Building Compassionate Communities to Improve Public Health [transcript]

Written by Christopher Kelly

Jan. 9, 2019


Tommy:    Hello and welcome to the Nourish Balance Thrive podcast. My name is Tommy Wood and today I am joined by Dr. Julian Abel. Hi, Julian.

Julian:    Hi.

Tommy:    Julian is now retired consultant in palliative care in the Southwest of England, an honorary senior researcher at the University of Bradford and one of the leaders of Compassionate Communities UK whose approach has recently shown some amazing results even in the published literature in terms of improving outcomes in patients in the community and I'm really excited to talk to you about all of that work and how we can maybe instigate that in other places as well.

    Before we dive into that stuff, Julian, maybe you can tell us a little bit about yourself, your background, your training and how you got into the things that you're doing today.

Julian:    Great question. Thank you for asking me to be on. Delighted to be here. I'm getting rather ancient now which is kind of funny. I qualified for medicine in 1982 and was somewhat disillusioned with it right from the very outset. I did it for a few years and then I got interested in martial arts and particular that led me on to the model of the Chinese physician in which the Chinese physician serves a community and if people get ill they stop getting paid. I thought that was probably the right way around.

    Anyway, I went and studied acupuncture and cranial osteopathy and did that for a few years. But in the UK at that time, I got a full grant for my studying in medicine and I felt a certain degree of social responsibility of not just quitting because an awful lot of money got invested me. I also got interested in palliative care.

    So, in the intervening years when I went and did the osteopathy and the acupuncture, medical opinion had changed enough to think that it might be quite helpful in the context of palliative care particularly with the acupuncture. I went back, did more studying, did what I said I would never do, and you'll know what this is like, which is a busy medical job. I did one in three. I did my membership at the Royal Colleges of Physicians which is a kind of masochistic post graduate medical exam, which I did, and went into palliative medicine.

    Just through reading around, through thinking about it and also coming across my colleague and friend Allan Kellehear, I got interested in what's termed the public health approach to palliative care but it's a, short way of looking at it is compassionate communities. It's about things that matter most to people who are dying and the supportive networks that surrounds them.

    Through that, through developing a compassionate community program in Somerset, which is a county of 500,000 people in the southwest of England I came across through medical practice and discovered that they've been doing what I've been talking about, they're not just about end of life care but in medicine as a whole for previous couple of years. We teamed up and it went on from there, really. That's a shortcut of my background.

Tommy:    Can you tell us a bit about what palliative care medicine involves in the first place? And then what might be lacking from the traditional model that then you're starting to integrate from this, the compassionate communities perspective?

Julian:    That's a great question. Obviously, people think about medicine as being focused around therapeutics, management of disease, good coordinated care, management of difficult symptoms and all of that. But the thing that attracted me to palliative medicine was that it's a very broad way of thinking about illness and what's going on with people because, naturally enough, if you're faced with a terminal illness then there are plenty of challenges in a variety of different spheres.

    And those include concern about -- it makes you rethink your life and rethink your relationships and you figure out what's important and what matters. And at the same time, there's enough medicine in there, if you like practicing medicine, to keep you interested because managing difficult symptoms that naturally leads on to not just thinking about the patient with the illness but more thinking about the person with the illness and then the context in which the illness occurs.

    Illness doesn't happen to individuals. It happens to caring networks. The impact of illness is felt amongst everyone who is in that caring network. And when you start thinking about what matters most then, actually, if we think about our lives now irrespective of whether we're ill or not, the things that are most meaningful are relationships. It's the people we know and love and the places we know and love.

    And so that you can then start to shift your gaze or your focus from just an illness and managing the symptoms of the illness to the person and what's meaningful to them and then the caring network that surrounds them. You can, through paying attention to those things and stimulating those processes and getting people to reconsider about how they treat each other, you can have absolutely dramatic impacts on illness.


    And we'll talk about it a bit later. But when you start to consider the different impacts of kindness and compassion on how we function as human beings, everywhere you look, there's an impact. It doesn't matter whether you look at biochemistry, physiology, behavior, hormonal, it doesn't matter, social function, all of those things are affected by kindness and compassion. What that means is this stuff is built into our evolution. This is not just a nice thing. It's fundamental to who we are as human beings. That's about the size of it.

