1. Themes
• Aim for person-centred healthcare
Not patient-centred health care
• Actions & decisions depend upon way of
thinking
• Person-centred healthcare depends upon
having a holistic understanding of health
No social admissions, bed-blocking patients,
difficult to discharge patients

2. What causes ‘functional illness’?
• People who experience symptoms (and
disability) but have no disease to account
for/explain their illness
Form 20% of all new out-patients in all clinics
Example diagnostic labels include:
•Fibromyalgia, migraine, chronic fatigue syndrome,
low back pain, chronic regional pain syndrome,
non-cardiac chest pain, irritable bowel syndrome,
myalgic-encephalomyelitis etc etc

3. To answer these puzzles
• Need an appropriate model of illness.
• A model is:
“A simplified or idealized description or
conception of a particular system, situation, or
process that is put forward as a basis for
calculations, predictions, or further
investigation.”
(OED 2006)

4. Common current assumptions
• Disease refers to disorder of organ within
the body
i.e. Disease is malfunction of part of whole
• All symptoms and illnesses are
attributable to disease
i.e. A person with symptoms is ill and must
have an underlying disease within body
• All disease causes symptoms and illness
i.e. Sooner or later disease manifests itself

5. Biomedical model of illness
• These assumptions are central to the
biomedical model of illness
Ill-defined; no standard definition
Current dominant model
• Basis of model is the scientific method:
Reductionist approach; identify single causes
Focus on pathology/disease within the body
as primary cause of illness

6. Biomedical model
• Incorporates other important assumptions:
Patient is passive:
•A ‘victim’ of disease, and
•A ‘recipient’ of treatment
Mental phenomena are separate domain
unrelated to ‘physical’ phenomena (Cartesian
dualism)
•‘physical symptoms/signs’ are not caused by
‘mental’ processes

7. Biomedical model
• Has been very successful over 100+ years
• Socially very important
Determines political policies
•Organisation of bureaucracy (e.g. CRS etc)
•Allocation of resources / basis of payment
Guides most people’s actions & decisions
Leads to ‘sick role’
•Lack of responsibility for illness
•Allowed to avoid social duties

8. Main assumptions are false
• Disease without symptoms is common
Screening programmes based on this
5% of 70 year old people may have ‘silent’
cerebral infarction.
• ‘Symptoms’ (i.e. Experiences considered
outside ‘normal’) are very common
Daily occurrence
Two ‘life-threatening symptoms’ each six
weeks

9. Conclusion
• The current biomedical model:
Is incomplete
•E.g. not explain functional illness or lead to
treatment
Is unable to resolve modern problems
•“Payment by results” tariff not able to work
– Major determinants of cost are social and disability
Incorporates a mereological fallacy
•The fallacy of attributing to parts of an animal
attributes that are properties of the whole

10. What did he mean?
“The NHS must focus on good case management
where patients with complex needs are identified
and supported by skilled staff working in a
holistic fashion in an integrated care system.”
From
Speech by Rt Hon John Reid MP, Secretary of State
for Health, 11th March 2004:
Managing new realities - integrating the care landscape

11. Holism
• “The tendency in nature to form wholes that
are greater than the sum of the parts through
creative evolution.”
• Smuts JC. 1870-1950. South African
lawyer, general and politician (Prime
Minister 1919-24; 1939-48), also a
philosopher.
• Book: Holism and Evolution. 1926
(second edition 1927).

13. Holism
• Concept led on to General Systems Theory
(Ludwig von Bertalanffy, 1971)
Concepts of:
•System being more than the sum of its parts
•Hierarchical and interacting organisations
• and hence to:
Complexity, and Chaos Theories etc
•Stressing importance of non-linear relationships
– Minor change in one factor may have major effect
elsewhere

14. Holistic medicine
• Holistic medicine first mentioned 1960 by F
H Hoffman:
“.. concern with teaching about the whole man –
‘holistic’ or comprehensive medicine ..”
• Best definition:
“… holistic medicine that integrates knowledge of
the body, the mind, and the environment …”
(Annals of Internal Medicine, 1976)

15. “Holistic medicine is the art and science of
healing that addresses the whole person - body,
mind, and spirit. The practice of holistic medicine
integrates conventional and alternative therapies to
prevent and treat disease, and most importantly, to
promote optimal health. This condition of holistic
health is defined as the unlimited and unimpeded
free flow of life force energy through body, mind, and
spirit.”
Holistic Medicine - 2
American Holistic Medical Association
http://ahha.org/articles.asp?Id=81

