Brief introduction to Hodges' model

Hodges’ model is a conceptual framework of universal value in theoretical work, practice, policy and care management. While this model is a product of the health-education sector, it is global in scope, taking in the current situation, history and future as complicated by scientific, socio-political, technology and climate change. Practice-based, Hodges’ model is a tool simple in form and yet powerful in terms of how it can help users frame the problems and opportunities of the 21st century. The model was originally taught in studies for the post-registration certificate of care of the mentally ill in the community and other courses. Student assessment included the completion of a case study (vignette), demonstrating competence in application of the model and its embedded (implicit) values.

Access to education, especially early years, is emphasised as foundational for personal and community growth and development. For individuals this can set the course for lifelong learning and an ability to contribute to society and the economy. Given this primary challenge, global institutions and policy makers point to the need for curricula that are relevant. In turn employers and industry leaders need a (global) workforce who are: 

• reflective practitioners;
• critical thinkers;
• able to see the ‘big-picture’; and focus on detail and priorities when needed (risk and triage);
• decompose a problem, but also integrate (care);
• work as team-members;
• and extend across several literacies.

These challenges are ongoing for education (being health literate, so as to address personal, social, health and economic education, and the sustainable development goals), and increasingly climate impacts.

ii Book: 'Complexity in Health Care - A Paradigm Shift for Clinical Practice'

I didn't have time to finish reading Frankel et al. before WCCS26. This book has an index which was very useful, to efficiently check certain points. It is amazing the number of books without an index.

Chapter 1 is 'Guiding Principles' and links really well with the index. At two pages it is brief and yet also constitutes Part 1. 

Part II The Clinical Situation, continues an introductory thread. Chapter 2 The “Clinical Situation”: An Introduction to Its Structure and Complexity is what attracted me to the book. At five pages, there was more in this vein. I looked ahead and found that the chapters all seemed short. Checking the book's web page, 50 chapters in 270 pages, so just over 5 pages and well referenced too.

Initially, you might feel short-changed, of course, I didn't with a review copy. But don't worry. You are in patient- person-centred hands here. Sometimes content matters. The three authors work and are researchers in psychiatry. For me, the guiding principles and part II provide a handshake with the index. The person here then, is given a literary hug. Immediately, there is a link between the variables of care and the structure of a case (or caseness). 

'But importantly that "structure" is dynamic changing over time. We classify variables as "clinical" as they are brought into play for the purpose of treatment, i.e., the goal of healing.

The clinician is not just challenged to unravel this complicated situation but also to represent the patient accurately, including his or her "human" elements as represented by temperament and personal attitudes. What are the patient's essential needs. tolerances, preferences? Yet, there is even more to know about each patient. Does she have children? What is her financial status, her ethnicity? What are her attitudes about medical professionals. Does she believe in medicine, or even in science?

Beware! None of these factors are dispensable when trying to understand a patient. Just try to leave out a few and you are left with a gutted rendering of that person, not a living human being.' p.7. 

(and continued in fragmented form below ...)

individual

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INTERPERSONAL : SCIENCES

humanistic ------------------------------- mechanistic

SOCIOLOGY : POLITICAL

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group

'The result even when this level of detail, is available may still be an anemic version of the patient.    Traditionally a medical patient is subjected to an extensive workup that includes a mental status examination, in addition to a detailed past and present history, ...	... and an extensive "review of (organ) systems.
Now add the multiplicity of problems, psychiatric and systemic medical, from which the patient suffers. ...	Multiplicity may include systemic medical, psychiatric, social, financial, and lack of access to health providers.' p.7.

'From this description it seems logical that complex patients presenting with mixed medical-psychiatric disorders be managed with an ongoing collaborative approach delivered by a multispecialty team. Included may be a primary care physician, psychiatrist, and/or psychotherapists. One or more of the collaborating professionals may be a nurse practitioner and/or a physician's assistant.' p.7

I will return to the 'logical' in the final quoted paragraph above. The author's declare their intent from the outset, and by the literature-to-date they achieve this (may I please add? 'in spades!').

