Lessons from Alaska on relationship-based care
Margaret Hannah describes herself as Scottish/ English. She has been married for over 20 years and has two teenage sons. She works in public health three days a week for NHS Fife, and spends the other two working days doing probono work for her husband’s organisation, the International Futures Forum.
When Hannah travelled with three of her colleagues from NHS Fife to the Southcentral Foundation (SCF) healthcare system in Alaska earlier this year to hear firsthand about their patient-centred, relationship-based approach to primary care, she learned the importance of such introductions if we are to get to know the person behind the job title, understand their personal connection with their healthcare system and start building good quality human relationships.
According to the SCF, “good quality relationships equal healthy people.” And it is worth listening to what they have to say. The healthcare system, which has been created, managed and owned by Alaskan Native people, is attracting international attention for its success. In ten years it achieved a reduction of more than 40 per cent in A&E usage, a 50 per cent drop in referrals to specialists, and a decrease in primary care visits by 20 per cent.
In June last year, a team from SCF visited NHS Scotland and NHS Fife and successfully bid for two days of their time. The board had already been using the International Futures Forum (IFF) Three Horizons framework as an aid for thinking about long-term systemic change, having recognised that the challenges the health service faces today are radically different from those that existed when the NHS was created over 60 years ago. During this process the SCF model was discussed as a local system of care to aspire to, and so they were “primed” to listen to what the Alaskans had to say, states Hannah.
“When we started to describe for ourselves the kind of health service that we wanted for the future it started to sound very different because it was driven by a set of values that currently are there but aren’t expressed explicitly enough. The kind of values we are talking about are, in many ways, reflected in the Quality Strategy – compassion, person-centredness, the relationship, a human system. That healthcare fundamentally is a human activity, not one that is going to respond to a machine-like efficiency.
“So you can have a discipline around efficiency in using resource effectively but you can’t keep squeezing people to do more without there being a human cost to that. What we are looking to do is something different and asking the humans in the system to be different, not just do things differently. Because if we are being more of ourselves and less in our role, we actually create a better healthy environment for ourselves and the patient we are serving.”
Meeting the Alaskan team and learning about their values-based approach was a “transformative” experience, says Hannah. The friendships forged during that visit continued across the Atlantic, and this summer Hannah and her colleagues were invited to return the visit to experience SCF in practice.
The team, whose visit was funded through contributions from the IFF, the Health Foundation and Dialogix, also attended and presented at a two-day conference during their visit and were granted free places on the threeday Core Concepts training course that is given to all SCF staff.
The training course focuses on creating more intimate, trusting relationships, Hannah explains.
“Unless you have that trust in an organisation, in a healthcare organisation in particular, you can’t instil that health-creating healing quality to the people you are serving. So it is very important, I think, to have that level of trust.” It also “completely annihilates the hierarchy,” she says, “because you are operating at a human level with people and you are valuing everybody’s skills and their technical expertise is a given and they have extremely high standards of care.” The four returned brimming with enthusiasm, and clearly moved by the experience – professionally and personally.
“If there is another lightbulb moment it is this complete collapse of the two,” explains Hannah.
“You can’t be an effective healthcare professional if you are not also very self-aware as a person. The two go together. You become more self-aware as a person when you are willing to be vulnerable and open to your colleagues. And that they too are skilled enough to recognise that what you are doing is also benefiting them. It is actually a very beautiful process to see how a culture can grow on the basis of this building trust and building quality relationships.” In NHS Fife the first tentative steps to translate this into a Scottish context will be taken at Muiredge Surgery in Buckhaven. The practice, which is situated in a deprived part of Fife, has around 7,000 people on its list who are very heavy users of primary care, and gives out around 47,000 appointments each year.
Initially the surgery will consider how it can reshape the front end of the practice to make each contact more effective – reducing the number of patients that need to be seen by a doctor and creating more time for meaningful, outcome-orientated conversations with those who do.
“We have triage already in Scotland, triage happens all over the world, but their triage is special in that it is focused more towards the whole person rather than their one symptom,” explains Dr Swapan Mukherjee, a GP from the Muiredge surgery, who was also part of the team from Fife that visited Alaska.
Like Hannah, Mukherjee was “very impressed” with what he saw in there – particularly the emphasis on mental, emotional and spiritual wellness as well as physical health – and is keen to discover how this can be translated to Scotland.
“We can’t bring Alaska here – we have to change it to fit our needs, our traditions. So we have to make it Scottish,” he says It is very early days, but Mukherjee is excited that his practice has been chosen as the pilot for this work in Fife and is keen to show that the Alaskan approach can also reap benefits in Scotland.
“We will prove to people that if you approach problems the way the Alaskans are doing we will create an environment where our customers will be happier and they will not need us as often as they do at the moment, which will then create a decrease in the demand, thereby making savings. And those savings can then be put back into the community to do other things.” There are many things we can learn from the Alaskan experience, he says.
“One of the main things would be a change in attitude. There has to be a cultural change in that we have to stop moaning, we have to stop blaming, we have to be proactive and try to understand what is it that our patient or our clients or our customers really want.” However, the starting point in Scotland will be different. In Alaska the existing infrastructure was so damaged it was decided the best option was to start again and build a new system from the ground up. In contrast, Scotland must seek to “re-design the plane whilst flying it”.
“The Alaskan model was so obviously broken when they got started, agrees Hannah. “Nobody was happy with it. Everybody was frustrated.” Whereas she says the Scottish health service has achieved a lot, highlighting the “great inroads” that have been made around waiting lists, HAI and patient safety in particular. However, while she notes that these achievements were backed by significant financial investment, she points out that we are no longer in that position.
“We are never going to have that massive growth of spend in the health service that we had in the last ten years. I think it is doubtful if it will ever happen again, actually. There is this notion that after 2016 things might pick up and by 2025 we will actually be raring ahead again – I think probably in our wildest dreams. The world will have moved on so far by then. What sort of economic system will we have in 2025? I don’t think anybody knows now. So I don’t think we can rely on money to sort this one out for ourselves.” However, this approach is not about money, she says, pointing out that we are rich in another resource: people.
“I think our health service has a massive opportunity to make the next evolutionary step in healthcare for the population, recognising that it is not going to be through spending more money. So it is actually an aspiration rather than desperation. We are inspired by the idea that we could create an even better health service than the one we’ve got and it is not going to cost us more money. We recognise that more money is not the way to do this. We are going to have to do it within existing resource and mobilise a different kind of resource to make this happen and that different kind of resource is the quality of the relationship. That doesn’t cost anything in money terms. In fact, if there is money involved it damages that relationship.
“…So the answer to our problem isn’t more money. It is to recognise that we have huge assets with the people we have in this organisation and I am very, very excited about where we are now.” Hannah’s experience in Alaska helped her to realise that this is something very much within Scotland’s grasp, she says.
“Two years ago I would have said no. I was really facing a bit of a wall myself. I couldn’t make the sums add up. I could see that this was a totally unsustainable system that we had and we do, and I couldn’t see a way through. But now I realise that the human potential in this organisation is pretty much infinite.
“We can’t spend our way out of this problem, but we can learn our way out of it,” she adds.
“But it is learning to have different kinds of conversations, learning to value the quality of relationships and building on that. Growing that will help us design a new system of care.”