Tommy:    The questions I had about how healthcare professionals integrate into the end of life process, which is obviously what you're intimately a part of as a palliative care doctor, is how should we think about death? One of the things that I notice myself as a doctor is some of the heroic, and I don't mean that in a good way, things that I took part in in order to prolong a life that maybe shouldn't have been prolonged, it wasn't in the best interest of the patient, it was in the best interest of the doctor or the family because they weren't willing to let that death happen. Can you talk a little bit about the process of death and how healthcare professionals can or should be a part of that, how they should think about that?

Julian:    I think that, if you think about the kind of traditional model where death is seen as something of a failure and people give up their treatment and it's like, "Oh, no, we haven't won," or whatever that is, that's very much a disease orientated model. I think that there's a shift in focus which can take place which is about, "Well, hold on a minute. This person is suffering from an incurable illness. Now, let's think about what is most meaningful? What can we do as health professionals that will help this person most of all?"

    That then is focused around helping the person come to terms with what's going on, resolving their worries and fears and, of course, making sure they're not in pain or suffering from distressing symptoms. But in addition, it's about focusing on the things that are most meaningful to that person for the end of their life. How are they going to get the most out of their last few weeks or months of life? And not just that. How does a caring network respond to that?

    One of the things that medicine misses is about focusing on the most meaningful things and not focusing on just, "Oh, we got to get rid of these symptoms," or try and cure the illness no matter what the cost. It's really about saying, "Okay, we accept that we're all going to die as human beings. Having accepted that, let's make the most."

    What does making the most mean? People want to be at home because they want to be with the people they love in the place they love. Okay, let's see what we can do to achieve that. And then you absolutely have to deal with the caring network. And then you find that that has traumatic impacts on the caring network in a very positive way particularly in the context of bereavement.

Tommy:    Do you have any thoughts on how we can start to expand that thinking into the broader society of medical professionals such that this becomes a standard or more standard way of thinking about things?

Julian:    You've asked two questions in there and I'm going to answer both of them. The first thing is about how do we persuade healthcare that being compassionate is something that is beneficial? This takes us directly to what happened in Frome. I'll talk very briefly about that. Frome is market town in Somerset of 28,000 people. It's a single GP practice.

    They started a program of trying to do what's best for people and not just thinking about the medical care but thinking about linking lonely people to community resource and asking people about what matters to them and what's most meaningful. They did this in a systematic way. One of the things that we had in common was an enthusiasm for institute healthcare improvement, quality improvement methodology which is a systematic way of doing small scale testing in repeated cycles to be able to build systems reliability.

    We found we have a lot in common. They had put a community development service called Health Connections Mendip into the general practice so that if somebody came in and was lonely or whatever, they could link them directly into community resource. And just to give you an idea about this, if you're suicidal from loneliness and you're suffering from diabetes and your family doctor tries to control your HbA1c which is another story about whether that does any good or not, but nevertheless, they try to control your HbA1c. Actually, you would rather the diabetes carried you off because you're suicidal with loneliness.


    So, it's about saying, okay, let's deal with what matters most to that person and then it's about the social connection. We did all of that and we carried it onto the program, and then we discovered when we were looking to try and keep the funding going to the project that Helen, the lead GP there, said, "I'll write a paper." So, she showed me the paper and I thought I can probably get some better results in this.

    I went and I managed to get hold of some data and we were absolutely staggered to find that there'd been a reduction in emergency admissions. In fact, in the final outcome, there'd been 14% reduction in emergency admissions from the start of the project. At the same time, in Somerset, emergency admissions had increased by 30%. This is over a four-year period. From my previous work, I worked in an acute hospital as well as a hospice, and I got involved in patient flow and was aware of management long term conditions, all that kind of stuff, and I knew that there were no interventions ever anywhere that have reduced population emergency admissions.

    What we come across was it was extraordinary because it was -- I mean, my jaw hit the floor. When I look at this, this is incredible. It's something -- If this were a pill, this would be an absolute miracle. There's a 30% reduction. In fact, its' a bit more than 30% when you compare the difference. It's completely unheard of. And the way that we understood that was that social scientists have known for more than 30 years that social relationships have a bigger impact on mortality, on increasing length of life than any other intervention.

