Imagining health care in a parallel world can reveal a lot about the health care system we enjoy in this one.
Counterfactual narratives have long been popular. Livy speculated about a confrontation between Rome and Alexander the Great, had the latter chosen to expand his empire westwards instead of eastwards.[1] Kingsley Amis wrote about a world where the reformation failed and Roman Catholicism continued to dominate Europe for centuries.[2] An alternate health service seems a minor alteration in comparison. What would it look like?
I recently took part in a workshop on type 2 diabetes in adolescents and young adults. Most of the speakers were medical researchers, and the audience clinicians. I was the public health afterthought. The talks focused on pathophysiology of type 2 diabetes, speculating on whether South Asians might exhibit a distinct illness trajectory to Europids. This effortlessly morphed into a speculative discussion of genetics. The medical academics were fascinated, leaning forward on their seats, vying with each other to interject. A single question about whether South Asians and White British might possibly have different lifestyles was brushed aside. The essential genetic homogeneity of the human species compared to its great ape cousins was ignored,[3] (see also our previous blog).
Although irrelevant to patients, pathophysiology and genetics fascinate doctors because they are the core of our undergraduate professional training. Pharmacological treatments predominate our therapeutic thinking because they are the logical response to pathophysiology. Doctors enjoy a near monopoly on prescribing and it is the defining and distinguishing feature of the profession. As the profession is a key influencer of the health services and research agendas, the ability to deliver the right drugs to the right patients is a central preoccupation of the health care system and the understanding of pathophysiology in order to develop and test drugs dominates the research agenda. From my background reading on the public health aspects of diabetes I learned that only 16.7% of newly diagnosed type 2 diabetics are offered structured diabetes education and only 3.6% attend.[4] How could an important and effective intervention be afforded such a low priority?
In another world a profession of health educators is in the ascendant. The profession dominates the provision of health care. Clearly the most important intervention for anyone developing a chronic disease is structured education. This conveys factual information about prognosis, life skills, confidence, and self-efficacy. The first intervention follows diagnosis. It serves an anthropological, as well as an educational, purpose, marking a life transition into a new state. Ongoing education reinforces skills, builds knowledge, and addresses the disease progression. Alongside service delivery, a vigorous research agenda constantly refines the educational interventions. New educational materials are developed. Innovative modes of delivery test new communication technologies, gamification (the use of game thinking and mechanics in non-game contexts to engage users), and virtual learning communities. Patients become co-producers of educational interventions. Stratified education is emerging where psychometric testing and preference elicitation allows patients to be matched to the most appropriate educational intervention. The primary outcomes of health care are the same: quality of life and length of life. The process measures by which we mark our progress are very different: self-efficacy, knowledge, and measurable skills replace physiological parameters. Even the typology of disease might change, with categories defined by the type of educational intervention as much as by pathophysiology.
What does this tell us? Sometimes they are so ingrained, we can’t see our own assumptions. The French call this déformation professionnelle. To a man with a hammer, everything looks like a nail. Which is why a hammer was referred to as the Birmingham screwdriver.
— Tom Marshall, Co-Director CLAHRC WM, Prevention and Detection of Diseases
- LiviuS T. The History of Rome (book IX, sections 17–19). English Translation by Rev. Canon Roberts. New York, NY: E.P. Dutton and Co. 1912.
- Amis K. The Alteration. London: Jonathan Cape. 1976.
- Prado-Martinez J, Sudmant PH, Kidd JM, et al. Great Ape Genetic Diversity and Population History. Nature. 2013; 499: 471-5.
- The Healthcare Quality Improvement Partnership (HQIP). National Diabetes Audit 2012 – 2013. Report 1: Care Processes and Treatment Targets. Leeds: Health & Social Care Information Centre. 2014
NIHR CLAHRC West Midlands News Blog 
> The process measures by which we mark our progress are very different: self-efficacy, knowledge, and measurable skills replace physiological parameters.
That’s all well and good. But if skills and knowledge haven’t produced a lowered A1c, nothing’s been accomplished. The tests are the ultimate measure of progress.
Fortunately, I’ve been lucky with my doctors and even though I can keep my A1c well under 6, they still let me order tests when I think I need them and let me have my test strips! (yay!)
An interesting alternative reality to consider, thanks Tom! Though many of these components already exist within the field of Health Psychology (or behavioural medicine). Health Psychologists don’t often propose education as the ‘most important intervention’ as it implies primarily information provision and increasing knowledge and skills, which we know are rarely sufficient to change patient behaviour (as lack of knowledge is rarely the main reason for failing to follow health advice). However, I acknowledge that by ‘education’ you may mean something broader, incorporating psychological methods (e.g. increasing self-efficacy, decreasing anxiety) and what we would term, ‘behaviour change techniques’. In Health Psychology we are already working on developing and refining these interventions, including the materials, communication technologies, virtual learning communities, and ‘gamification’ approaches mentioned above. Interventions are often developed in collaboration with NHS services, Public Health teams, and patient groups, but the challenge for our discipline is to increase our visibility and authority within the health system as a whole. Perhaps in the future we may reach a point where the parallel world envisioned in your post becomes somewhat real, co-existing with the pathophysiological approach. To do so, Health Psychologists must influence health care policy and practice, which will require greater collaboration with health service researchers (including CLAHRCs), clinicians and policy-makers.