16. Holistic healthcare: conclusion - 1
• The concept has mutated to encompass
and even exclusively represent
‘alternative’ health care:
Often said to be ‘an approach’
Often focused on ‘spiritual care’
Always difficult to specify

17. Holistic healthcare: conclusion - 2
• Health (and illness) is comprised of
various hierarchical systems.
• A person (ill or healthy):
encompasses several ‘components’
•Spirit, mind, body etc
lives within a context
•Past, personality, social milieu
lives in a certain way, their ‘life style’
•Have their own goals, expectations etc

18. Achieving holistic healthcare
• To achieve holistic healthcare effectively
requires
a model of illness that is holistic, giving
a systematic and comprehensive approach
to all domains of health and
to all domains influencing health
• Biomedical model is not holistic

19. There is an alternative model
• Biopsychosocial medicine
1977, Engel (building on sociology etc)
Systems approach to illness
Psychiatry and chronic back pain
• At same time World Health Organisation
was developing a new classification of
consequences of disease

21. World Health Organisation’s Inter-
national Classification of Impair-
ments, Disabilities and Handicaps
• WHO ICIDH - developed in 1970s
Published first in 1980
• Put forward as a classification system
like ICD, to complement ICD
for all consequences of disease
•Impairment, disability, handicap
• Did not acknowledge environment

22. WHO International
Classification of Functioning
• Revised ICIDH > ICF (1996-2001):
added contextual factors:
•physical (buildings, carers, clothes etc)
•personal (experiences, strengths, attitudes etc)
•social (family/friends, culture etc)
changed words (not concepts)
•disability -> (limitation in) activity
•handicap -> (restriction on) participation
added global concept of ‘functioning’

23. Adapted WHO ICF model
• Basic WHO ICF model is incomplete:
No mention of ‘quality of life’
No mention of choice (‘free-will’)
Only takes perspective of outsider (not ill
person)
Does not take time into account
Wade DT, Halligan PW Do biomedical models
of illness make for good healthcare systems?
British Medical Journal 2004;329:1398-1401

24. Organ (pathology)
WHO ICF Description of illnessFour Levels Three Contexts

25. Organ (pathology)
WHO ICF Description of illnessFour Levels Three Contexts
Person (impairment)

26. Organ (pathology)
WHO ICF Description of illnessFour Levels Three Contexts
Person (impairment)
Person in environment
Behaviour (activities)

27. Organ (pathology)
WHO ICF Description of illnessFour Levels Three Contexts
Person (impairment)
Person in environment
Behaviour (activities)
Person in society
Social position
(Participation)

28. Organ (pathology)
WHO ICF Description of illnessFour Levels Three Contexts
Person (impairment)
Person in environment
Behaviour (activities)
Person in society
Social position
(Participation)
Personal

29. Organ (pathology)
WHO ICF Description of illnessFour Levels Three Contexts
Person (impairment)
Person in environment
Behaviour (activities)
Person in society
Social position
(Participation)
Personal
Physical

30. Organ (pathology)
WHO ICF Description of illnessFour Levels Three Contexts
Person (impairment)
Person in environment
Behaviour (activities)
Person in society
Social position
(Participation)
Personal
Physical
Social

31. Organ (pathology)
Traditional Model of illnessFour Levels Three Contexts
Person (impairment)
Person in environment
Behaviour (activities)
Person in society
Social position
(Participation)
Personal
Physical
Social

32. Organ (pathology)
WHO ICF model of illness (1)Four Levels Three Contexts
Person (impairment)
Person in environment
Behaviour (activities)
Person in society
Social position
(Participation)
Personal
Physical
Social

33. Organ (pathology)
WHO ICF model of illness (2)Four Levels Three Contexts
Person (impairment)
Person in environment
Behaviour (activities)
Person in society
Social position
(Participation)
Personal
Physical
Social
Well-beingWell-beingChoiceChoice
Within body

34. Organ (pathology)
WHO ICF model of illness (3)Four Levels Three Contexts
Person (impairment)
Person in environment
Behaviour (activities)
Person in society
Social position
(Participation)
Personal
Physical
Social
Well-beingWell-beingChoiceChoice
Within body
Body & physical environment

35. Organ (pathology)
WHO ICF model of illness (4)Four Levels Three Contexts
Person (impairment)
Person in environment
Behaviour (activities)
Person in society
Social position
(Participation)
Personal
Physical
Social
Well-beingWell-beingChoiceChoice
Within body
Body & physical environment
Person and social environment

