As people present to their GPs in increasing numbers with lifestyle illnesses the traditional constraints of our medical systems are creaking. Hospitals established on a factory model to achieve economies of scale on routine procedures are a poor fit for today’s patients who often present with co-morbidities including diseases such as diabetes, obesity and heart disease. GPs that evolved1 to provide holistic in-community care and support find themselves less able to prescribe solutions to today’s lifestyle illnesses. And so we are left to operate in a system that is an increasingly poor fit for purpose. It is into this poorly-aligned system that we are trying to land new ideas and innovations, attempting to change things for the better. Trying to facilitate a shift to a new system.
A critical challenge in systems change is the vulnerability of newly born ideas. It is often hoped that these ideas grow into innovations that will form elements of a future system, one that addresses the shortcomings of the old. Yet the self-preserving instincts of the existing system will often capture and adopt such ideas as their own. As they become subsumed by the current system these innovations also become bound by its rules and conventions. Co-opted ideas add new energy that helps sustain the dominant system and those that benefit most from it.
In health systems we have resorted to asking GPs to prescribe activities that connect people socially and encourage them to spend time in nature2. Some have even recommended that the NHS takes over the running of our local parks3. To do so is to offer a solution to an epidemic of loneliness and poor mental health that can be accommodated within the current paradigm, institutionalising the response within our current structures. Known as social prescribing, this is an illustration of the dominant system capturing a new idea and bending it to its rules. To do so the problem has to be translated into the language and processes of the current system. In this example, we first pathologise the problem of loneliness, treat it where it shows up most visibly, and then medicalise the solution by ‘prescribing’ social activities or time outside in green space. This makes the whole concept more palatable for GPs, too, and perhaps carries more weight with their patients. But who wants to spend years training only to spend their time recommending their patients join a community group or go for a walk in the park?
And so we carry on with what went before because we convince ourselves its easier than trying to change things. We don’t adapt health systems to make them more responsive to the needs of the communities they serve, instead we adapt our responses to work within the current system. We pathologise lifestyle choices in order to medicalise the solutions, following the existing dominant approach of diagnosis – solution – prescription. It’s the system reasserting its dominance through its language and concepts.
If we zoom out a little we might ask why we need to couch the idea of helping people connect with others in medicalised language – as a prescription to be taken. We might further ask what is going on in our wider social, political and economic systems that are leaving people feeling isolated and disconnected without any easy solutions. That drives them to turn up and talk to their GP because they can see little other alternative and, perhaps, because we’ve been conditioned by those very systems that there’s a solution for everything if we can find the right expert.
Instead we might seek to realign voluntary, heath, housing, community and other relevant services in such as way as they collectively offer more responsive, preventative support to the most vulnerable at critical times of need. We might invest more in grass-roots community groups not because they can write a good funding bid or have great metrics to share, but simply because a vibrant and active community requires some basic infrastructure to flourish. We might more actively encourage young people to participate in their local sports club not because they are a great athlete but because they are creating positive habits for life that will lead to additional health benefits of exercise and connection.
This is not to give a free pass to those of us who don’t currently work in the UK health systems. In welfare systems we diagnose unemployment as largely an individual failing and prescribe a myriad of conditions and a punitive sanctions regime to ‘encourage’ people back into work. In humanitarian aid systems we can prescribe western solutions to countries beset by crisis and disaster and ask their communities to be grateful recipients of our expertise and resources, and report to us in detail on how they’ve used it effectively. The focus here on health serves purely to shine the light on all social systems, from education and humanitarian aid to urban planning and social care.
Perhaps there is hope. As the dominant socio-economic paradigm comes under increasing challenge, so too do the systems that were designed within it. Few, however, want to actively change them and fewer still even try. To try and change the system is the preserve of the mavericks and rebels, whether overt about their intentions or acting covertly4 within the very system they are trying to shift for the better. People who have left their ego and reputation at the door and are attempting, against the odds, to redesign things. To land new innovations as harbingers of the new. We should be helping them. It’s the work of our time and it’s work of real value. Because without it we are not truly testing the potential elements of a new system, how it might operate, the benefits it might yeald.
To land a new idea that seeks to be part of a wider system change we must therefore consider more than the idea itself. We must also consider how it is to be implemented if we are to avoid co-option of the new by the old. Brilliant ideas and initiatives have historically been wrecked and lost with little trace, lured onto the rocks by the Siren’s song of the current system. We must therefore recognise and address the self-preserving instincts of the current system to co-opt or reject innovations. We must work to prepare the land for innovations to flourish within our complex systems. It’s not easy. But that’s where those of us who might – reluctantly – label ourselves systems entrepreneurs find our purpose.
1 https://bjgplife.com/a-short-history-of-general-practice-consumerist-medicine/
3 https://www.smf.co.uk/smf-media-release-give-the-nhs-power-and-money-to-run-parks/
4 https://www.thersa.org/reports/rough-guide-to-being-a-public-entrepreneur-in-practice
Ian Burbidge. 
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