Copyright 2017 - Clinical Commissioning Groups Association

Biopsychosocial models of care - the new way forward? - Dr Ishak Nadeem

The tremendous pressures of patient expectations which have to be met with the squeezed finances, under which the CCGS have to operate, can only be understood by someone who has been at the coalface. As the former chair of one of the lowest funded CCGS, I can see those pressures from your perspective. 

The 5 Year Forward View (FYFV) and the promise of increased investment when announced came as a welcome relief but the reality has turned us all sour with the passage of time. The aims of prevention, self-empowerment of patients and a move towards self-care touted in the FYFV are yet to take off and the promise of more investment in general practice, which is the lynch pin of NHS is just that, a promise. The aims are no doubt laudable but the reality is far from it. 

The NHS with its lofty aim of healthcare for all, free at the point of care has grown over the years into a large unwieldy ship, which has become separated from the mass of community. Operating in isolation to treat, fix and send back people onto the land mass. Resources are poured into just keeping the ship running forwards and to keep it afloat with little power left for changing direction. You are all aware of how resources meant for sustainability and transformation plans are ploughed into sustainability with very little for innovative working and transformation. Taking the analogy of the ship a little further, sustainability is a large ship with transformation a patched up leaking life boat. The added pressures of social, political and economic pressures with recent local and world developments will no doubt have an adverse impact as indicated by the lack of resources allocated for both health and social care in the recent autumn statement. 

So how do we continue to rise to the challenges and meet the realistic expectations at least, if not all the expectations of our citizens? Healthcare as I have stated, has drifted and isolated itself in institutions away from the community. It is important that what we do- has to be based on sound evidence, but have we gone too far in this focus? It is imperative to provide high quality investigations, cost effective treatments and to treat patients with world class NHS resources but that’s only the tip of the iceberg. Focus on resource sapping investigations, diagnosis and treatment in isolation away from the lifestyle that people are used to cannot solve the problems. Our GP’s and Hospitals do a marvelous job, which is second to none in the world but the time spent by our citizens in our hospitals is a miniscule proportion of their lifespans. The lifestyles we lead, the social, psychological and financial pressures we live under add stress which in turn leads to our lifestyle diseases and mental health problems. Add to that the financial pressures from recent politico-economic conditions the impact on our health is great. Unless we move away from the medical model of care to one of Biopsychosocial model of care, no matter how technologically advanced we become or how much resources we pour in we are doomed to fail. 

Prevention is better than cure is an age old adage to which we aspire, pay lip service and move on. Many of these what we call alternative modalities don’t have the traditional evidence and without evidence we are reluctant to put our eggs in those baskets. If we are to embrace the above adage, we need to change the culture of our medicine, our attitudes to health and our lifestyles. We are in a catch 22 situation and keep pouring resources to keep the ship afloat and moving forwards. Can we think and see from an entirely different angle?

Volunteers working in the third sector do a dedicated job due to their passion for a cause and jobs done with passion achieve greater results and give greater return on investment. But how do we as CCGS put in resources with our hands tied behind our backs, tied by financial constraints and the need to invest only when there is evidence especially in these times of economic squeeze. 

Some, if not all of our companies and corporations work to a set of ethics and are keen to fulfil their corporate social responsibility.  Can we not bring in these companies to perhaps invest in the voluntary sector and help with such interventions like social prescribing for which there is emerging evidence which might not be robust enough for public sector money to be invested?

Our aim is to raise the conscience of the corporate sector to their corporate social responsibility, revitalise our communities and build healthy communities. We would like to invite you to tell us what your problems and priorities are, work with us to build these communities of which both health and social sector form a part.

The biopsychosocial model of health and illness is a framework developed by George L. Engel that states that interactions between biological, psychological, and social factors determine the cause, manifestation, and outcome of wellness and disease. Historically, popular theories like the nature versus nurture debate posited that any one of these factors was sufficient to change the course of development. The biopsychosocial model argues that any one factor is not sufficient; it is the interplay between people’s genetic makeup (biology), mental health and behavior (psychology), and social and cultural context that determine the course of their health-related outcomes.

Also included in the social domain are cultural factors. For instance, differences in the circumstances, expectations, and belief systems of different cultural groups contribute to different prevalence rates and symptom expression of disorders. For example, anorexia is less common in non-western cultures because they put less emphasis on thinness in women.  

Culture can vary across a small geographic range, such as from lower-income to higher-income areas, and rates of disease and illness differ across these communities accordingly. Culture can even change biology, as research on epigenetics is beginning to show. Specifically, research on epigenetics suggests that the environment can actually alter an individual’s genetic makeup. For instance, research shows that individuals exposed to over-crowding and poverty are more at risk for developing depression with actual genetic mutations forming over only a single generation. 

The biopsychosocial model states that the workings of the body, mind, and environment all affect each other. According to this model, none of these factors in isolation is sufficient to lead definitively to health or illness—it is the deep interrelation of all three components that leads to a given outcome.

Health promotion must address all three factors, as a growing body of empirical literature suggests that it is the combination of health status, perceptions of health, and sociocultural barriers to accessing health care that influence the likelihood of a patient engaging in health-promoting behaviors, like taking medication, proper diet or nutrition, and engaging in physical activity. 

Content provided by Dr Ishak Nadeem. Dr Ishak Nadeem was a GP Partner at Grovelands Medical Centre for 16 years. His career comprises of several chapters, after qualification and post graduate training in India he worked for about 6 years in Saudi Arabia, moving to UK in 1994 he trained to become a General Practitioner. In 2014 he took over as Chair of South Reading CCG and was in that position for two years during which he has gained close experience of commissioning and the demands placed on the NHS. He is also a part-time Occupational Health Physician providing services as independent contractor for various Occupational Health providers like Heales Medical and Nexus Healthcare.

His other passion is photography and poetry and he has recently self published a book of pictures and poems- Rhythm Of Life, in aid of Dingleys Promise and Homestart, two local charities working for under 5’s with special needs and with vulnerable families respectively. You can read more about his interest in poetry on www.nadeem.invicom.co.uk. He is currently honorary consultant and commissioning Editor for CCGA and is working on his second book of poetry “Dreams in a dream”.

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