    Julianne Holt-Lunstad at Brigham Young University did a fantastic meta-analysis about social relationships and mortality and she shows that social relationships, good social relationships are more important than giving up smoking, drinking, diet, exercise, treatment of hypertension, pneumococcal vaccine, it doesn't matter what it is. What we figured out how to do was through a compassionate community program we learned to bring that into clinical practice.

    To get around to the question that you asked me, this was about how do you influence doctors or medicine in general about how you bring this more into routine clinical practice? And it's really, for doctors, if you're a doctor, the thing that you're really interested in is improving patient outcomes. And we've been able to show that if you want to give the patient the best treatment you have to include compassionate communities because it's more effective than anything else.

    You can't leave that out. It's a no brainer. At the same time, in the context of how do you introduce this into health services, then it also answers two problems. The first problem is that western health services have increasing numbers of people being admitted to hospital, 42% in the UK increase over the last 12 years. It's a tsunami of emergency admissions and it makes the functioning of hospitals impossible. Until now, there've been no interventions to do it.

    Hopefully, if you're talking to health service managers and commissioners and then they can see at least to some degree, the wood from the trees, they'll know that this is a single biggest problem facing them and go, "Oh my god, there's nothing else that does that. We should be doing that as well." But the other side of it is the money and the money is extraordinary. Through implementing this program we estimate that you would save, just simply through not paying for emergency admissions, you would save more than 5% of the total healthcare budget.

    In UK, total healthcare budget is £120 million, 120 billion. It's probably looking at saving, purely on emergency admissions, of saving somewhere in the region of seven to eight billion pounds. The figures are mind boggling. We feel a little reductive in talking just about emergency admissions because really what we're talking about is population health.

    We can talk about emergency admissions because you can measure it and you can measure cost and it makes it really convenient. You can use it as a primary outcome measure. But, actually, there's a whole host of other interesting things going on, early intervention and catching diseases before they become severe, and one of the long term consequences of that, and then you start looking at the social outcomes of community development which is there's a very well established history about the impact of community development on a whole variety of different communities which can be transformative.

    It's a bit reductive to look at emergency admissions but it's a very convenient handle. We believe that we have a really good reason for saying this should be part of routine clinical care.


    That is, we can demonstrate that it has done something that nobody has been able to do before and have a dramatic impact on health outcomes. We think that's the best reason for doing it.

Tommy:    I'm wondering how else you might be able to easily and conveniently track outcomes such that you can pass out whether the reduction of emergency admissions is also leading to better individual health outcomes. Just because people are not going to the hospital doesn't necessarily mean that they're having a better outcome. People could argue that, let's say that. So, how might you be able to track these individual healthcare outcomes to show the benefit on the other side as well?

Julian:    We measured a variety of outcomes. We're submitting an NIHR grant for doing a prospective study but the type of things we'd been looking at is --you can measure social connectedness. You can look at people's ability to manage their own disease. You can look at the Warwick-Edinburgh Mental Health and Well-being Scale. You can use patient activation measures. Of course, you can use qualitative stories about how people feel about what's going on.

    Everywhere you look with this stuff you see people are delighted with what happens to them. What you might do -- I mean, to get an idea about the impact of this is you can go to the Health Connections Mendip website or Frome Medical Practice website or Compassionate Communities UK website and look at the -- we've had a lot of media interest. There's quite a lot of patient stories up on those websites where people tell you about the impact of what's happened to them.

    Just to give you a clue, one of the things that was started was a men's shed. Now, a men's shed, you have to try and find ways of doing something that appeals to people. Men like to do their DIY gathering in sheds, that kind of stuff. And the social relationships happen along the way. This guy was talking about going to the men's shed. He had suffered from a stroke. And then he struggled to adapt psychologically to the stroke. He got very bad tempered. His wife left him and he felt incredibly lonely.

    So, he joined the men's shed and there's about 25 blokes down there. Of course, he makes friends. This guy is elderly. He describes how if he's feeling lonely and he rings someone up, they never say, "No, I haven't got time for you." They'll say, "Come around and have a cup of coffee." And then he tears up and says, "I never thought I would have friends like this again."

    The heartwarming stories which helped to give a narrative around what's going on in the community are amazing. And when you hear those stories you can really see how this stuff affects people's health.