 

Over the years and as raised on W2tQ, several colleagues and contacts have asked "Where is the book on Hodges' model?" Not to sound weird, but this book asks that same question through some challenges to the usual 'medical' text. There are several lessons to take away here, even if only to keep a dream alive. While the physical size of a textbook, its practical appeal and stance makes it appear as something to pop in your top shirt/jacket pocket. A pocket guide: quite an impression just 10-20 pages in, and in this digital age.

 

As you would expect from mental health practitioners - psychiatrists - psychotherapists, interpersonal, subjective-objective and intersubjective factors are integral to how complexity is defined and measured. In Chapter 2, pp.11-12 there is mention and reference to the Value-Based Integrated Case Management Complexity Assessment Grid:

Specker, S., Andrew, R., Drexler, E., Koithan, E., Thurber, S., & Frankel, S. (2026). Development of the Self-Administered Health Complexity Screening Instrument. Professional case management, 31(2), 81–89. https://doi.org/10.1097/NCM.0000000000000845

I will check this instrument as I complete this review. As noted on April 9th this book was published in 2023, so I remain grateful to Daniela and colleagues at SpringerNature for the review copy (which also enjoyed WCCS!).

Previously: 'complex' : 'holistic bandwidth' : 'mental health' : 'person(-centred)'

More to follow ...

Steven A. Frankel, Steven D. Thurber, James A. Bourgeois (2023) Complexity in Health Care: A Paradigm Shift for Clinical Practice. Cham. Switzerland: Springer. ISBN: 978303114948.

Global Experts call for Paradigm Shift in Medicine, Health and Education to Save Lives and Fight escalating Health Crisis

ACCESS NEWS WIRE – for PRESS RELEASE on Tuesday, 28. April 2026

A global consortium of 64 experts (72 entities, 5 continents) unveiled two coordinated consensus plus policy brief reports, outlining a science‑driven roadmap to confront escalating health crises and to tackle the growing burden of noncommunicable diseases (NCDs—including cardiovascular diseases, cancer, diabetes, etc.: 75% of global deaths; 82% in low-/middle income countries; 90% of all death in European region).

The centerpiece is HEAL—Healthy Eating & Active Living, ideally whole‑food plant‑predominant/vegetarian-vegan diets & daily exercise outdoors/active mobility—as the minimum, first‑line standard in health and care. The authors urge immediate action on Prevention-over-Treatment and reforming education and human‑relevant science (drug failure rate from animal studies is 90-95%, and as high as 99.6% for Alzheimer disease), with a rapid shift from disease‑centered reaction to person‑centered, lifestyle‑first cure and care.

Figure 1. HEAL means choosing a whole-food, plant-predominant (ideally vegan) diets coupled with daily exercise outdoors/in nature to kick-start better health. Credit: iStock/LightFieldStudios.

“Sustainable health is for free but cannot be downloaded or prescribed—it must be lived daily and earned across lifetime through informed lifestyle choices, with HEAL as starting point. As childhood-entrenched health literacy lasts a lifetime; embedding HEAL from primary to tertiary education is the policy priority of our generation.” —Lead author Katharina Wirnitzer | PHT, University of Innsbruck & CCCTIM

Foto 2. Katharina Wirnitzer/Keynote on Vegan Diet in Sports. Credit: ©Katharina Wirnitzer.

Why change is imperative.

• The paradox: Despite rising health spending and scientific advances, public health gains lag while ever-growing NCDs. The expert panel offers 101 consensus statements and a 10‑step policy roadmap to act across the lifespan—from individual behavior to population‑level change.

• Why HEAL, and why now: HEAL combines Healthy Eating (whole‑food, plant‑predominant; preferably vegetarian/vegan) with Active Living (regular, ideally daily, including outdoor activity and active mobility). Evidence shows synergistic benefits beyond either alone, reducing reliance on drugs and surgery while improving resilience and sustainability of health systems.

• Prevention-First (3:1): The reports recommend prioritizing prevention, health maintenance, and health promotion over treatment by 3:1 (Figure 3), making healthy choices the easy, first‑line intervention and reserving medicalized treatment for specific indications.