36. Organ (pathology)
Disease/diagnosis
WHO ICF Model of illnessFour Levels Four Contexts
Body(impairment)
Symptoms/experiences
Person in environment
Goal-directed behaviour
Activities/disability
Person in society
Social position
Participation, social roles
Well-beingWell-being
ChoiceChoice
Social
Friends,
colleagues
Physical
Close &
distant
Personal
Attitude,
beliefs, etc
T
I
M
E
P E R S O N

37. WHO ICF & holistic healthcare
• Model suggests that a person
Has a body which
•Functions as a whole
– Experiences, skills etc
•Has subsystems
– Organs,
•Interacts with physical environment
Acts as a conscious social being
•Has goals , makes choices, experiences spirituality
•Interacts with other people (social context)

38. WHO ICF model and illness
• Illness arises when the system of:
Person within their context
Fails to adapt to demands (stresses):
•Externally (e.g. prolonged cold)
•Internally (e.g. reduced function of an organ)
• Illness is a phenomenon of the person,
Not of a part of the person

39. WHO ICF & NOC
• Brief discussion of how WHO ICF could
be used to transform NOC
Clinically
Organisationally

40. WHO ICF & holistic clinical
care
• Use it to analyse clinical situations
Identify all relevant factors related to
situation
• Use it to plan holistic clinical management
Intervene in as many factors as possible
•Directly
•Liaise with others

41. Achieving holism clinically
• Key is to consider a person’s social role
functioning
What roles do they have or aspire to?
What roles could they achieve?
Do they have any roles at all, other than
patient?

42. “And lest this last consideration - no mean or
secondary one with Sir Mulberry - should sound
strangely in the ears of some, let it be remembered
that most men live in a world of their own, and
that in that limited circle alone they are
ambitious for distinction and applause. Sir
Mulberry's world was peopled with profligates, and
he acted accordingly.“
(Charles Dickens: Nicholas Nickleby, Chapter 28)
The importance of social roles

43. Changing roles:
an important goal for healthcare?
“The kindest thing anyone could have done for
me would have been to look me square in the eye
and say this clearly:
‘Reynolds Price is dead. Who will you be
now? Who can you be now and how can you
get there double-time’”
Reynolds Price. A whole new life: an illness and a healing.
New York Atheneum 1994

44. Holistic healthcare systems
• WHO ICF model can help organisation

45. Impairment
Activities
Social roles
Expertise - condition
Expertise - locality
Focus changes over time
- Level of illness
- Context
- Type of expertise needed
Acute phase
Pathology
Physical context
Social context
Time

46. Specialist disease service
Specialist rehabilitation service
Locality rehabilitation service
General practice complete service
Self-management
Time course of a long-term condition, and service needs
Acute phase
Post-acute phase
Time
NOC?NOC?

47. Holistic healthcare requires:
• Use of a holistic model of illness to:
Analyse clinical situations
•Understand multi-factorial causation of illness
Plan healthcare interventions
•Multi-factorial, not simply disease-focused
Organise services and notes etc
•Around different levels
Be basis of commissioning and funding
•Condition management not disease management
•Across all boundaries

48. Therefore the NOC should
• Embrace WHO ICF in all its activities
Clinical, planning, administration etc
• Develop seamless relationships with
Community services and primary care
Social services (and others)
• Develop services centred on problems
Of people with relevant long-term conditions
Across their lifetime

49. Summary
• Holistic healthcare requires a comprehensive,
coherent model of illness
• The expanded World Health Organisation
International Classification of Functioning
biopsychsocial model is holistic
• The Nuffield Orthopaedic Centre should
join the Community Health Organisation
to become the first healthcare organisation
to use this model fully

50. Holistic health care
It is our only future!
Dr Derick T Wade,
Professor in Neurological Rehabilitation,
Oxford Centre for Enablement,
Windmill Road, OXFORD OX3 7LD, UK
Tel: +44-(0)1865-737310
Fax: +44-(0)1865-737309
email: derick.wade@ntlworld.com

51. The WHO ICF model
Organ
Disease (actual pathology)
Whole body
Symptoms & signs experienced
Impairments of function implied
Personal context
experience, expectation, attitude, choice, belief, disease label
Social context
Expectations, attitudes, beliefs etc of
others
Quality of life
Participation
Roles, patient’s interpretation
Roles, others’ interpretation
Physical context
Objects, structures, bodies etc
Activities
Behaviour: goal-directed interaction with
environment
T I M ET I M E

52. Holistic health care: our future?
Dr Derick T Wade,
Professor in Neurological Rehabilitation,
Oxford Centre for Enablement,
Windmill Road, OXFORD OX3 7LD, UK
Tel: +44-(0)1865-737310
Fax: +44-(0)1865-737309
email: derick.wade@ntlworld.com