Towards a healthier health system

Joining up futures thinking and a holistic view of health

By Stuart Candy A paper prepared for NHSU, London August 2004 Introduction Towards a more holistic understanding of health Towards a new way of running organisations The challenge Thinking about the future A deep challenge calls for a deep solution Joining ideas together: holistic health and healthy organisations Where to from here? Introduction In Britain today, there is an enormous amount of concern about the National Health Service and its ability to provide medical support to the millions of individuals who rely on it both for general health purposes as well as for treatment when things go wrong. Newspaper headlines frequently feature stories of the systems inadequacies and idiosyncrasies, and many of us have our own tales drawn from first-hand experience. Of course, it should come as no surprise that such a system attracts criticism, it being so large and important to the whole population particularly as the proportion of aged persons increases. Criticism is not only inevitable, but it is also to some extent a necessary part of a healthy health service. Any organisation founded on a democratic service ethic must accept the role of informed criticism to keep it relevant, efficient and honest. But there is a need to go further and deeper in this process of reflection, to revisit the foundation principles and structures of such systems from time to time, however complex and uncomfortable that may be, to look past the facts and figures of hospital beds and waiting lists, and ask whether the basics themselves are right, or if not, how they might be improved. In this article some very broad themes are laid out and drawn together. Due to the breadth of terrain and limitations of space, it is impossible to explore each in depth, or to offer detailed empirical support in every area. Accordingly, this paper does not aim to prove a thesis, but rather to extend an invitation to the reader: to think about health, and the systems that support it in Britain and other developed Western countries, in a somewhat different way from the ordinary. If by the end you have had pause to reflect on some of the major challenges at the heart of the health system, then the main aim will have been satisfied. Perhaps some will care to critique or elaborate aspects of the argument tentatively offered here. It is broadening the terms of debate

Towards a healthier health system -- Stuart Candy, NHSU -- August 2004

around the health system which is identified as the most important task for now, and to this end the paper is addressed. The starting point for this exploration is a consideration of the way in which our understanding of health is becoming wider. A second theme is a similar change around the conception of organisations, in how they are understood, structured and led, in order to be most effective at doing what they do. The third step is to examine the value of looking at these questions with a strategic futures orientation. It is suggested that all three of these processes are under way, and that they resonate with each other. But to acknowledge and connect these trends, and follow them towards their logical conclusion, entails a monumental task. We need to be prepared to reexamine the basis of our health system, and try to imagine one founded on a different way of thinking. This is the invitation, and a challenge to us all, but especially to an audience of health practitioners, administrators and educators. Towards a more holistic understanding of health It is becoming increasingly apparent in the Western medical establishment that the phenomenon of health is a great deal more complex than the scientific biomedical paradigm has generally allowed us to realise. Being truly healthy is not about merely ensuring that the body is free of ailments and discomfort, but actively exercising ones body and mind, being engaged, stimulated and happy about life in general. If health is more than bodily well-being, then medicine, hospitals and treatments are just the first of a vast fleet of factors with a bearing upon the futures of health. More and more of us now understand health as not merely a question of repairing individuals medical problems as they occur; we are seeing how individuals can be served by focusing on prevention of problems at a systematic level. The rising popularity of so-called alternative and complementary treatments therefore may be testimony not only to the growing cultural diversity of the British population, but perhaps also to a growing dissatisfaction with the tunnel vision of a narrow biomedical view of health, illness and medical treatment. Health in public discourse is traditionally understood, or at least administered, quite narrowly. As a field of policy, it lies alongside education, the environment, and other areas of governmental responsibility, as if they were separable ideas rather than interdependent aspects of life. Health is in fact still generally understood in majority culture as a question of medicine and treatment. This is the model of health around which Britains National Health Service was conceived in the wake of the Second World War. Prominent futures thinker and writer Ziauddin Sardar has commented on the cultural basis of the NHS. He writes:1
We understand medicine as modern Western medicine, which assumes there was nothing before the arrival of modern, scientific medicine; diseases, sickness, ill health and premature death were the norm before the emergence of the modern scientific miracle. It is therefore necessary to make a special effort to remind ourselves that what we call modern medicine is as old and venerable as 60 years, beginning with the development of penicillin.

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The basis of the NHS is a view of medicine and the body which comes from a Western European philosophy and way of knowing. For some centuries the rational, Cartesian tradition has been teaching us to accept, for instance, the notion that body and mind are divided, although it appears we may have led ourselves astray in this regard,2 and it is interesting that we persist in speaking of and treating mental health as a basically separable domain from bodily well-being. Yet our medical tradition is gradually awakening to the fact that human health has spiritual and emotional dimensions as well as the physical, bodily ones. The elementary, but very profound, psychosomatic phenomenon of the placebo effect is one sign of the power of the mind and emotional state behind bodily health, which cannot be ignored. Human health is a global ecology, embedded in and dependent upon the state of the planet as a whole and how we treat it. Linguistic, cultural, medical and political conventions may make this easy to overlook on a day-to-day basis, but it is a scientific fact which fits with our emerging understandings and experience of an increasingly globalised world. Recent health scandals are merely the tip of an iceberg, a dawning realisation slowly being assimilated into our cultures understanding, of the convolutedness and fragility of our systems of food production and distribution: mad cow disease, foot-andmouth, and the genetically modified organisms debate are three major examples. Health can clearly not be realistically pursued on a purely medical, case-bycase basis, as can be seen by examining the collective or community context for individuals decisions. In a bestselling self-help book on weight loss, Dr Dean Ornish highlights how overeating in America is partly attributable to social changes which have left more people lonely and dissatisfied with their lives.3
[A] hundred years ago more people in this country had a sense of community and connection. They were born, raised, lived, loved, worked, played and died in the same place. They had the same neighbors and their children went to the same schools. They attended the same churches and synagogues. They often held the same job for many years, and people at work knew each other. They lived in communities in which people knew they needed each other. These social networks protect us from isolation, illness, and premature death. A sense of community and connection can directly address and help heal the emotional and physical pain of isolation. [] People who feel socially isolated have two to five times the incidence of disease and premature death due to all causes as those who feel a sense of community and connection.

