Dr Gray’s Walking Cure

Exercise! exercise! exercise! what do these words conjure up?  The gym, sweat, leotards, slimming, living longer, getting fitter, obesity, cancer, diabetes, heart disease.  Take more exercise is the general advice but how should this be done easily, enjoyably and cheaply?  Daily walking as the answer hardly gets a look-in when the different options are considered, but it is the simplest, most freely available, and medically by far the best of all possible answers.

Walking is the way mankind has kept fit for purpose ever since evolutionary times.  The reasons why we don’t do it enough in developed countries now is because we have made it just too easy NOT to do it.  This book sets a challenge, which you can easily achieve – to walk 1,000,000 EXTRA steps between 2009 and 2013 – revolutionising your daily life, your health, and your carbon footprint.

Walking Plus means walking plus a few minutes of exercise to increase all four aspects of fitness

  • strength
  • stamina
  • skill
  • suppleness

Erewhon Healthcare System

A system is a set of activities with a common set of objectives and an annual report. For each objective one or more criteria are identified to measure progress or the lack of it and for each objective standards have been agreed and there are three standards:

  • A minimal acceptable standard, for which no service should fall;
  • An excellent standard, the best standard of care in the world;
  • The achievable standard, the level of performance that distinguishes the top quartile of services worldwide from the rest.

These 3 levels of standards have been chosen because experience has shown that simply asking people to be the best, an approach once popular based on the book called “In Search Of Excellence” can be disheartening to those who are far away from the best or for those who see the best services delivered by what they perceive to be services privileged by either an excellent investment or rich resources, for example by charismatic or excellent people, as a result of chance. By identifying the achievable standard however is usually possible for a service in the lowest quartile to being shown a service serving a population in the top quartile which is very similar in terms of wealth and deprivation. Services in the top quartile can of course be encouraged to try to equal the best and the best service itself will be constantly looking for ways to do even better.

Systems of care are based on symptoms such as headache or pelvic pain, on diseases such as bipolar disorder or asthma or stroke or on population subgroups such as children or frail elderly people or people with the triple diagnoses namely physical health problems, psychological health problems and substance abuse, sometimes called people with co-morbidity.

It is useful at this point to distinguish between complexities and complicated because when describing the systems approach of Erewhon to clinicians from other countries they often remark that people have more than one condition. We recognise that maybe people have complex problems, for example an 81 year old woman with 4 diagnoses and 7 prescriptions who is looked after by her 52 year old daughter who lives 2 miles away and who has an alcoholic abusive husband and an unemployed son living at home. This is complexity but it is the need meant frequently by general practice or family medicine. Generalists excel in the management of complexity. Of those 4 conditions diagnosed one may cause problems from time to time requiring referral to a specialist because the problem has become too complicated for the generalist. Specialists excel in managing the complicated. The relationship between generalists and specialists need to be carefully worked out but the distinction between complexity and complicated is accepted as part of the language of the Erewhon Health Service.

Erewhon Healthcare – The Best in the World

Erewhon has a population of 5 million people. It is a population with an age distribution typical of most developed countries with about 15% of the population over the age of 65, and the population is ageing. Most live in cities, with two big cities each with a medical school, and city living is increasing and there are some thriving towns and some depressed industrial areas and large sparsely populated rural areas.

The economy of Erewhon is improving slowly but taking into account the impact that population ageing has on health and social care; it is wise to work on the assumption that there will be no real increase in resources available for health and social care.  The population of Erewhon is covered by a payment system that is based on combination of tax and insurance but the responsibility for health services is discharged to 10 geographical areas each with a budget taking into account age and deprivation. They have the responsibility for resource allocation; the responsibility for health service provision is based primarily on programmes and systems. Each of the populations, served by the Health Boards called A-J, happen to have a hospital, largely for historical reasons, with two of them being larger teaching hospitals and there are ten Mental Health Services and about 50 general practice teams in each.

Ten Key Value Questions in Choosing Healthcare

For decades to come need and demand will increase faster than the resources available. Society will need to maximise value from the resources it allocates for public services including healthcare and to do this ten questions need to be addressed

Question 1: How much money should we spend on healthcare?

Question 2: Is the money allocated for the infrastructure that supports clinical care at a level which will maximise value?

Question 3: Have we distributed the money for clinical care to different parts of the country by a method that recognises both variation in need and maximises value for the whole population?

These questions are primarily the responsibility of the Cabinet and the Secretary of State for Health. Then comes the role of the Commissioners. They will want they resources they allocate to be used in ways that have a positive answer to questions 5-10 but they hold those to whom they have allocated resources to do this. The answer to Question 4 is, however the primary responsibility of commissioners. It is important to note that specialist commissioners produce some of the answers to question 5 but do so with regard to the effect their decision this has on the distribution of resources to the different and the thirty sub groups of the population outlined in Appendix 1

Question 4: Has money been allocated to different patient groups in a way that is not only equitable but also maximises value for the whole population?

Question 5: Are all the interventions being offered likely to confer a good balance of benefit and harm, at affordable cost, for this group of patients?

Question 6: Are the patients most likely to benefit, and least likely to be harmed from the interventions, clearly defined?

Question 7: Is effectiveness being maximised?

Question 8: Are clinical risks being minimised?

Question 9: Can costs be cut without increasing harm or reducing effectiveness

Question 10: Could each patient’s experience be improved?

This game focuses on Question 4 which is not only a responsibility of commissioners. They have to make decisions about the allocation of resources between programmes, for example between respiratory disease and cancer. Clinicians will be responsible for the allocation of resources within programmes, for example between asthma, COPD and sleep apnoea within the respiratory programme budget and, with patient involvement making decisions within each system , and the STAR tool is a related game designed specifically for this purpose (2)


There is a negative, over pessimistic view of old age and older people. This derives partly from a failure to understand how many of the problems of old age are preventable and are not due to the ageing process. Poverty, for example, leads many people to withdraw from society but it is not a consequence of ageing. It is a consequence of social inequality and injustice. Some individuals can retain a positive attitude in the face of the these negative pressures but this requires resilience and a definitely decision to think positively about one’s position, capabilities and potential.