• Education and workforce: Embed HEAL from primary through tertiary education and continuously upskill healthcare and education professionals to deliver evidence‑based lifestyle counseling, routine assessment, and monitoring. Improve meal standards and support active mobility in schools and public spaces.

• Human‑relevant science: Accelerate the transition to non‑animal, human‑relevant methods for basic and preclinical research and for efficacy, safety and toxicity testing through funding priorities, validation, and regulatory adoption.

• Policy roadmap: Apply Health in All Policies (HiAP) to link individual choices with systemic supports (Figure 4); invest in supportive defaults (healthy public catering, active transport, public‑space design, community HEAL programs); embed HEAL in curricula; and track outcomes with robust evaluation to scale what works.

“Every dollar/euro invested in evidence-based prevention saves multiples in treatment. HEAL is the smartest first investment a health system can make.” —Bernd Haditsch | ÖGK – Austrian Health Insurance Fund, Prevention Unit
“Obesity is a disease with powerful drivers. HEAL gives every patient a proven, first-line foundation to reclaim their health.” —Fatima Cody Stanford | Harvard Medical School & MGH
“A doctor who cannot counsel patients on the Power of Lifestyle, especially on food and movement, is only half-equipped. Lifestyle education in medical school is the missing foundation of modern medicine. Helping our patients to eat a more plant-strong diet is the most powerful healing medicine we can prescribe.”
—Michael Klaper | Moving Medicine Forward
„Plant-forward diets provide a powerful opportunity to concurrently improve health and wellbeing for people, farmed animals and the environment.“ —Andrew Knight | Griffith University

Figure 3. Four areas-of-action, balanced 3:1, to achieve lifelong health. Credit: ©Katharina Wirnitzer.

“Given its cost-effectiveness, Traditional, Integrative, and Complementary Medicine will be the evidence-based mainstream of tomorrow’s global healthcare.” —Tomáš Pfeiffer | ITCIM & SANATOR
“Treatment alone will not sustain health systems. HEAL connects prevention, lifestyle medicine and integrative care to advance salutogenesis on a planetary scale. We must invest far more in creating health.” 
—Georg Seifert | WHO CC & CCCTIM, Charité Universitätsmedizin Berlin

“The science clearly shows that, when it comes to human health, animal protection is a win-win.
Given human health’s complexity, and since animal testing virtually fails to cure human diseases, human-relevant methods already outperform animal experimentation and must therefore be implemented with priority in science, with funds going to human-focused research.
Citizens in the EU and US have spoken clearly in favor of this transition.
HEAL can prevent many diseases, avoiding the need for animal studies altogether.“
—Merel Ritskes-Hoitinga | Universities Aarhus & Utrecht; Doris Wilflingseder | Vetmed Uni Vienna, Aysha Akhtar | Center for Contemporary Sciences, Corina Gericke & Gaby Neumann | Doctors Against Animal Experiments

 

Figure 4. Systemic application of HEAL to reach target groups and improve personal and public health across micro (individuals/families), meso (communities), and macro (state/government/federal policy) levels, ensuring optimal vertical and horizontal permeability and integration. Credit: ©Katharina Wirnitzer.

Key Actions at a Glance.

• Make HEAL the universal starting point and minimum, first‑line prevention standard.

• Implement lifestyle‑first counseling before routine prescriptions.

• Prioritize Prevention-over-Treatment with an 3:1 balance.

• Mandate lifestyle education in schools; embed HEAL across tertiary programs.

• Continuously upskill professionals for evidence‑based lifestyle counseling and monitoring.

• Accelerate adoption of human‑relevant methods to end animal experiments in research, education and regulatory testing.

  
  

Figure 5. The Power of Lifestyle: Start with the dual HEAL approach across 6 interconnected areas to improve health and well-being. Credit: ©ACLM. Graphic modification: ©Katharina Wirnitzer (permission: 24.11.2021).