This analysis, which relates directly to the hotly debated obesity epidemic, goes a step beyond the preoccupation with what people are eating, to ask why are people eating the things they eat, in the way they do? There are layers of explanation here, and a holistic understanding of health considers these underlying factors as essential. There are encouraging signs in Britain that the reductionist biomedical view of health is now being tempered by a broader, more holistic view, even at the heart of the medical establishment. In the June 2004 document The NHS Improvement Plan: Putting People at the Heart of Public Services, several
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references are made, notably in Chapter 4, to transforming the NHS from a sickness service to a health service.4 Increasing public attention is being devoted to lifestyle choices which affect health, such as reducing smoking and the incidence of obesity. This is a step in the right direction from the perspective of those who regard supporting health as a question of nurturing an ecology of human and other elements, rather than as an exercise in troubleshooting illnesses, case by case. If our idea of health is growing to include prevention as well as cure, this is a promising development, but it is neither a radical nor complete transformation. We remain a long way from implementing this holistic understanding of health, and confronting its consequences head on. Indeed it can be argued that at base the focus on sickness remains, but the emphasis is simply moving further back in the causal chain; in other words, stopping people from crossing the threshold where they cannot properly function without medical assistance. This is certainly a part of maintaining good health, but who really believes that its the whole story? If health consists in more than the treatment of disease, it is also surely more than prevention. The absence of physical malady remains the focus, and a rather uninspiring criterion of health. A broad view is also necessary broad in the geographic sense. In contrast, the February 2004 report by Derek Wanless, entitled Securing Good Health for the Whole Population (also known simply as the Wanless Report) notes that its predecessor document Securing Our Future Health was based on first catching up, and then keeping up with other developed countries, which had moved ahead of us over recent decades.5 National competition as a motivation for providing a functioning health service is a rather curious idea, appearing to imply that the aim of an English health system is simply to ensure that the English enjoy better health than everyone else. Even if this were possible, which is open to doubt, this approach speaks of a view of health not as a value in itself, but as a consumer good, and the health agenda of government begins to bear an alarming resemblance to the corporation that vies with its competitors to make better widgets. Health issues and services need to be understood as being geographically broader in reach than the areas which governments have a mandate to rule. Ultimately the health of those in England the composition of which is changing all the time is tied to the health of its neighbours, near and far. An approach to health that stops at the border would be highly vulnerable to a single virus from outside the control area, which in view of the massive amount of traffic to and from all corners of the globe, for migration, business and leisure purposes, is not at all difficult to imagine. (Take for example SARS, which is clearly not just a problem for the countries where it first broke out, but a problem for us all to face.) Higher walls are not a viable solution here; but broader horizons may well be part of it. Therefore, the process may be gradual, and qualified by anomalies belonging to a disappearing era, but science is reaching toward a more holistic understanding of health, and the health system and popular conceptions are following suit. This broadened understanding of health is clearly reinforced in other areas, as people think about the world and approach problems they
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encounter within it in the light of an increasing awareness of the interconnectedness of individuals and the issues they face. As Elisabet Sahtouris has observed, First and foremost, we must recognize globalization as a biological process something that is happening to a natural living system we call humanity.6 Such relatively recent intellectual developments as the study of ecology and systems theory have provided powerful new perspectives on the world, which look simultaneously to the wholes of things as well as the parts, and the links between them. The Gaia hypothesis, proposed by James Lovelock in a highly influential 1979 book, proposed a view of the world as a self-regulating planetary ecosystem.7 In recent years, a heightened awareness of the globalisation process in regard to economics and communications, and the understanding of networks that is both demanded and enabled by those technological drivers, have helped to reinforce the application of interconnected, systemic thinking to social phenomena. The next section shall examine how these impulses are echoed by the changes in our understanding of organisations, where a similar awakening appears to be underway. Towards a new way of running organisations Every organisation faces challenges posed by change both within and without. In any given domain, these challenges seem to grow more numerous, complex and rapid even as we watch. In an industrial era dominated by mechanistic logic, it seemed sensible to see people as cogs in an organisational machine. The constituent parts, individuals, were basically replaceable, and valued less for their personal attributes than for their role narrowly defined in keeping the whole operation running smoothly. However, the fact that organisations now face constant change to which they must adapt in order to survive, has brought a corresponding change in our understanding of what they are and how they behave. Instead of seeing organisations as being like machines, robotic devices whose purposes and methods are fixed and stable, we have begun to see how they operate as communities; as organisms. We have started to incorporate complex biological and social factors into our understanding of peoples collective endeavours, and the mechanistic corporate entity is now all but extinct. This shift has obviously begun to affect how organisations are managed and led. A less mechanistic, more biological model and metaphor suggests that success is not a question of self-contained function as for a machine. Instead, success is closely connected with the environment in which the organisation operates, and can be seen as the product of a good fit between an organisation and its environment. This fit is achieved and maintained through a sort of organisational evolution. Learning is essential to organisational evolution, the way adaptation genetic and behavioural is the key to survival in the natural world. In human affairs, the key to this type of evolution or adaptation is not genetic but memetic; cultural. Responsiveness to change is the common element, and in a word, it is accomplished through learning. To gain new insights and understandings, and to produce new patterns of behaviour on a sustained and organisation-wide basis, all depend upon learning taking place continually. What kind of learning is necessary will
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accordingly vary with the goals and contexts of organisations. The learning skills which enable adaptability are the key to an organisation remaining viable over time. However, with fewer competitive pressures in public sector organisations, this trend appears to be proceeding much more slowly there than among than their private sector counterparts. Leadership in this context is less about maintaining control and more about creating conditions for semi-autonomous development of organisations and individuals within them. No longer do we seek to create a perfect machine from the perfect components, because once-and-for-all perfection is no longer ideal: Gone is the need for an autocratic leader who makes every decision, then establishes rules and regulations for carrying them out. Instead, all parties within the organisation need to operate in a culture that is open to and encourages innovation and change, provided they base all decisions on sound, agreed-upon core principles and vision.8 A large body of literature has grown around the concept of the learning organisation (popularised by Peter Senge9) which refers to a corporate culture that values and enables continuous improvement. This has been intensively discussed and theorised in light of the imperative for constant adaptation to survive and thrive in fast-changing times. What is intriguing, however, is that this idea has been enthusiastically embraced for reasons not directly or obviously related to learning. The online discussion group Learning-org features a collage of reasons collected from various people for their advocacy and support of the learning organisation concept.10 Although many note the competitive and business advantages conferred by the approach, just as many people make mention of passion for learning, spirit, humanity, improvement of peoples working lives, and similar factors. The participatory and creative aspects of the learning organisation, it seems, are welcomed as an antidote to the weaknesses of the traditional alternative, what might conveniently be described as a mechanistic organisation. The enormous popularity of the learning organisation idea exemplifies a shift in thinking, away from viewing people as instrumental to the ends of the organisation and its management, and towards holism, with the interests including the interior lives (intellectual, emotional, spiritual) of people working and living within it. Indeed, in management and organisational theory literature, there is an abundance of alternative organisational models floating around which have been devised to fill this gap in the traditional conception, seizing this latent or hoped-for dimension of the learning organisation to take it further: the ecological organisation11, the conscious organisation12, the living organisation13, the inquiring organisation14, and most appropriately in the health context, the healing organisation15. This last idea, the healing organisation (an idea to which we shall return) is conceived by futurist Sohail Inayatullah as the missing other half of the learning organisation. It attempts to engage with the crisis of the postmodern employee, concerning what is lacking in the mechanistic organisation, and also in the learning organisation, which deals largely with the intellectual dimension. For workers, being a part of this would mean having meaning in their lives and working in organizations that sustain life,
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heal self, others, and the planet the emotional dimension of working and living.16 This model, like the others mentioned, proposes a new type of organisation to which we might aspire to belong, whose endeavours would take account of human dimensions unknown to or unwelcome in the mechanistic organisation. There are resemblances between the changes occurring in the way health is viewed, and the way organisations are understood and managed. The old organisational management model and the biomedical paradigm of health spring from the same mechanistic understanding of the world. There is the expert doctor who examines, diagnoses and prescribes treatment for bodily ills; and there is the expert manager whose leadership is based on engineering correct solutions. In both cases power is highly concentrated in the hands of one party, while the other (patient or employee) submits. The success or otherwise of the intervention depends almost entirely on the subtlety, sensitivity, knowledge and good fortune of the individual concerned, since the actual contribution of the patient or employee is in this way of thinking largely disregarded. The more holistic and organic understandings of health, and of what organisations (including communities and governments) are all about, are reaching towards the same fundamental insights. They are redressing an imbalance inherent to a rational worldview that has long denied, in the public sphere at least, a place for the spiritual and emotional dimensions of experience. Inayatullah writes:
For those who study macrohistory, the grand patterns of change, this is not surprising. Modernity has brought the nation-state, stunning technology, material progress but the pendulum has shifted so far toward sensate civilization that it would be surprising if the spiritual as a foundational civilizational perspective did not return.17

