledging dependency is a critical part of transformation work and particularly so in efforts to integrate mental and physical health care. Change of any sort, none the least implementation of ambitious policies designed to reconfigure the boundaries on how we deliver healthcare, invoke hope and desire but also involve endings, loss and pain. There is a reason integrated models of mental and physical health care are so slow to get off the ground and spread; it is painstaking work. It requires professionals to change how they do things, to give up power, to acknowledge and embrace their dependency on other aspects of the health, care and social system.
Marana Health Centre in Arizona was one exemplar model of integrated care included in my study. It had fully integrated all services for patients with mental health conditions in a primary care setting, offering true parity of access to both physical and mental health care. This model arose through years of painstaking work by the senior management team and staff. Arizona had one of the highest excess mortality rates for serious mental illness in the USA. Their relentless ‘we should do therefore we can do attitude’ had moved staff and systems to deliver exceptional care and outcomes.
Many of these models of integrated care require new roles and ways of working. They require the flexibility and agility to respond holistically to patients in all their glorious complexity, rather than treating one aspect of their health so as not to be overwhelmed by the whole. It requires different clans with different languages, upbringings, cultures to work together and also, to acknowledge core professional differences in how we conceive of and respond to patients as autonomous and accountable, or dependant and vulnerable.
Mental health services have long assumed accountability in principle for their patients. Not always well done, but it is implicit in their care models. Historically mental health has been highly paternalistic involving various degrees of control, containment and care. Embedded in our culture, service structures and care processes are beliefs that it is our job to assertively engage a patient. We take on accountability for the patient turning up and relentlessly follow up until we are confident that no further input is indicated. Primary care has evolved differently, with less robust systems and capacity to follow through in event of non-attendance. There is of course huge practitioner and practice variation but broadly speaking, as a primary care patient you are deemed responsible and accountable for if and how you interact with this care.
These differences in professional cultures are not always detailed in literature nor explicitly tackled in current service redesign plans but were even more strikingly illuminated in the USA. The primary challenge to delivering integrated mental health and primary care in the USA is the absence of billing codes for these core activities; the chasing, the engaging and relentlessly following up of patients. It simply wasn’t ‘a thing’ in primary care and the awareness that perhaps it should be only came to the fore when people tried to build these integrated models. Pulling these disciplines together is not just about overcoming lack of office space and designing new roles and pathways. It is also about how to resolve fundamental splits in assuming responsibility for a patient’s health. In short, how we navigate this tightrope between dependency and autonomy.
I noted that the problem with desire for transformation is that inevitably, we have to bring ourselves along with us. We have to let go of systems, behaviours, boundaries and ultimately relationships and upbringings that have defined the how and what of our work. True transformation may be an illusion but as I have seen, integration is possible and it is usually painful. The task of managers, policy makers and reformers in creating supportive systems to manage this process of breaking down and building up could not be more important.