Tommy:    Just to point out based on what happens through Health Connections Mendip, but it's not just men's shed, it's basically anything that anybody might need in terms of something that people can gather around in terms of their own interests and multiple different groups and community actions can come together. We don't need to -- I'm just thinking in terms of the -- you talked about the stereotypical men's shed but there's just a vast array of options that people can get involved with.

Julian:    I'll give you some more examples. If I talk too much, Tommy, I would say I'm enthusiastic about this, you just have to shut me up. Health Connections Mendip has got four key functions. The first thing that happened was mapping community services, mapping the stuff that's out in the community. In fact, if you look in any community there's an enormous amount of stuff going on whether it's choirs or sports club or walking groups.

    In fact, there were so many that there were too many to put in one place. Jenny Hartnoll, who leads the Health Connections Mendip, cut it down to about 400 and she placed that on a really simple web directory. You've got all this stuff out there. It doesn't matter what it is, whatever interests people. I mean, we do this as human beings. We're not aardvarks or polar bears. We're not solitary animals. We gather together and we talk.

    There's knitting groups or, as my friend call it, stitch and bitch. They serve a really useful function. All of this stuff is on the web directory which is accessible to everyone. The minute you do that, the next thing is, okay, why don't we let community members know about the stuff that's on the web directory? They started a program what they called community connected training because, very naturally, if you know stuff that's going on and you come across someone who is in trouble, you want to help them out. You say, "By the way, this is going on. Here it is on the service directory."

    What happened is that they've done this community connected training. They discovered that after people have been through this training, they're not volunteers, they're just activated community members, that they have on average in a year, say, 20 conversations about stuff that's going on in the community. They've trained a thousand people.


    That's 20,000 conversations a year in a population of 100,000 people. The number of people being trained is just increasing exponentially. You can see that this is an absolutely deep dive into the community. The power of how we relate to each other as human beings is incredible. Everyone is community connected. They just don't know it yet. We all want to help each other out.

    Then the third thing that happens with Health Connections Mendip is around one to one work that the health connectors do. Health connectors are not health professionals. They're people trained in motivational interviewing. They do care planning which is along the lines of, well, what is it that you want to achieve? What matters to you? That creates the opportunity for people to say, "I'd like to get out and meet people," or whatever it is.

    And then you can start to really help people achieve their goals, whatever it is. If they're too shy to go to the choir then the health connector will go with them to the choir. Or if they need a lift to the choir, they'll look at community transport groups and see what they can do about it or they'll work with a supportive network to get the supportive network to function in much more effective ways and gather people around.

    And then, finally, the last bit is about the groups in the community. Sometimes there are gaps. The men's shed was started by Health Connections Mendip. People were interested in it. If community members want to start a group, Health Connections Mendip will help them. In addition, they do things like talking cafes. Talking cafes, our health connector or community connector, someone who knows what's going on in the community will just go and sit in the Cheese and Grain on a Monday morning and anyone who comes in can talk about whatever it is they want.

    In that sense, what you've got is an organized program of community development that is linked intimately into healthcare. The love, laughter and friendship happened along the way while you're doing something else. All you got to do is create the something else and allow people to connect to it and then the rest will take care of itself.

Tommy:    One of the things that I really like about -- Again, this is taking the wording from the paper, is that Compassionate Communities bring networks to people rather than the people having to go and find networks. We know how important or we know the risks that poor health outcomes associated with social isolation but if somebody has deteriorating health, saying, "Oh, do you know what you need? You need more social connectedness," while you sit at home by yourself and you have no idea where to go and get that. I just love how that sort of brings it to people because then you're solving that problem immediately.

    But the other side of that, actually, I was thinking about is that we know how important having purpose and meaning in our lives is, again, in terms of health outcomes. So, you've increased social connectedness for the patients themselves but actually you've also increased the purpose and meaning in the life of the health connectors. So, actually, probably in the long term you're boosting the health of the other people in the community at the same time.

Julian:    A colleague completed a PhD on a compassionate neighbor program in Hackney which is an amazing program because it's a very multicultural area and brought people together. One of the major themes that came out is reciprocity. What that means is that the people who do the giving get as much from it as the people who do or on the receiving end of it.

    I'm not so much an advocate of exchange schemes which seem to be popular in various places because this is really about altruistic motivation, that you're not making a commodity out of compassion, and that when people give from just purely because they want to give without expectation of return then they absolutely know that that's a good thing. You just help someone because it was a good thing to do. People really get that. In the context of meaning and value, that actually adds an awful lot.