Related processes can be seen elsewhere in the arena of public debate, I think, in the emergence of the corporate social responsibility movement, the globalisation protests which in recent years have highlighted concern over the deleterious effects of businesses seen as acting exclusively in the interest of profit, and the success of ethical investment funds and companies with socially and environmentally aware agendas, such as Fair Trade and the Body Shop. The recognition of the interconnectedness of problems is beginning to appear even in very traditional and conservative domains, such as parliamentary politics. The idea of providing joined up solutions for joined up problems which has characterised the idiom of Britains Labour government18 appears to draw on this perspective, albeit in a way that is so far largely confined to political rhetoric. The elements and ramifications of this gradual shift comprise far too large a topic to be discussed properly here. However, if this is a plausible characterisation of how a change in worldview may presently be underway, it contains a great challenge for us all.

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The challenge The British healthcare system is over half a century old, over which period most of the change in mindset discussed so far in this paper has come about. Ziauddin Sardar has pointed out how worldview is embedded in social institutions, including health systems:
How we enjoy life, what we think of our bodies and how we treat them, how we shape our environmentall this is governed by our worldview. [] There is thus a direct relationship between worldview and health. By promoting certain life-styles and producing an environment within which these life-styles can flourish, worldviews determine the state of health of individuals and societies. But worldviews also form the matrix of health care systems.19

