What flowers can tell us about designing healthcare services
Oct. 13, 2023
This morning I had a dentist appointment, taking me out of my way and past The Word, an independent bookshop in New Cross. Feeling good that my teeth had been given a clean bill of health I stopped off to pick-up a book, which I started reading on my journey to the office.
The book is Orwell’s Roses by Rebecca Solnit. It’s a quasi-biographical look at the novelist and essayist George Orwell, through his relationship with plants and nature. The book’s starting point is several rose bushes Orwell planted in his garden in 1936 . Solnit reflects on the roses and the symbolism of roses more generally. This triggers a broader thread about the importance of flowering plants to humans and human society. She suggests we often see flowers as ‘dainty, trivial, dispensable’. Yet flowering plants (or angiosperm) are incredibly successful in evolutionary terms. Spread across the globe, seeds produced by these plants form food for a huge number of mammals, specifically beneficial due to the concentrated nature of the energy they produce.
Flowering plants exist in exchange-based relationships with animals, providing food through nectar, fruits or seeds. In turn, animals who eat this food help plants reproduce across wider areas. This exchange and relationship triggered some of own thoughts about how we think about services, particularly in healthcare.
Seeds — services as exchanges
When designing in healthcare services we are often thinking in terms of caring for, not caring with. It is without question that care is paramount with many incredibly dedicated professionals and volunteers making immense sacrifices to do it everyday, in incredibly challenging environments, both locally and globally. However, what is less certain are the types of exchange and relationship which we are delivering.
Caring for represents a paternalistic model of service delivery, based on a hierarchy in which there is an obligation for one party to do something for the other. It leads to experiences which are around cajoling and encouraging patients (as we can see on public health messaging instructing on the dos and don’ts) or around conforming to the system (such as planning your day to be able to do the 8am rush to call the GP).
This is not only the case for interactions between the community and healthcare providers but also between staff in different parts of the care system. Primary and secondary care clinicians make instructions for or, one-way requests of each other. Not only do they do this when caring for individuals, but also when they attempt to restructure their whole systems and services.
So how might we be inspired by the seeds and reframe these interactions as another type of exchange? We need to create a balanced exchange in which both parties have an equal stake. This might be by finding different benefits that each party can gain from in the exchange. An example of this is when you buy something, you get the product that is useful to you the seller receives some money. An alternative is to find a shared benefit between the two parties and focus the exchange on that. For healthcare this could be framing issues not in terms of how a service is badly designed such that it makes it hard for GP or hospital doctor to deliver their care, but instead in terms of the patient and what is important to them as a result of receiving care.
In this way, rather than directing someone else to do something as part of delivering care, everyone can work towards a common goal which is self-evidently important. This framing will also open up more possible solutions and opportunities than previous directives to change. For example, “As a patient, I need to be kept up to date whilst waiting for my hospital appointment” provides a range of interventions that would be more difficult to envisage than when thinking “As a GP I need hospital letters to have a phone number on so I don’t have to deal with so many patient enquiries”.
Flowers — services as relationships
Exchanges are still highly functional representations of services. They are countable and balanced, we can rationally understand, breakdown, analyse and predict how they will work. We can consciously design and model their entirety. But exchanges are not the only things we can learn from flowering plants. To understand more we need to turn to the flower itself. The seeming flourish which accompanies the exchange of food for pollination. Flowers are often brightly coloured and eye-catching, they form a recognisable signal to animals that an exchange is possible. Some flowers form relationships in quite specific ways. As Solnit notes, “the Madagascar orchid [has] a neck so lengthy only one long-tongued sphinx moth can pollinate it”. Here we can see how a relationship (of exclusivity) builds up around the exchange.
Unlike exchanges it is much harder to model and plan relationships across the scale of a system. They can evolve in a more haphazard manner, which are not as easily explainable. However they are incredibly powerful, both for positive and negative ends. Take, for example, a patient who has known their GP for many years and is now referred to a hospital. They are waiting a long time for their operation and want to discuss whether they can plan a holiday next year. They have no obvious connection to the hospital so fall back on their strong existing relationship with the GP who they trust. The relationship is strong driver of this interaction, pulling people towards it, even when the GP might not be best placed to help.
Relationships describe the phenomena of getting reassurance as well as as results from exchanges, getting pleasure as well as progress. If in designing services we do not attend to relationships they are likely to form in ways which might be counter productive, as in the example above. Relationships are highly meaningful and override some of the rational mechanics we might embed into systems.
Gardening is a fascinatingly human activity of attempting to curate, predict and encourage nature to create places which provide pleasure as much as food. If we can learn about exchange and relationships from flowers, how might we understand designing services based on exchange and relationships from gardening?
If we frame our services around exchanges, identify and framing problems in mutually understandable and beneficial ways, then we can more powerfully deliver solutions. Like knowing what type of soil a plant likes, we should take time to understand the motivations of people taking part in services. Catering to their needs when we structure the exchanges, so we can work with their perspectives rather than against them. In practice this may lead to unpicking some assumptions about what the core of services really are. Caring for is a well understood framing, in which the doctor holds knowledge and power and instructs the patient and other clinicians on what to do next. Caring with is much less well understood, but could look like discussions around how to manage long-term conditions to help people live in the ways they wish. That might be about a focus on mobility for an older adult who wants to keep playing tennis or about a focus on self-management for a diabetic young person who is going to university.
And alongside these exchanges we should be nurturing relationships. As with flowers we are powerless to predict their bloom, but we know the conditions necessary to encourage them. We should pay attention to nurturing relationships across whole services, avoiding creating individual people or points where over-dependence becomes a problem. This means facilitating relationships in different ways, helping all care givers appear more human and present in their communities.