Tommy:    In terms of implementing this from beyond the community in Frome, I know it's being expanded out into the county at large and also there might be some information that you have based on the work in Hackney that you mentioned just because I'm thinking about, again, when I was working in hospitals, central London might be slightly more difficult to integrate some of these things into healthcare compared to a small fairly rural community in another part of the country. How might we start thinking about bringing these things into the bigger more multicultural city type healthcare systems?

Julian:    Because we had to bid for -- we have this year on year pernicious process of getting funding for our project. We have to be really clear about what we were spending the money on and what the important components are. With the roll out program in the Mendip area of Somerset, which is about 100,000 people or 115,000, we figured out a program of how you introduce this. What we have is a very organized package. We know what the roles are. We know how much you need to spend and we know how you implement the program.


    So, it costs about £10 per head of population but purely in terms of reduction in hospital emergency admissions, for every £10 you spend you save £60. We then went around the seven health boards of Wales and gave presentations to these health boards and two of the health boards in particular put in bids and have had successful bids for implementing the project.

    What they have is a fully funded project so we are doing the two things of altering how primary care functions through setting up internal hubs for managing all of these people and identifying them and arranging the care planning, et cetera, et cetera, and using a mentoring system within each GP practice and then, in addition, setting up the community development services.

    At the same time, as these projects are getting underway in Wales, then Wales is committed to become a compassionate country. Wales got a population of 3 million people and a certain degree of independence from England and we are in the process of designing a program of how you become a compassionate country. That's got to -- you can look at the Compassionate City Charter which is not a charter for compassion. It's a Compassionate City Charter. You'll find that on the website Public Health Palliative Care International which is, which has got 13 different areas to focus on. That includes running programs in schools, in education institutions, in work places, in religious organizations, it doesn't matter, in nursing homes, in prisons.

    It's a systematic public health approach to making sure that you cover all the major areas and you introduce how you bring compassionate approach into the functioning of those organizations. Just to give you an example, we were running a compassionate community project and I went to a hospice to visit it and the person that was running it said, "My dad died last year. The hospice were amazing. They gave me time off work. Everyone looked after me and made meals, et cetera, et cetera." He said it was fantastic.

    She was saying she was talking about it with a social worker who was visiting the hospice and the social worker said, "Yeah, my dad, that happened with my dad last year. I told my line manager and he said, 'You've got half a day for the funeral,' and it was never mentioned again." You can see how big an impact. If you're a compassionate organization, what an enormous impact that has on your life if you're going through hard times.

    So, the Compassionate City Charter is essentially saying that life's hard times including ill health and death and bereavement and caregiving are a matter for everyone because we are all having to go through it. And so it's a public health imperative because we all need to participate because we are all going to use it. You can see how hopefully what I've described is that there is a systematic implementation program based around the principles of community development using IHI improvement methodology which allows you to build the systematic changes that you make in all the areas that you need to make.

Tommy:    So, if people are maybe trying to apply this outside of a formal healthcare setting, you've obviously mentioned companies, how might we be able to show that this is going to improve the company culture or maybe improve output in terms of how people are working or how productive they are? Do you have any thoughts on how if people are part of a large company or maybe they're in a position to institute some of these things, how can we maybe start to show people that it's worth trying to implement some of these compassionate processes?

Julian:    Measuring, I mean, it's a -- Taking a compassionate approach in companies is a relatively new thing. It will take a number of years to tease out the things that you're talking about. But what we theorize is staff recruitment and retention is much improved, people's enthusiasm for being at work improves and their productivity improves. What we know, and one of the things you never get to hear about has been known from an academic perspective in management is that if you're going to increase productivity, the miracle cure is to treat people well.

    And this has been known in management, in academic management circles for -- I mean, I can remember doing modules back in the '90s, management modules where this was absolutely known about back in the '90s and had been known for 50 years before then as well. It doesn't deviate from what's already known. But being specific and measuring it and showing the changes is going to take a number of years. But we would theorize recruitment, retention, all of that, will improve, contentedness at work and productivity will all go up. Those are the sorts of things you can look at.