What basis is there, then, for believing that a healthcare system rooted in the worldview of another era can be changed modestly and incrementally to arrive, fully functioning, in a different one altogether? Its not unlike trying to ride a bicycle across a lake with the ill-founded confidence that there wont be any problems because it worked so well on the road. We can see that systems spring from the worldviews which underpin them. But most of the efforts to reform the NHS have nothing to do with this deeper understanding of what health is: they miss the point entirely, and to that extent leave entrenched ideas that we know to be increasingly outmoded and irrelevant. In terms of how we understand our bodies (health) and our collective endeavours (organisations), our worldview is changing quite quickly but the system is not. Meanwhile, our society is unwell. A health system that focuses on illness, whether prevention or cure, misses the point if it fails to address its context, namely a culture which values the growth of economic activity above all else. Somewhere in our past, the ideal of becoming healthy, wealthy and wise that triumvirate of perennial values became hopelessly lopsided. Health and wisdom fell by the wayside. Unhealthy behaviours are unlikely to change unless we work on their root causes, and rethinking the health system around a positive commitment to health, personal and collective, bodily and spiritual, is a way to deal with root causes. Thats the challenge. Indeed, the emergence of a multicultural, pluralistic society raises the obligation to accept and engage other worldviews, including other cultures systems of medicine, as equal partners. Currently, as Sardar points out, nonWestern medicines are still marginalised and labelled alternative, complementary and traditional systems. Non-Western traditions (Islamic, Chinese, Ayurvedic) are generally way ahead of Western scientific medicine in their recognition of the complex processes involved in illness, and their nonphysical aspects. He continues:
As traditions, the diversity of systems of medicine can learn from each other, interact with each other, and cooperate with each other. Medicine then becomes a model of how a multicultural society operates as an ongoing dialogue of values among citizens sharing equal responsibility for improving the well-being of society.
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This ability to consider divergent ways of looking at health and medicine requires the same kind of effort to critique our cultural biases at arms length. But where, practically, does all this leave us? What tools do we have at our disposal to meet such a challenge, and how can we be sure that this fundamental rethink is a good idea? The approach offered by futures studies to this problem will be considered in the light of earlier analysis, and a possible way forward sketched out. Thinking about the future People often have a very vague sense of their futures, both individually and collectively. It is nothing new to remark that our experience of life and the pace of change itself are quickening, and it is clear that increasingly rapid change is highly challenging to our sense of order and stability. As a result it is not uncommon to encounter the view that the future is beyond anyones control or knowledge: que sera, sera. In this fatalistic view, the future is regarded in much the same way as some have described history just one damn thing after another, to be weathered as best one can. Another attitude, perhaps more optimistic but no less mistaken, is to hope that the stubborn uncertainties of the future can be overcome with clairvoyant techniques either low-tech (the crystal-balls-and-tea-leaves variety) or high-tech (such as computer modelling). Yet both the blind hope for the best attitude and the follies of prediction leave much to be desired as ways to deal with uncertainty. First, outside of a few very confined areas (such as meteorology) prediction demonstrably does not work as a strategy of future orientation; the more complex and further out in time the domain in question, the more obvious this becomes. Second, in both approaches the issue is taken to be what will happen, which implies that there is a future which is certain, in advance, and cannot be changed or influenced for the good. They are two different ways of thinking, in that one says the future cant be known, while the other insists it can. However, at one level they share the mistaken assumption that the future is fixed. An alternative stance is seen in the academic pursuit of futures studies, which is committed to anticipating and articulating a range of potential futures (hence the plural). It is accepted that the way things unfold is in some regards essentially unpredictable, at a highly detailed level for example, and in largescale discontinuities which could occur at any time (wild cards) but futures meets the challenge of producing useful information about the patterns, forms and causes of change processes. This emerges in the shape of possible, probable and preferable futures. Futures studies is about learning to live with uncertainty, and can help us to turn our minds from the fait accompli to the yet-to-be. It reveals in the unpredictable an opportunity to take action, through making use of the multiple possibilities which are the obverse of unpredictability. It also helps to manage apparently intractable problems by alleviating short-termism, the reflex of perceiving things in an urgent, immediate timeframe. As one futurist thinker has remarked, There are problems that are impossible if you think about them in two-year terms which everyone does but theyre easy if you think in fifty-year terms.20
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Futures studies is thus an empowering domain concerned with increasing understanding and improving the wisdom of choices, and its underlying goal is to help identify how concrete outcomes can be constructively influenced via thoughtful intervention. One definition describes it as:21
A transdisciplinary, systems-science based approach to analyzing patterns of change in the past; identifying trends of change in the present; and extrapolating alternative scenarios of possible change in the future, in order to help people create the futures they most desire.

How is it used though? The September 2001 publication by what is now the Prime Ministers Strategy Unit provides an outline of some of the most common tools used by futurists to explore possible, probable and preferable futures. These include Delphi surveys (involving an iterative process of expert consultation on future issues), qualitative and quantitative trend analysis, scenario planning and analysis, and visioning exercises.22 The tools provided by futures studies can be applied to many different problems at almost any level. Another report from the same organisation, dealing with best practice in futures, states: The turbulence which strategic futures work seeks to master can be about any sort of organisation or external change, whether market conditions or a newly elected mandate.23 Whether the context is an automobile company attempting to improve its grasp on changes in the market for its products, a national government seeking to formulate a new policy on smoking in public places, or a university administration hoping to reform its curriculum to meet the emerging learning needs of undergraduates, futures techniques can be put into play. This is important because the use of futures tools does not dictate an agenda. In my view, the adoption of a strategic forward view is naturally conducive to values such as sustainability, ecological protection, and accountability; these become more apparent the further into the future one is working. Historian of technology Paul Saffo has said, The first thing you learn in forecasting is the longer view you take, the more is in your self-interest. Seemingly altruistic acts are not altruistic if you take a long enough view. In the long run saving yourself means saving the whole world.24 However, these are meta-tools for approaching the understanding of change and can be used to advance virtually any agenda; and the most common applications are indeed shorter term and quite instrumental. Futures techniques have been adopted at various times in the discussion of British health issues. For example, the technique of scenario building, one of the most popular techniques in the futurists methodological repertoire, is central to the Wanless Report. One writer neatly sums up its purpose: You dont plan for a single certain future but rather for multiple possible futures, each based on a different theory of whats really going on.25 Scenarios instil flexibility towards the future and exemplify a commitment to the notion of

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multiple possible outcomes, and in principle, strategic intervention can help to nudge affairs towards the most desirable of those possible outcomes. The Wanless Report discusses the steps necessary to achieve a fully engaged health scenario for 2022, which is articulated in the 2001 interim report, Securing Our Future Health: Taking a Long-Term View and nominated as a preferred future.26 The other two, less attractive scenarios of the health landscape twenty years hence are labelled slow uptake and solid progress. This is a good example of the conventional use of a futures method to illuminate (not eliminate!) uncertainty about how things might unfold. The preferred, fully engaged scenario refers to a population of individuals fully engaged with the responsibilities involved in looking after their own health, driven by the provision of health information. Consequently, in this hypothetical 2022, there has been a sharp decline in health risk factors such as smoking and obesity, and other benefits including decreased acute ill health among the elderly and higher overall life expectancy. This provides a vision to work towards, and it is a picture of the existing system working better than it currently does. Turning to another example; rather than using scenarios, the Kings Fund report The Future of the NHS published in January 2002 simply discusses three major problems identified for urgent attention within the service overpoliticisation, excessive centralisation, and lack of responsiveness. It is interesting that a document which explicitly seeks to provide a framework for debate about the future of the NHS does not make the framework of the NHS itself part of the debate. It deals with political and structural concerns of the NHS as a bureaucracy, which are of course extremely important challenges, but they are less to do with addressing underlying health issues, and more to do with oiling an ailing juggernaut. Both examples illustrate a typical future orientation, which unfortunately engages less deeply with the underlying ills of the health service than they might. There is in fact a specialised area of futures practice called health futures, which represents the application of various futures tools to the arenas of health and health care.27 Health futures imports a broad conception of health, and there is a valuable distinction to be made between this and the narrower domain dealing with the technologies and structures of Western medicine:28
Medical futurism deals with the institutions and professions that comprise what is sometimes referred to as the medical-industrial complex Health futurism also encompasses the subject of healthy public policy, exploring what policies might be developed if health were a prime determinant of official decision making. The value of health futures stems largely from its ability to take people beyond their mistaken preoccupation with medical care, to an examination of the real determinants of future health. It also serves to focus our attention on human and ecological ends rather than on the economic and technological means that dominate medical futurism.