Contact for further information

Katharina C. Wirnitzer—Professor for Sports Public Health with a special focus on Child Public Health

Email: katharina@wirnitzer.at | Cell: +43 (650) 5901794

University College of Teacher Education Tyrol (PHT), Innsbruck, Austria

ii 'GlobalMinds' - NHS study severe mental health problems

GlobalMinds has clearly stated goals and objectives. Three challenges that are highlighted:

1. Diagnosis can take years
2. Treatments target symptoms, not underlying causes
3. Half of the prescribed drugs cause severe side effects

These are, to put it mildly, highly contested issues. Diagnosis in mental health/illness is problematic in several respects, for example:

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a) Lack of Theoretical, Practical and Philosophical(?) agreement between:  Psychology Psychiatry b) Individuals are self diagnosing c) Access to mental health services can be highly structure - single-point entry d) The evidence-base for treatment of mental illness is growing,but remains contested. e) Perhaps there is a phenomena of people getting stuck, with not just a label, but a mindset?	a) Loss of trust in classification/coding schemes: DSM b) Proposed alternatives in - Power Threat Meaning Framework HiTOP c) Data defined scientifically: existing diagnosis biomarker
a) Increased awareness of mental illness, ADHD.. b) Behavioural explanations for mental illness c) The determinants of mental illness (unlike, health?) are poorly researched (hence understood) d) The vocabulary of mental illness (psychiatry) is more widely disseminated, hence used; not necessarily with full contextual understanding e) Stigma associated with mental illness is nevertheless ongoing.	a) Reduced economic productivity b) The socio-economic phenomena of NEETs c) Increased demand on welfare benefits d) The role of primary care - GPs      - fit / sick notes      - 'functional assessors' (Who is best placed?) e) Loss of mental health beds, community compensations incomplete.

This will be a space to watch: and related (global) initiatives? 

Viewed from Hodges' health career - care domains - model, it appears an individual's life chances and expectations (family, and educational experience?) can result in their life chances being frozen?

Thoughts ii re. 2026 Lancaster Philosophy of Psychiatry Work in Progress Workshop

For me, applying Hodges' model I tend to place philosophy and psychiatry (mind, thought, belief, truth, intention ...) within the humanistic part of the model. So, Ewa Grzeszczak and - Philosophy of psychiatry and the methodology of social ontology - stood out. This is helpful as Homeostatic Property Clusters (HPC) are a useful structure, spanning bio-mathematics. As suggested previously with 'equality', we can place the philosophical non-trivial question of kinds at the centre of Hodges' model and proceed (if possible?) from there.

The requirement for a holistic, integrative and pluralistic framework is there in literature. A statement supported by Alessandra Civani's talk: 'What kind of concept is ‘incongruence’? I located a paper:

Enactive psychiatry - A pragmatic and pluralistic approach to mental health and disease

- (and now have a copy c/o and thanks to Alessandra) and am grateful to being pointed to de Haan:

An Enactive Approach to Psychiatry

 I will (must) return to these papers. Earlier on Hodges' model, I'd opined (as on 'X') how the -

• medical
• biomedical
• bio-psycho-social models - are insufficient in the 21st century.

There was a thematic feel to the presentations with Anna Golova - Self-illness ambiguity without a self-illness distinction - following nicely. The styling on the slides was an added bonus. I located an informative (co-authored) paper by Golova:

‘Is it me or my illness?’: self-illness ambiguity as a useful conceptual lens for psychiatry'

Part of the power of Hodges' model derives not so much from its duality; as its dual axes. The two axes can encompass and handle the relatedness between/within reductionism, holist perspectives, the self and otherness, illness and health (well-being).

An hours break brought us to an event which was very well attended, clearly open to the public:

6-7pm Prof Miriam Solomon – Royal Institute of Philosophy talk ‘Stigma as an actant in the history of psychiatry’

In setting out the talk's structure I liked Prof. Solomon's reference to the common, implicit "grime" theory of the dynamic of stigma, and "punching down" as a strategy for managing stigma. 'Grime' made me think of sense of smell, the grime in my father's work van, a diesel. Now so many memories are evoked with the merest whiff. More positively, the patina of physical and mental life also came to mind. You would - might think stigma has been dealt with by now, but of course we are socio-politically far from it.

