‘Why treat people and send them back to the conditions that make them sick?’
Michael Marmot

Universal healthcare in a society that is poor at prevention and in denial about death is like attempting to rescue a never ending stream of people from a river of illness. As science advances, we dive deeper and deeper into the river to pull out people who are sicker and sicker. The right to healthcare for all means that all too often, we treat the untreatable. Just because we can do something doesn’t mean it’s kind or wise to do so. A high-tech death can be very unkind. We spend so much time, effort and money pulling bodies to the riverbank, that we have no energy left to wander upstream and stop them falling in.

We live in a very unequal society, with huge disparities in both life expectancy and years lived in good health. Unless we can improve living and working conditions as well as lifestyle, with a strong emphasis on helping people to build resilience and stay mentally healthy, then no system of universal healthcare can cope, no matter how it is designed or funded. Those of us who are lucky enough to be healthy at present have a responsibility to try to remain so for as long as we can. The best hope for the NHS lies outside its structures. We must reduce poverty, promote healthy minds as well as bodies, lessen the burden of avoidable illness and permit choice in dying. There’s more than enough unavoidable illness to keep the NHS in business.

This burden of avoidable illness could be further reduced by being honest about medical harm and the limits of medicine, and restricting over-medicalisation. Too many serious errors have been covered up and repeated in healthcare systems primed to protect professional, institutional, corporate and political reputations. Too many tests and treatments of marginal benefit turn healthy people into anxious patients. Enough people fall into the river of illness without being sucked in by the health industry.

There simply isn’t a sound evidence base for the mass medication of the elderly, many of whom are either unable or unwilling to take so many drugs as prescribed. Waste due to ineffective treatments, non- attendance and non-adherence is significant. When patients are given the time and opportunity to fully understand and participate in decisions about their care, taking in the likely long-term risks and benefits in absolute as well as relative terms, they often choose less medicine, not more. Universal healthcare must also be prudent healthcare, using the minimal effective intervention wherever possible. Sound evidence based on real life data, as well as compassion, must inform health policy and provision.

Above all we must see healthcare in the context of all care. The boundaries between self, health and social care are entirely superficial, and we must extend our circles of collaboration and compassion as widely as possible and consider the environmental impact of what we do. Indigenous populations have a better understanding of how to live on this planet without taking so much as to threaten the health of future generations, and how to die. We only die once, and a gentle death for as many people as possible is the kindest service society can offer. As the Australian Aboriginal elder Dr Noel Nannup explains: ‘Human beings are the carers of everything.’ But to care for everything, we must first care for ourselves and build our own resilience. The NHS has had enough top down ‘re-disorganisations’. It’s time for a bidet revolution. From the bottom up.

Healthcare begins with self-care

‘Tell me, what is it you plan to do with your one wild and precious life?’
Mary Oliver

Self-care requires time to reflect and to do some ‘self- work’. What are our goals, values, passions and purpose? Can we get near them without burning out? How can we be kind to our minds? How will we cope with pressure, failure, and adversity? Is our current lifestyle making avoidable disease more likely or even inevitable? Physical health stems from mental health, and learning how to be happy, how to self-care and how to cope under pressure should be taught and revisited at every stage of our lives. And we need to build happy and resilient cities, communities and organizations that promote mental health and allow individuals to flourish.

And yet as a society, we aren’t great at talking about what matters most (mental health, sexual health, how we want to die). Self-care needs the self-knowledge that comes from these difficult conversations, and also self- love. Can you disappear inside your mind and like what you find there? Enjoying our own company is key to happiness and resilience. Accepting responsibility for self-care is also fundamental to the sustainability of universal healthcare. Every day we don’t need to use the NHS, someone who does benefits.

The CLANGERS self-care model

Universal healthcare must embrace the continuum of self-care to intensive care, and I would restructure it around the CLANGERS model. The Clangers of the children’s television series were, and probably still are, a community of mauve mice who spoke in whistles and ate sensible portions of soup, made by a dragon, and blue-string pudding, none of which was processed. They lived a simple yet serene life built around friendship, collaboration and enjoying the little things. Very seldom, if ever, did they need to go to hospital or indeed die, because they were so good at self-care and pleasuring themselves in a safe and sustainable way.

The Clangers’ habit for a satisfying and meaningful life can be learned by anyone, at any age:

• Connect with the world around you. Reach out to people, pets, plants and places. We like to feel as if we belong, as part of something bigger. These connections are the cornerstones of your life. Take time and care to nurture them. And don’t forget to connect with yourself.

• Learn. A purpose in life often stems from learning what matters most to you, developing a passion for learning and keeping your curiosity alive. Why do you get out of bed in the morning?

• be Active, in mind and body. Rediscover activities and passions you left behind, and have the courage to try new ones. Aim for five portions of fun a day, each different, at least one outdoors and one that involves getting pleasantly breathless.

• Notice, and be present in, the world around you. Fill up your senses. Catch sight of the beautiful. Remark on the unusual. Enjoy the everyday. Savour the moment, and your place in it.

• Give back. Helping and caring for friends, strangers and those less fortunate than ourselves is fundamental to good emotional health. It cements us as part of a community and develops more meaningful connections and insights. The joy of being human is to be humane.

• Eat well. Learn what’s good and enjoyable to eat, and in what quantities. Learn how to grow it, where to buy it and how to prepare it. Set time aside to sit and eat with friends and family. Eating well on a budget isn’t easy. For excellent help try Cooking on a Bootstrap by Jack Munroe

• Relax. Take time to rest and reflect on the day you’ve had, reliving and re-savouring the happy memories and having gratitude for friends and family. Learn to meditate. Be kind to your mind and let it wind down and de-clutter.