Perhaps this can help us to restate the problem: for a long time we have seen health as being about medicine, and the health system about curing illness. A
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purely technological and institutional approach to the issues is too narrow to get to what health is really all about, although much of the work that appears to be about the futures of health is in fact caught up in the narrower medical conception of health. This shows how, notwithstanding the incorporation of a futures orientation and techniques it is possible for foundational questions and assumptions to remain more or less untouched. Neither future orientation generally, nor the use of futures tools specifically guarantees that the approach being taken, or the goals guiding the process are the best or most desirable that they could be. The point is, although in Britain we are looking at and thinking about the future(s) of certain aspects of health, this does not mean that in each case we are addressing the real underlying problem. There is however a possibility and a powerful but latent need to use futures to engage in a fundamental reconsideration of what health is, and how it could be dealt with differently, from a governmental and organisational point of view. A deep challenge calls for a deep solution Futures is not a monolithic or undifferentiated enterprise, and it is vital to distinguish between different kinds of futures work, from the purely facilitative at one end of the spectrum, to quite visionary and transformative work at the other end; the latter challenging both the existing agenda and the underlying assumptions on which it is based. It is this which I suggest is needed to make a real difference to the health system, but it is the former which tends to prevail for the time being. Futures studies can in fact be put to its most powerful use not merely as a way to carry out current agendas more effectively, but as a way to re-conceptualise and transform those agendas. The transformation at issue here has profound implications for both the health system and the organisational and governmental context of which it is part. Richard Slaughter, probably the key theorist in academic futures today, has written extensively of the need for critical futures which deal with the fundamental assumptions and priorities in our culture.
The best (ie. most positively useful) critique operates self-consciously out of these deeper layers of Critical Futures work. That is, the writer or speaker functions as a human agent who is fully conscious of his/her immersion in, and debt to, particular sets of cultural resources. [] Futures work that avoids this engagement may function as a diversion, as entertainment, but is otherwise largely without value. It misses the main game and is not to be taken seriously.

This deeper approach to designing futures may help us more effectively to approach the task of reforming institutional and governmental efforts to embed health in society. Lets take an example. There is a futures technique available which helps to clarify this point, called Causal Layered Analysis.29 This approach identifies four layers, which are qualitatively different and describe problems, and their solutions, as being located at these different levels. The first layer, and the

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most obvious at first glance, is the litany, which consists of quantitative trends and problems, often in news reports, appearing as a sequence of discontinuous concerns. Beneath this is the layer of social causes, including economic, cultural, political and historical factors. The third layer is described as structures and the discourse or worldview which supports them. The fourth, and deepest layer that can be subjected to analysis, is that of metaphor or myth, which deals with deep stories and collective archetypes: in other words, the very basis of culture. It is the deeper layers that we must consider in identifying whats awry in the present circumstances. If a changing view of health is part of a changing worldview, then incremental adjustments to a system founded in the old view are unlikely to suffice. Systems theory, on which futures is partly based, can offer a direct insight into why change in this case must occur at the foundations. Donella Meadows, one of the authors of The Club of Romes 1972 report The Limits to Growth, once wrote a short introduction to the levels at which one can intervene in a system. The least effective level of intervention is labelled numbers, or in systems parlance, parameters.30
The amount of land we set aside for conservation. The minimum wage. How much we spend on AIDS research or Stealth bombers. The service charge the bank extracts from your account. All these are numbers, adjustments to faucets. So, by the way, is firing people and getting new ones. Putting different hands on the faucets may change the rate at which they turn, but if they're the same old faucets, plumbed into the same system, turned according to the same information and rules and goals, the system isn't going to change much. [] Numbers are last on my list of leverage points. Diddling with details, arranging the deck chairs on the Titanic. Probably ninety-five percent of our attention goes to numbers, but there's not a lot of power in them.they RARELY CHANGE BEHAVIOR.

Funding levels, managerial changes, incidence of administrative error, distribution of staff and other resources: they are not the stuff of real change. And yet these are the usual preoccupations of health reform. Several levels further up, we find the goals of the system, which is a considerably larger leverage point. It could be argued that adopting the goal of people taking greater care of their own health needs, described in the preferred Wanless scenario, represents a change at this level. But it leaves the most significant leverage point: the mindset or paradigm out of which the system arises:31
The shared idea in the minds of society, the great unstated assumptions unstated because unnecessary to state; everyone knows themconstitute that society's deepest set of beliefs about how the world works. [] Paradigms are the sources of systems. From them come goals, information flows, feedbacks, stocks, flows.

It is this level which is in the process of changing: the basic view of what constitutes health. It is this level which is in greatest need of attention if our health problems are going to improve.

