This is a summary of the May 2023 COIN discussion, to be seen at https://www.youtube.com/watch?v=NY-Z3Qi6m-M.

It is poetic that Donald Trump applied for re-election as American President in the same month (March 2023) as World Piano Day and when the film ‘Everything, Everywhere, All at Once’ won seven Oscars. They highlight three different ways of thinking and acting (‘paradigms’, ‘domains’) that healthcare needs: 1) A way of thinking that imagines that the world operates in isolated compartments (useful to make medical diagnoses), 2) A way of thinking that imagines that the world has lots of different parts that can be combined to make different ‘tunes’ (useful to understand bio-psycho-social-spiritual aspects of Health), 3) A way of thinking that imagines that everything is adapting to changes in everything else, co-creating multiple, overlapping stories (useful to understand Meaning). 

We expect generalists, like General Practitioners (GPs) and End-of-Life (EOL) Carers, to do everything, everywhere, all at once. We also expect them to have simple answers to complicated problems. So, they need to know how to use, and integrate, these three paradigms.

The three paradigms are not contentious. How to integrate them is. Complexity theorists, like Fritjof Capra, call them Simple, Complicated & Complex. Researchers, like Egon Guba, call them Positivism, Critical Theory & Constructivism. Each paradigm thinks quite differently from the other two so they cannot be integrated in Simple ways.

Yvonna Lincoln and Egon Guba describe how to integrate them - 4th Generation Evaluation recognises that Simple and Complicated fact(or)s are snapshots of Stories-in-Evolution. ‘Hermeneutic dialectic’ allows people to stand back and consider various perspectives, then adapt to co-create the evolving story. Small, ongoing co-adaptations develop communities as multiple “I’s” become overlapping “We’s”. A similar process is advocated by Learning Organisations - cycles of collaborative inquiry and coordinated change help people to stand back and consider their roles inside evolving stories, then get their heads down to do their bits before the next review. This potentially aligns the actions of Researchers, Educationalists and Practitioners who usually, unhelpfully, operate in isolation from each other.

Cycles of learning & change build relationships – in families, projects, organisations, localities… Also in GP consultations and EOL situations. They help to combine Short- & Long-Term Concerns, Individual & Collective Identities, Public Health & Primary Care Practice. University-Linked Localities, working with Primary Care Networks (PCNs) and Integrated Care Boards (ICBs), could promote them as part of Community-Oriented Integrated Practice.

Those who think that these three paradigms are different versions of the same thing prevent understanding, including ‘Far Left’ and ‘Far Right’ political positions – both prioritise the first two (Simple & Complicated), resulting in naive strategy to defeat ‘the enemy’. Doctors too – we are trained to identify individual diseases and kill them with powerful drugs. We need strategy that empowers as well as controls.

In my book, Collaborating for Health, I argue that the human brain is pre-wired to recognise these three paradigms. That is why we instinctively recognise them but don’t think about them. We don’t notice the different ways we think when we eat a Ready Meal (Simple), follow a recipe (Complicated) and create a new dish (Complex); nor when we appreciate an individual Tree (Simple), its (Complicated) Nutrient Flow and a (Complex) Garden. We do, however, appreciate their difference and inter-dependence when we try to change something. A Healthy Death requires change in all three: 1) Individual problems (like toileting), 2) Interconnected concerns (like care), and 3) Developing communities to share the load and make good things happen.

These two videos (5 and 9 minutes) show the good that can come out of weaving together these three ways of thinking:  In 2009, we used them to develop primary care in Southall; in 2019 to develop a community around my home when my wife was dying. 

 With support, EOL Carers can do this. First, they privately describe their concerns to a facilitator who helps them to form Core Caring Teams. A Course helps Carers (or Caring Teams) from the same locality to facilitate cycles of learning & change that build supportive communities around their situations. Professionals participate, integrating care in ‘horizontal and vertical directions’, using mobile phones for ongoing time-efficient support. 

Local groups can help to build a supportive culture - Pharmacies & Undertakers; Voluntary, Community & Faith Groups; Schools, Musicians, Sports & Arts Groups…. 

Evaluation of whole Primary Care Network areas can find out if this approach is Time-Efficient, Cost-Effective and Health-Creating. 

Paul Thomas.