Tommy:    Taking part in your training as a doctor, one of the things that is often warned against is becoming too involved. We don't become too emotionally involved because then it's very difficult when that relationship ends with the patient for whatever reason. I'm wondering what your thoughts on that are. Should we be thinking about protecting ourselves? Is that something that doctors or healthcare practitioners should be worried about? If you're thinking about becoming more compassionate, are you putting yourself at risk? Yes or no? Where do you then go from there?

Julian:    I'm smiling, as you can see, because it's a great question and it's something that I always thought was absolute nonsense. It's kind of emotionally tight and slightly autistic. If you can't be compassionate for goodness' sake, what are you doing in medicine, in healthcare in the first place? If you want to be useful, you have to be able to figure, put yourself in someone else's shoes. Because otherwise, it comes back to that old adage that if all you got is a hammer, everything looks like a nail.

    You just think you're going to give people the medicine, do the surgery and then they're better. Actually, as we know, you can cause immense amount of harm through doing that. But if you can figure out what's going on with that person and actually figure out what's meaningful and -- Okay, this leads us into another place which we can talk about now, which is actually give your care with kindness and compassion, then that has a profound impact on the person that you're treating.

    I think that there's a bit about emotional maturity in there as well. I figured out at one point that I wasn't the person with the illness. I didn't have to take on the suffering because I also don't want the suffering. And that kind of freed me to think about compassion but not carrying it around with me. But the other thing is, when we were talking about this before, you alluded to it, what we're saying is that the impact of social relationships has a therapeutic effect.

    You can look at that. We know that. We know about oxytocin, dopamine, whether you're going down the fat burning pathway or carbohydrate burning cortisol that comes with stress and all of that. It's part of us. So, what we're saying is that in the powerful position, the very loaded position you have as a healthcare professional, that you have to be able to demonstrate trust and compassion and kindness and that has a therapeutic effect on the patient.

    And, of course, the implication for this is that if these powerful relationships have a dramatic impact on outcomes, you cannot control, you cannot standardize the relationship between two people. Which means that when you're thinking about randomized placebo controlled trials, your methodology is shot to pieces because you cannot control for individual relationships. And maybe, maybe when we're thinking about placebo, maybe the whole idea of placebo is nonsense. Maybe we're talking about the impact of one human being on another. Like we say, you can measure that in so many different ways.

Tommy:    I guess that's a whole can of worms that you essentially just opened there. You kind of just touched the surface. I know you have quite a few thoughts on the health outcomes of compassion and how that maybe intricately tied into the placebo effect and the therapeutic relationship. Can you expand on that a little bit?

Julian:    Let's say I go to the doctor and I'm worried because I've got some chest pain or something like that. Maybe it's not cardiac pain but I'm worried that it's cardiac pain. And then I go to the doctor and the doctor is just not interested in what I'm saying, not a compassionate doctor, just like the doctor has figured out that this isn't cardiac pain and just cold shoulders me. And then I leave the surgery and I'm still worried about the cardiac pain.

    And then you find, you start looking at what is the impact of that worry particularly in the long term, and you start looking at stress pathways, inflammatory pathways, how that affects eating habits and on and on it goes. You can see that the long term outcomes of chronic stress, I mean, we know what that is with all the -- particularly when you associate it with poor diet and that takes us back to the whole carbohydrate thing and all that kind of stuff. That you can see that a different interaction at that point of contact will have had very different outcomes. And you can start applying that to a whole variety of different things.

    We suspect that loneliness and isolation, we might assume that this is a problem for elderly people who live alone.


    But, actually, it's a problem for teenagers and that you can think that if you have a teenager who may or may not be able to talk about it but is being bullied at school and that bullying continues on social media, we know the long term consequences of bullying which can lead to poor education achievement, drug and alcohol problems, risk taking behavior, mental health problems including suicide, and somebody whole life maybe beset by those kind of problems that happened early on.

    Now, how you approach that as a health professional will have a profound impact on the outcomes. If you think that you have somebody, a teenager comes to see you with stomach pains and you are kind of going, "Okay, well, this doesn't fit into your traditional recognizable pattern that I can name it as a disease, what else is going on?" And then you start progressing down that route. And then you have that enormous community resource at your fingertip.

    When you start looking at the size of the resource, you may have a compassionate schools program which is where the children have figured out what to do about bullying and you can link those people up and find how they support each other. I mean, we see incredible examples of it in the media where a child is bullied and then people respond in amazing way.