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The key level of worldview, mindset or paradigm described by Meadows, loosely corresponds to the third and fourth levels of analysis in the Causal Layered Analysis model. These are the layers that need to be addressed to make a real difference. Joining ideas together: holistic health and healthy organisations We have considered in turn three sets of ideas. The first is that the concept of health in our society is coming to be regarded more holistically, and less in the instrumental terms of biomedical science, technologies and techniques. The second is that the conception of what organisations are, and what they do, has (like health) become less mechanistic and more organic in recent times. The third idea raised here is that futures studies can provide a valuable set of tools in empowering todays decision-makers, but that to take up the challenge extended by changes in the other two areas, we must find transformative ways of taking action which go beyond merely facilitating existing agendas. How do these three ideas come together? Each is a key aspect of the question at hand. We are interested in improving the organisation infrastructure (including governance) that supports health for the future in Great Britain. I believe that the trends in thinking about health and organisations are urging us toward much greater changes than we have so far prepared ourselves for, and that preparing ourselves to undertake transformative futures work can help us to understand and design the deep changes required. Health is at the centre of this whole topic, the conceptual foundation on which all else rests. There is considerable evidence, which it has been possible to consider only very briefly in this paper, that this understanding is undergoing an important change, and that consequently a thorough examination of how health is provided for may lead to some very significant reforms. There are basically two reasons why health is key driver here. The first is because, holistically understood, almost everything has a bearing upon health. The second is because of its paramount importance as a value in our lives, as an end in itself. Lets look at these in turn. Firstly, health is distributed. The determinants of health can be seen as a series of concentric circles, with the individuals personal profile of age, sex and hereditary factors in the centre, encircled by (moving outwards):32 - individual lifestyle factors; - social and community factors; - living and working conditions; and finally - general socioeconomic, cultural and environmental conditions. If we face the fact that holistic health is not what the current system is all about, then thats the level at which the current system needs to be reconstructed. Having accepted the range of factors bearing upon health, the notion of a discrete health service itself begins to appear rather absurd. Such an arrangement is inevitably a sickness service. On the other hand, if virtually everything helps to determine health, then surely the conditions of health need to be built into virtually everything. A holistic view, if truly absorbed into our way of doing things, would mean a transformation in
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priorities at every level: governments, communities and organisations both public and private. Health in this broader sense ought to be regarded as central and essential to the enterprise of governance. Ideally, health would be a natural output of the system as a whole, rather than a tacked-on service, a pitstop for human bodies in poor shape. Secondly, health is a key value. Today there is a yawning gap between the priorities we espouse privately as individuals and those pursued in our behalf publicly and collectively by our representatives in government. When houses, furniture, cars, and other assorted possessions the trappings of modern life and the symbols of success defined in economic terms are lost in a crisis (flood, fire, earthquake, war) it becomes obvious what really matters to people: at least I still have my health, my family and friends. While there may seem something rather platitudinous and Forrest Gump-like about this, it would take a hard heart indeed to deny that health a long and rewarding life in the company of those nearest and dearest to us is ultimately, for most people, their major priority. Health and community are the essential things to which we return when the trappings of the lifestyle recommended by homo economicus fail us. We can confidently state that health is crucial to what both individuals and communities are all about. It is a far more subtle, significant, and indeed inspiring goal to pursue than maximising GDP.33 Inayatullah has written:
If strategy has defined business and nation the last five hundred years, there is emerging evidence that it will be health and healing that will define us for the next five hundred. Along with the triple bottom line of people, planet and prosperity, perhaps health is the fourth dimension, or even more likely, that which supports the entire enterprise.34

Difficult though it may be to measure its more esoteric aspects, health could, and perhaps should be considered as the paramount goal of government; certainly it carries more legitimacy than a purely economic index, because good health presupposes sufficient wealth, evenly enough distributed such that all can benefit. In this sense it is a better, more evolved criterion of social development. In sum, then, the discrepancy between public and private values highlights a need to place health more centrally on the agenda, and the fact that health impacts are distributed across a range of other areas conventionally regarded as separate and administered separately by government needs to be addressed. Health should be made a central consideration in the setting of policy and the evaluation of progress of governments how this can be measured is a key question for another occasion. From healthy organisations to healthy communities and a distributed health system Although we have discussed paradigms as being the key leverage point, the central issue from which all else flows, we cannot legislate new ways of thinking into existence. And even were that possible, it would still be

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necessary to change our concrete institutions and practices. What we can do is try to develop our organisations and modes of governance in accordance with the holistic view of health. We can try to imagine a health system that reflects and embodies this way of regarding health, which as we can now see, has many faces. Attaining it is not about maintaining a series of individuals who arent sick, like a fleet of functioning vehicles. The group (collective, organisational, community, social) aspects of health need to be addressed. However it is important to note that, lest it be misunderstood, the tenor of this call is not entirely critical. Implied in the task of rigorously critiquing how things are is the even more important job of imagining how they could be done better. Critique and vision, then, are simply two sides of the same coin. What kind of futures can we envision? If one way to begin to change things is through modification of organisations and their priorities, lets revisit the notional organisations discussed earlier. Although, as suggested above, there are certainly philosophical overlaps between the various ideas on offer, the one which most clearly resonates with the task at hand is the healing organisation. This (so far hypothetical) entity takes seriously that there is an inner dimension and external dimension to organizational efficacy.35 This is not a concept that has been comprehensively expounded to date, but it helps to crystallise the holistic conception of health as applied to the practical task of running a company or other organisation. On this question, Ornish adds:36
[T]ransforming and transcending isolation is the essence of real healing. Even the word heal derives from the same Indo-European root as to make whole and to become holy. Social support is only one of many approaches that can help you begin healing the pain of isolation.

Instead of healing organisations, we might talk about healthy organisations, by analogy with the established movements for healthy communities and healthy cities. What, we might wonder, would a distributed health system look like? It is in these ideas that some preferable futures for our health system might be sought out. The notion of a healthy community tries to meet the challenge of making health the central idea, and distributing it throughout everything the community does. One commentator, Joe Flower, describes the concept particularly well:37
Somewhere, you've experienced it - a community that nurtures its members, that makes us all more than we were. But what makes a community healthy? What builds health, it turns out, also builds community, safety, wealth, and families. The health of a community grows from how many children people have, in what kind of families, with how much money and education, from a sense of choice, and from friends and family who give life meaning, from clean water and air, and basic medicine, from families who eat well, are well housed, secure from crime, and not deranged by drugs or alcohol. Building a healthy community requires all the energy the community can muster, from everyone who can make a difference - but it can be done. There are ways to do it. This powerful idea has taken hold in over a thousand cities and towns around the world. This is how to build a world that works.

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This is not merely an idea, but a movement towards empowerment of groups of people and establishment of health on that basis the basis of community that has been in action for some time. The movement for healthy communities, or in the urban context healthy cities, has gained particular currency across Europe and North America since the mid-1980s. The World Health Organizations European Health Cities program has now been operating for over 15 years:38
Health is everybody's business and most statutory and non-statutory sectors have a role to play in health development. Modern public health calls for comprehensive and systematic efforts that address health inequalities and urban poverty; the needs of vulnerable groups; the social, economic and environmental root causes of ill health and the positioning of health considerations in the centre of economic, regeneration and urban development efforts.

