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Too much of a good thing?

I am facilitating a discussion about coaching and its association with systems thinking at a local Community of Practice meeting in Hampshire this week. All sorts of things are floating around my mind about information and activities that I can share with attendees to make appropriate and meaningful connections. I am in the dangerous position of knowing a little about systems thinking while being a surer position in my knowledge and experience of leadership, development and life coaching which, by the way, is my business.

So where do systems thinking and coaching connect? Systems thinking is a means of looking at a system in terms of its parts and how they interrelate and impact on each other. In a change situation systems thinking helps to surface the likely consequences of change in part A on part B (and so on) and how all of these part changes will impact the system as a whole. It is a way of avoiding being the victim of unforeseen circumstance and is particular in raising two important observations (i) the relationship between cause and effect may not be at all obvious and ‘not closely related in time and (ii) ‘today’s problems tend to result from yesterday’s solutions!’

Borrowing ‘systems thinking language’ coaching is about supporting a client to think and feel their way through a change in the complex system that is the human condition. How are the various parts of their system working most effectively to help an individual be the best they can be? What would be the consequence of change in one part, a value, belief or emotion perhaps, on the whole?

Something came up last month that offers a challenge to both systems thinking and coaching. It is something close to all our hearts: our health. More specifically it is what are we going to do about managing our prolific ability to diagnose disease (great news!) and our desire to medicate on the back of that particular diagnosis? A key word here is ‘particular’ because for people with multiple health conditions, often the younger and older generations, the diagnosis and medication for each condition occurs with a worrying degree of separation. It would be scaremongering to suggest that prescription of medicines is not done with care. Of course it is. Every prescribed medication we take comes with clear instructions about dosage and ‘contraindications’ – those instances where the use of a particular drug is at high risk of causing a fairly immediate problem. However, what is less clear are the consequences of taking more than one medication over a long period of time.

So what you might say? Consider these two facts. Firstly multimorbidity, having more than one disease condition (needing treatment) at the same time, is recognised as one of the biggest healthcare challenges facing world, particularly in relation to an aging population. Secondly, a recent report noted that the number of people over 65 taking five or more medicines has risen from 12% to 49% in the last 20 years. Are we really that much more sick compared to 20 years ago?!

I am thinking that increased sickness levels are not behind this polypharmacy. Instead it likely stems from the good news story of how much better and faster we are at diagnosis. We have more effective medications, also great news! We have our brilliant NHS, in both primary and secondary care, treating patients who themselves have an expectation that they will be treated with the best available methods. We have a pharmaceutical industry who are striving to develop ever better treatments at the same time as generating profits for investment in future research.

Actually, I need to be clear about my background here. I started out as a pharmaceutical research chemist at the beginning of my careers and am a strong advocate for what the industry has done for health on a global stage. Although the industry is not without controversy I have no doubt that the world is a healthier place because of these synthetic or semi-synthetic medicines. The complement natural remedies and therapies that offer value too with the exception of homeopathy that has been shown to offer no benefits over and above what you might expect from the placebo effect.

To get back to the story. We now have a situation where a significant number of our population are almost rattling given their medicinal intake and here’s the thing. While their survival is being protected their quality of life is not. We do not have any real mechanisms or capability for knowing when to stop taking long term medications! Patients are often in a position where they don’t want to raise any ‘trivial’ symptoms that might be developing; medics are overwhelmed with treatment and have limited time for review, and all the guidance to the medical profession is geared to when and how to start medication without the same rigour being applied to the question of when to stop. It is not just about health either. If we are over medicating (with no associated health benefit) there is a cost associated which could clearly be used more effectively. There is also the indirect cost of the re-hospitalisation of people with multiple medication.

There are those within the system who recognise this and who are raising awareness of the importance of what they are calling de-prescribing. In England this discussion is being moved forward by the English Deprescribing Network (EDeN) which is drawing on the experience of similar groups in Canada and Australia (you can find out more by catching up with the BBC Radio 4 programme Inside Health that aired on 03/07/2019).

Their challenge is one of dealing with a complex system with different needs for each of the stakeholder communities. Perhaps systems thinking will have a part to play in ensuring a health care future where polypharmacy is as informed by when to stop treatment as when to start it. Coaching might well help with developing action plans considerate of the needs of the different stakeholder groups in engaging in what is something of a culture shift.

Coaching might also help a system wide reflection on what happens when it starts overdoing something that it has become very good at. When coaching individuals who find themselves underperforming it is often helpful to get them to think about what natural strength they might be overusing? Perhaps diagnosis and prescription is a system wide ‘natural strength’ that we have inadvertently over applied and which now needs to be reined back in?

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