• Sleep. Don’t cheat on your sleep. It’s vital recovery time for mind and body, and boosts your energy, creativity and productivity. You eat better and exercise more when you’re well rested. Relaxing and winding down beforehand is key. Learning to housekeep your mind and deal with stress is vital. If you doubt the power of sleep, read Why We Sleep by Mathew Walker

Some lucky people will do all eight steps intuitively, partly out of habit. Others will struggle through sickness and circumstance but with support and time, can continuously improve and slowly raise their own bar – hopefully without the stress of comparing themselves to others. If you need more detailed help with your CLANGERS, I recommend the book The 4 Pillar Plan – Eat, Sleep, Relax, Move – by Dr Rangan Chatterjee. He is one of the few lifestyle medicine gurus who isn’t trying to sell you a fad diet or his own brand of nutritional supplements, and his enthusiasm is infectious. You can also check out his podcasts here.

Your Clangers may be very different to my Clangers, the only rule is that we should try not to harm ourselves or others. The ‘clang’ in CLANGERS comes from the government-funded Foresight report, ‘Mental capital and wellbeing: making the most of ourselves in the 21st century’. It gathered the evidence on simple ways to a fulfilling life that just about anyone can do, irrespective of wealth or health. I added the ‘ers’ because they’re also fundamental to living well and slowing down the rust.

CLANGERS works not just as a model for living well, but also as a way of coping in adversity. When I interviewed patients and carers for a book about how to get the best from the NHS, it was striking how it fitted in with a successful model of patient engagement.

• Connect with the team treating you, and get to know them if you can. Know their names and something about them. It’s easier to ask questions when you know someone.

• Learn as much as you can about your illness, the treatment options, what you are entitled to, the standards of care you should be getting, what you can do to improve your odds and who to speak to if you have concerns.

• Be Active, both in the management of your illness and preventing further illness, be your own advocate when you can, have others to act for you when you can’t. The five portions of fun a day may be different to the ones you might enjoy when you’re well, but still try to have the energy for joy, warmth and purpose each day.

• Notice the good and bad in your care, and speak up if you have any questions or concerns. Notice the little acts of kindness that make illness bearable, and be thankful for them.

• Give back to the NHS and your carers by providing thanks and constructive feedback. Share vital information with other patients and carers. Get involved in research, service improvement and design and volunteering for your local NHS and charities.

• Eat well, Relax, Sleep – even more important when you’re ill.

The CLANGERS model equally applies to staff engagement and wellbeing. Health systems will always be high pressure places to work and so need to comprise of resilient organisations that support the mental health of the staff, encourage learning, are free from fear, bullying and blame and encourage everyone – patients, carers and staff alike – to speak up, feedback and continuously improve.

Ultimately, patients and carers must be handed as much control and responsibility as they want, and supported to live lives governed by their own goals and values, not the mass-produced end points of clinical trials. The best population evidence has to be combined with empathy for the individual. There is no single structure for healthcare provision that works in any context, and to continually seek the perfect structure in the NHS has proven to be hugely disruptive and disastrous for morale. Different models and structures will work in different parts of the country, but they must be built around common values and understanding of the needs of the individual. If each person can go about their daily CLANGERS, united by compassion, candour, competence and collaboration, then we can rediscover a values based service that is also effective and affordable.

Conclusion: competent, compassionate, cost-effective collaboration

In the 34 years since I first set foot on an NHS ward, I’ve lived through a dozen major structural reforms, more ideological than evidence-based, seldom embedded long enough to prove their worth before being uprooted by the next political vanity project. So I’m loathe to suggest any structural miracle pill for universal healthcare. Continuous evidence-based improvement is far more likely to work, raising the quality bar a little at a time, as resources allow. Consultations – or rather meetings between experts – must be long enough to be safe, effective, enjoyable and meaningful. Transparency and accountability must embrace innovation and learning from failure. The spirit of competent and compassionate collaboration must triumph over competition.

Patients and carers must have as much choice and control over their illnesses as they – and a fair system – can manage. Anyone must feel free to speak up and challenge, knowing their concerns will be acted on. Pure knowledge, like pure water, must be available to all who need it. Communities must promote health and meaningful work for all, and we should all be taught the skills of resilience from a young age. The healthy must accept responsibility for trying to remain so, and society must support them. Artificial divisions must melt away (self-care, healthcare and social care are all care). And all of this care must be prudent, and mindful of the cost for the planet and the payer. The minimum necessary intervention is usually the kindest and the least obstructive. We have but one wild and precious life, and we want healthcare to improve us, not imprison us. Release the joy of your inner CLANGERS.

Above all, we need Collaboration to solve the complex problems facing us. It was defined brilliantly by Margaret Heffernan in her book ‘A Bigger Prize‘

‘Innovative organizations thrive not because they breed superstars but because they cherish, nurture and support the vast range of talents, personalities and skills that true creativity requires. Collaboration is a habit of mind, solidified by routine and prepared on openness, generosity, rigour and patience. It requires precise and fearless communication, without status, awe or intimidation. Everyone must bring their best. And failure is part of the deal, an inevitable part of the process to be greeted with support, encouragement and faith. The safest hospitals are those where it’s easiest to acknowledge an error. The biggest prizes grow as they are shared.’

I believe politics would lead to much more progress if we adopted this constructive, collaborative scientific approach to all the great challenges of our time – Brexit, improving public health, reducing poverty, funding public services and pensions, caring for an older population, Global warming etc. I also believe we need experts rather than politicians overseeing their fields of expertise (education, pensions, health etc). The issues facing us are far too complex for politicians with little or no experience and damaging tribal loyalties to flit in and out of every few months. Time to put some grown-ups in charge.