It is tied to a recognition that the health of individuals and that of collectives are directly related, and can be favourably influenced by appropriate action at the local level. Such action emphasises but is by no means confined to local government. It is intriguing to note that an awareness of the role of urban environment in maintaining health has been present for much longer than this. In 1875, the English physician Benjamin Ward Richardson gave a presentation to the Social Science Association meeting in Brighton, called Hygeia: City of Health.39 Richardsons conception of an ideally healthy city recognised and proposed to address directly the environmental aspects of health. The questions at issue were, in his words:
What are the conditions which lead to the pain and penalty of disease; what the means for the removal of those conditions when they are discovered? What are the most ready and convincing methods of making known to the uninformed the facts: that many of the conditions are under our control; that neither mental serenity nor mental development can exist with an unhealthy animal organisation; that poverty is the shadow of disease, and wealth the shadow of health?

Substantially similar ideas are embodied in the healthy communities movement, and indeed Wards paper served in part as inspiration for that development.40 It is intriguing that nearly 130 years later, we are still beginning to address the same questions about the environmental factors behind morbidity and mortality, and strategically building the broader determinants of health into our societies and living spaces. The notion of community health, as opposed to individual health, is an idea which offers great potential, but as Sahtouris suggests, this way of thinking has only recently become possible again:41
Words such as community and communal values were consciously or unconsciously suppressed in our culture during the Cold War because of their linguistic similarity to communism. We have, in fact, suffered greatly from

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their absence. The big question is whether we can restore community and communal values to our globalization process before all is lost.

The notion of healthy communities is connected to this kind of thinking, encouraging people to solve their own health challenges locally, from the grassroots up. Where to from here? It does not seem appropriate to offer a conclusion here: the thoughts offered in this paper intentionally lead to further exploration rather than resolution. But in which direction? Let us revisit the main points. I remarked at the outset of this article that criticism is a necessary part of a healthy health service. But at the level at which such criticism or reflection is pitched makes all the difference. To complain about waiting lists, access to services, treatments, budgetsthis is one kind of criticism, and it is legitimate for people to feel hard done by when there is a failure to deliver in these areas. But these are the outputs of the system, the numbers we experience but they are not the source of the real problems, as Meadows argument implies, and they will not therefore lead us to real solutions. They are part of a superficial litany of complaints relating to the health system. A healthy health system must be understood holistically, like health itself. We must be prepared to query and critique the very foundations of the health system, and the way we think about it. This has been the invitation offered here. Our sense of what health means is gradually changing. The consequences for approaching a holistic view of health, and one that accommodates different cultural perspectives, are that we must bring our priorities and methods into line with it. Real solutions are not going to come from doing slightly differently what were already doing, but from reframing the problem, which is why looking at the future of the NHS offers little prospect for transformative solutions. Instead, we should accept that there is a central role for health in governmental priorities generally, and try to run our organisations in ways that acknowledge and give a place to the non-tangible aspects of human experience. It has been suggested that building healthy communities may serve as a focal point for a national system, helping to put the embedded meaning of health into practice, beyond the provision of medical service and advice; this businesslike approach which leaves untouched the key issues of isolation and social breakdown, and which treats health as a matter of individual, and mostly physiological, well-being. Says American novelist Kurt Vonnegut, We are healthy only to the extent that our ideas are humane.42 Our ideas about what organisations, communities and governments are there to do are, I venture, becoming more humane as we leave behind our crude, mechanistic understandings of both human individuals and groups. However, to date the soft technology of social infrastructure has changed much more slowly than the hard technological change that demands so much attention and is frequently credited with driving society towards its future. Ultimately, though, it is our ideas that

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matter, for our technology and our medical techniques serve and are subordinate to them. Rather than letting the gap between the principle of holistic and spiritual health and the practice of a biomedical health system grow any wider for in this gap cynicism and disillusionment thrive it is time to look for ways to put our healthy, humane ideas into practice. Our system should be embedding the conditions of health across whole communities and societies. Is it too much to ask a national health service to actively promote happiness, health, and spiritual growth? To demand such major change instantly, yes it would be too much; but over a longer time horizon why not? But what would such a system look like? No specific proposal for the design of a holistic or distributed health system is offered here. As Slaughter has written, critique is no longer merely an option. It has become a necessity in a fundamentally compromised world.43 Envisioning something better is critiques constructive, and essential, other half, and its the next step in which we all have a part to play.