    When you start thinking about broadening your therapeutic outcomes you can have a dramatic impact on what happens to the people you're caring for and that is through compassion. That is through simply putting yourself in someone else's shoes.

Tommy:    Can you talk a little bit about the system in which this happens? I'm thinking about your cold doctor dismisses, maybe measures your troponin level, says you're not having a heart attack, go home, there's nothing wrong with you, they've sort of ticked that box, said it's not the acute life threatening thing that I'm there to deal with, are they maybe cold and calculating like that because they only have five minutes to talk to you? Because they're not in a system that allows them to have the time it takes to show that compassion. And is there any scope to change some of that?

Julian:    Yes is the answer. For this to work, we have to figure this out. So that the first step is if you have a community development service and you got a service directory you can have your service directory opened during the clinical consultation. If you want to see what a service directory looks like, you can go to or, I can't remember which, but the service directory is there.

    You can see that if a conversation arises, which goes beyond the medical, you can just click on the relevant bit of the service directory and that comes up as some resource that somebody may be interested in following. You can just click on whichever of those resources which interest them and print it out and give it to them. This doesn't take more time. This is something that you can do within the context of a short consultation.

    What happens is when you do that and you alter the health outcomes then people don't use medical support for problems which don't require medical support. And just to give you a clue about how you can take that into clinical practice in a hospital setting, there's an interesting project going on in Birmingham, in the accident emergency department, because when you look at how things have changed, who's attending emergency departments these days compared to how things were in the past, where does the increase in admissions come from, it's not just that elderly people are flooding into hospitals. This is across all age groups.

    A friend and I are writing a book about this and he coined a great term. He's saying what we're suffering from is malnourishment of compassion. If you're a young mother and something is going on with your baby and you don't know who to turn to because you haven't got that kind of supportive network around you, you end up going to hospital.

    What they've started to do is that they've started to have people in hospital in the emergency department who can link people coming into community resource. That's actually -- you can stop hospital admissions. You can stop people unnecessarily seeing health professionals when they don't need to. You can take this argument even further because what we're saying is that you're turning your people in your emergency departments into community connectors. They can signpost people to stuff that's going on in the community.

    You can extend that because you can think, "Well, the police would be really good at that. What about the fire brigade?" And then let's think about, if we're thinking about compassionate organizations, I came across this example the other day, is that the people who go and disconnect people's electricity because of them not being able to pay for their bills, they're actually going to people's home and then start having conversations with the people, like you do, and they discover that actually if you disconnect this person's electricity you're going to cause an incredible amount of harm.


    If you can think about the different resources in the community that you'd be able to signpost to people towards, maybe it's debt management, maybe it's some kind of -- maybe they have a caring problem. It doesn't matter what it is. You can actually think that this is a way of bringing everyone on board including hospitals. It's not time consuming. It's just kindness and compassion.

Tommy:    There just seems to be no downsides to any of this. If you're a bean counter, you can talk about the financial benefits and if you're a human with feelings you can just talk about how you know, you just know these little right things to do and how important those connections with other humans are. I'm really excited about where you guys are going to be taking this and what some of the outcomes are. It's been fabulous. I'd love people to find out more about you and your work. Maybe you can tell us about where they should go for that.

Julian:    We will slowly keep updating the Compassionate Communities UK website. There is continued media interest. In Frome at the moment, a German TV company spent the last four days there. It's worth looking at the Frome Medical Practice, Health Connections Mendip website and that we're continuing to write our schools and we're going to write a book and we're planning a TV documentary.

    Through a relatively small article in a magazine called Resurgence, which got a circulation of 7,000, that led to an article by George Monbiot in the Guardian and that led to worldwide interest. It was absolutely extraordinary. This continuing interest just goes on and on. And we expect that will continue so unless we're just totally wrong and mistaken you'll be hearing more about it anyway. And it's worth going to the British Journal of General Practice website and just checking out the article and seeing where we go from there.

Tommy:    We'll absolutely post links to all those things in the show notes. I definitely recommend that people go and find that. Also, I wrote a short piece about the paper itself in the highlights email and we'll put a link to that if people want to read that as well as George Monbiot's article which is great. Thanks so much, Julian, for your time. This is really a lot of fun.

Julian:    Pleasure to talk to you.

[0:42:21]    End of Audio

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