Dr Julian Abel tracks the emotional way to good health.
England is about to undergo another reorganisation of health and social care by integrating the two. Theoretically, this should make for smoother referrals between organisations which have not always worked together in a harmonious way.
However, the lesson from major health service changes is that they seem to cost a huge amount of money, increase bureaucracy and often worsen frontline services. Top-down approaches to change rarely result in ground-up improvements.
Meanwhile, the compassionate community project in Frome, a small town in Somerset in the west of England, has taken a very different approach. It is building neighbourliness, friendliness and kindness from neighbourhoods up. The medical practice has integrated the community resources the project has uncovered to remarkable effect.
The primary principle of evolution, we are told, is survival of the fittest. Success is a dog-eat-dog world, with the strongest winning. Although attributed to Darwin, the phrase “survival of the fittest” was coined by the 19th century British philosopher Herbert Spencer. In fact, Darwin was much more interested in the role of emotion and cooperation. His final book was The Expression of Emotion in Man and Animals, published in 1872.
As often happens with science, what you find depends on what you are looking for. Over recent decades, a number of leading scientists, including Professor Dacher Keltner at University College, Berkley, Professor Steve Cole at UCLA and Professor Julianne Holt-Lunstad at Brigham Young University, have all become increasingly interested in the impact of social relationships. They have studied how relationships, loneliness, compassion and the expression of emotion play such an important role in human health.
Julianne Holt-Lunstad published a groundbreaking research paper in 2010 which summarised the evidence that good social relationships were more effective at reducing the risk of dying than giving up smoking, quitting drink, improving diet, taking more exercise, drug treatment of high blood pressure and pneumococcal vaccine. This is curious indeed. How could the way we treat each other have such a strong impact on reducing our risk of dying?
At the same time as Professor Holt-Lunstad had been completing her work, Professor Cole had been looking at the impact of loneliness on our immune systems. He found that lonely people suffered from chronic inflammation, a significant factor in many modern diseases.
How could the way we treat each other have such a strong impact on reducing our risk of dying?
They include heart disease, neurovegetative diseases such as Alzheimer’s Dementia, and the spread of cancer. And surprisingly, he was able to show decreased resistance to viral infections in lonely people. The combination of chronic loneliness, chronic inflammation and the spread of a highly infectious Covid-19 virus has had devastating effect across the globe.
The final piece in this jigsaw of evidence is Professor Dacher Keltner’s work on the social role of emotions. Dacher analysed videos of people speaking, slowing down the video into microsecond frames, and coded and analysed the flickering emotions crossing people’s faces. Through this painstaking analysis, he has been able to show the prosocial role of emotions, discussed in his 2009 book Born to be Good.
But what use is this information?
In Frome: population, 28,000 people, an innovative primary-care physician, Dr Helen Kingston, looked to help people who were suffering from a variety of illness by developing a compassionate community programme for the people of the town. This involved drawing together the large number of activities that exist wherever people gather. This might be knitting clubs, walking groups, Men’s Sheds, choirs, book clubs and many others. There were so many in Frome – more than 1,000, that the numbers displayed on their web directory, available to the public and health care staff alike, had to be scaled down.
Jenny Hartnoll was employed as a community development worker from within the medical practice to collate the wide variety of community activities. And she started so-called talking cafés, places where people who did not want to join a group, could just sit and chat with other community members.
She also employed, a team of health connectors. These are not health professionals but people trained in motivational interviewing. Many patients referred to them for support were not aware that some of their problems related to loneliness. Talking over their problems with a health connector, they were able to develop some clarity and seek companionship, laughter and friendship amongst the community in which they lived.
Jenny also instituted a programme of training community connectors. These are active community members, who know about the talking cafes, the web directory and the presence of health connectors in the medical centre. Knowing what is available in the community, means that when community connectors hear about the problems that naturally arise in conversation, while they may not know the answer, they do know where people can get support.
And this is where the magic starts. In Frome, more than 700 kindhearted people have stepped forward to receive the one-hour training as a community connector. Whether they are hairdressers, café owners or library workers, on average they have 20 compassionate conversations a year. Added together, this is 14,000 conversations of kindness in a community of 28,000 people, with each having a ripple effect of kindness on the people involved, and the ripple effect of kindness that happens thereafter. It is no surprise that people are moving to Frome, based on its reputation of being a friendly town.
The final piece of the jigsaw was put in place by Dr Kingston inside the medical practice. She instituted a programme of building links with the health connectors, so that the routine assessment of patients included questions about their life, their relationships, and their sense of loneliness. Having asked these questions, when people began to speak about their problems, which extended beyond the physical manifestation of their illness, Helen was able to bring in the huge number of community resources to help people develop a sense of belonging in the community in which they lived.
Having come into the project about two years after it started, from a background of end-of- life care and compassionate communities, Helen and I were interested to find out whether the project she had started was having a positive impact on the health of the people of Frome. The figures we discovered astounded us. While emergency admissions to hospital in the county of Somerset had increased by 30%, in Frome they had decreased by 15%.
The outstanding nature of these results was not lost on us. Despite rising emergency admissions being the biggest concern facing health services in the UK and abroad, there are no interventions that have reduced whole population emergency admissions to hospital. To us, we seemed to have stumbled upon a fortunate medical miracle, a side effect of treating the whole person to make them well.
We seemed to have stumbled upon a fortunate medical miracle.
The financial implications are astonishing. Reduction of emergency admissions by 30% in England alone would save about 5% of the total health budget – about £10 billion.
Since discovering these extraordinary results, I have studied and searched still deeper to understand why compassion is so powerful in keeping us alive. That led me to the work of the Professors Holt-Lunstad, Cole and Keltner.
Our work continues to grow across the world day by day. Projects adapting the Frome Model for local interpretation and use are underway in England and Wales and internationally. Part of the Frome work includes social prescribing. All primary care networks in England have a link worker, whose main purpose is to develop social-prescribing schemes. This is a way of linking people who are isolated or lonely with groups in the community, with the hope of providing companionship. A number of medical centres in Florida, New York, and Colombia are also using the community approach.