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ENDNOTES

1 Ziauddin

Sardar, Medicine and Multiculturalism, New Renaissance, vol. 11, no. 2, Summer 2002, http://www.ru.org/sardar-112.htm. 2 See Morris Berman, The Reenchantment of the World, Cornell University Press, Ithaca, 1981. 3 Dean Ornish, Eat More, Weigh Less: Dr. Dean Ornish's Life Choice Program for Losing Weight Safely While Eating Abundantly, Perennial Currents, 2000, pp.61-62 4 Derek Wanless, Securing Good Health for the Whole Population: Final Report, Department of Health (UK), London, February 2004, http://www.dh.gov.uk/assetRoot/04/08/45/22/04084522.pdf. The Wanless Report recommendations also note that A NHS capable of facilitating a fully engaged population will need to shift its focus from a national sickness service, which treats disease, to a national health service which focuses on preventing it. (para 9.1, p. 183) 5 Ibid, p. 3 6 Elisabet Sahtouris, The Biology of Globalization, adapted from Perspectives in Business and Social Change, 1997, http://www.ratical.org/LifeWeb/Articles/globalize.html. 7 Lovelock, J. E., Gaia: A New Look at Life on Earth, Oxford University Press, Oxford, 1979. 8 NCREL, Systems and Leadership, North Central Regional Educational Laboratory (NCREL, USA), http://www.ncrel.org/engauge/framewk/sys/sysdef.htm. 9 Peter M. Senge, The Fifth Discipline: The Art and Practice of the Learning Organization, Doubleday Currency, New York, 1990. 10 Learning-org, Why a Learning Organization?, http://world.std.com/~lo/WhyLO.html. 11 NCREL, above, note 8. 12 John Renesch, Conscious Organizations, Executive Excellence, vol. 19, issue 5, p. 19, May 2002; Richard Hames Creating the Conscious Organization: The Art of Intelligence-making for Strategic Navigation, http://www.saxton.com.au/saxton_db_data/files/Hames_Consciousorganisation.pdf. 13 Leandro Herrero, The Living Organisation, Scrip Magazine, June 2002, http://www.thechalfontproject.com/services/pdfs/Organisational_Innovation/The_living_organisatio n.pdf; William A. Guillory, The Living Organization: Spirituality in the Workplace, Innovations International, 2000. 14 Henrik Herlau et al, Exformation and Preformation in the Age of Information: Designing Inquiring Organisations, paper for conference Risks and Challenges of the Network Society, 4-8 August 2003, Karlstad University, Sweden, http://www.cs.kau.se/IFIP-summerschool/preceedings/rasmussen.pdf. 15 Sohail Inayatullah, The Learning and Healing Organization, article provided by author. See also The Learning and Healing Organization in Questioning the Future: An Anticipatory Action Learning Guide for Transforming Organizations, Tamkang University Press, Taiwan, 2002. 16 Ibid. 17 Sohail Inayatullah, Spirituality as the Fourth Bottom Line, http://www.shapingtomorrow.com/mediacentre/spirituality_as_4th_bottom_line__10_10_20031.doc. 18 Gerald Wistow, Modernisation, the NHS Plan and Healthy Communities, Journal of Management in Medicine, vol. 15, no. 5, 2001, pp. 334-351. 19 Ziauddin Sardar, above, note 1. 20 Danny Hillis, quoted in Stewart Brand, The Clock of the Long Now: Time and Responsibility, Phoenix, London, 2000, p. 157. 21 This definition comes from a presentation by Wendy Schultz, Futures Studies: An Overview of Basic Concepts, 2003, http://www.infinitefutures.com/essays/prez/overview/index.htm. Since we all have a stake in the future, and no single academic enterprise or perspective has a monopoly on it as a subject of study, it is important to note that there are related fields of study with quite different names (such as strategic foresight, and change management). Conversely, there are entirely different activities with similar names (for example, although futures studies is sometimes called futures for short, it has nothing to do with the futures market in the financial sector). Futures studies has also been known as futurology, a term now out of favour due to its pseudo-scientific connotations. As in any other domain, not all futures work reaches the rigorous standard that it ought to meet. 22 Performance and Innovation Unit (UK), A Futuristss Toolbox: Methodologies in Futures Work, September 2001, http://www.number-10.gov.uk/su/toolbox.pdf. 23 The Henley Centre, Understanding Best Practice in Strategic Futures Work: A Report for the Performance and Innovation Unit, October 2001, http://www.number10.gov.uk/su/understanding.pdf, p. 1. 24 Quoted in Stewart Brand, above, note 20, p.122. 25 Stewart Brand, above, note 20, p.118. 26 Derek Wanless, Securing Our Future Health: Taking a Long-Term View: An Interim Report, Department of Health (UK), November 2001, pp 39-40, http://www.hmtreasury.gov.uk/media//82EE3/chap3.pdf. 27 Clement Bezold, The Future of Health Futures, Futures, vol. 27, no. 9/10, 1995, pp. 921-925; p. 921.

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28 Trevor

Hancock and Martha Garrett, Beyond Medicine: Health Challenges and Strategies in the 21st Century, Futures, vol. 27, no. 9/10, 1995, pp. 935-951; p. 936. 29 Sohail Inayatullah, Causal Layered Analysis: Poststructuralism as Method, Futures, vol. 30, no. 9, 1998, pp. 815-829. 30 Donella H. Meadows, Places to Intervene in a System: Strategic Levers for Managing Change in Human Systems, Whole Earth, Winter 1997. Capitals in original. 31 Ibid. 32 A diagram from Dahlgren and Whitehead, Policies and Strategies for Promoting Social Equity in Health, 1991 is reproduced in Wanless, above, note 4, p. 25. 33 Consider the proposed alternatives to Gross Domestic Product, such as the Genuine Progress Indicator (GPI see http://www.redefiningprogress.org/projects/gpi/). This modifies GDP to take account of economic activity that has negative consequences or is carried out purely in compensation for social ills. Joe Flower makes the following related point: A car crash is good for the economy -- by traditional measurements. Ambulance companies make money from it, emergency medical technicians pick up overtime. So do healthcare workers, body-and-fender shops, car dealerships and the car companies, insurance adjusters, physical therapists, and psychotherapists. All these are counted by traditional economic measures, and in those measures probably far outweigh the lost capital represented by any undepreciated value of the destroyed cars -- and may even outweigh the costs of the lost work hours and lowered lifetime productivity of the injured, and the hiring and training costs to replace the dead. What is not measured, what is not considered measurable in traditional economics, is the human suffering. That is dismissed as an intangible. (Joe Flower, Healthy Economy, Healthy Communities, The WELL, 1997, http://www.well.com/user/bbear/hc_econ.html.) 34 Sohail Inayatullah, above, note 15, emphasis added. Elsewhere, he discusses the notion of spirituality as the fourth bottom line (above, note 17), inviting an interesting analogy between health and spirituality. 35 Sohail Inayatullah, Spirit@Work New Zealand, http://www.mang.canterbury.ac.nz/people/nilakant/spirit/inayatullah.htm. 36 Dean Ornish, above, note 3, p. 68. 37 Joe Flower, Healthy Cities - Healthy Communities, The WELL, 1996, http://www.well.com/user/bbear/healthy_communities.html. 38 World Health Organization Regional Office for Europe, Healthy Cities and urban governance, http://www.who.dk/eprise/main/WHO/Progs/HCP/Home. 39 Benjamin Ward Richardson, Hygeia, A City of Health, originally published 1876, http://www.blackmask.com/thatway/books153c/hyge.htm. According to the Dictionary of the History of Ideas; Hygeia, from whose name our word hygiene is derived, was one of the personifications of Athena, the goddess of wisdom. (Environment, vol 2, p. 122, http://etext.lib.virginia.edu/cgilocal/DHI/dhiana.cgi?id=dv2-13.) See also Victor G. Rodwin, Urban Health: Is the City Infected?, Lecture at the Millennium Festival on Medicine and the Humanities, London, May 2000, http://www.nyu.edu/projects/rodwin/urbanhealth.html. 40 Ibid. 41 Elisabet Sahtouris, above, note 6. 42 Kurt Vonnegut, Breakfast of Champions, Delacorte Press, New York, 1973. 43 Richard Slaughter, The Role of Critique in Futures Work, http://www.foresightinternational.com.au/07resources/Critique_in_Future_Studies.pdf.

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