There is a related podcast from 2025, which also covers Prof. Solomon's early studies. A previous paper was also noted in the slides:

Solomon, M. (2025). The Elusiveness of Hermeneutic Injustice in Psychiatric Categorizations. Social Epistemology, 39(2), 166–177. https://doi.org/10.1080/02691728.2024.2400068

 

Discussion of the DSM inevitably followed (and in the above podcast). In questions the 'reality' of severe mental illness, and suggestion of the acute challenge of managing the negative symptoms of psychoses.

 

Prof. Solomon's conclusion was well worth waiting for, including:

Stigma as an "actant" (cf. Bruno Latour's concept of an agent: causal role without intention)... DSM - ICD...

 

If stigma disappeared tomorrow, the DSM would not have the same categories. 

 

Stigma (more specifically, its management) is shaping the conceptual space, with both scientific and moral consequences.

[Added 4th March...] On Friday - Sam Fellowes, took on, or has taken on - the non-trivial issue of - Modelling psychiatric diagnoses when self-diagnosing - how does this work? Complexity was acknowledged on the first slide, with self-diagnosis, and modelling, set against the Duhem-Quine thesis. 

This technical aspect is welcome and no doubt essential given the socio-technical nature of diagnosis, touching as it does the public (society), primary care, psychiatry, service user groups, policymakers, informatics, and HM Treasury, amongst several 'stakeholders'. With the impact of the internet and social media, much (if not all?) of the vocabulary of mental health professionals has been co-opted and re-framed(?) by patient / service-user groups? It does not, for example, appear that the agency behind the DSM will be able to claim it back. Autism and ADHD were also discussed and debated. I located a previous chapter by Sam (pay-wall):

Fellowes S. Self-Diagnosis in Psychiatry and the Distribution of Social Resources. Royal Institute of Philosophy Supplement. 2023;94:55-76. doi:10.1017/S1358246123000218

 

This really is a thicket of thorns, it spreads as and wherever you go.

 

The welfare bill is such that there should have been government Ministers in attendance. I have responded on behalf of clients to PIP assessments. Agencies have invited me to interview for 'Disability Assessor' roles. Not only is this a complex web, but several logics obtain: a perverse temporal logic operates, binary logic and a fixed mindset can develop so that some (vulnerable!?) individuals can get stuck. Perhaps, a social imperative steps in and disrupts, life chances: their being a NEET ('a young person who is no longer in the education system and who is not working or being trained for work'. Ecosia) is better for someone else? 

 

To unpick, make sense of this, you need a foundational universal model.

 

There is a (co-authored) paper from Giulia Russo, who presented - Epistemic and political role of experience: https://philpapers.org/rec/RUSTPO-112 from which:

'As it is widely known, epistemic injustice was introduced by Fricker (2007) to unveil power relations that have negative consequences on people as epistemic agents. She distinguished in particular two different kinds of epistemic injustice: testimonial and hermeneutical. The first kind occurs when a person (usually in a disadvantaged and oppressed role within the epistemic relation) is damaged as a knower because, as the name suggests, their testimony is overlooked, dismissed or invalidated. The second kind of epistemic injustice occurs when a person is deprived of the epistemic resources to even explain or articulate their experience of distress, or of systemic oppression. In connection to this, the concepts of neurodivergence and neurodiversity come from the political and social arena, and are born explicitly to contrast dominant pathologizing narratives in psychiatry.'

In seeking some 'test' cases to try to model relationally, Hodges' model suggests at least four - without letting the care / knowledge domains wag-the-dog. Giulia's talk was very helpful, ranging across forms of epistemic injustice (addressed by others too), identity, neurodivergence, lived experience, self-, counter- and collective narratives with references. A great resource.

 

Frank Denning, reminded me of an important phenomena, in Using Stebbing’s Directional Analysis to Evaluate ‘Mentalizing’. Talking therapies, or more properly referral to talking therapies often presents several criteria that would-be subjects must 'pass'. An ability to mentalize, can represent one. This is understanable, for effectiveness, efficiency, efficacy ... it is to be found in the manual. But, in terms of power relations, gate keeping in various forms is a literal (virtual) key to service access. Hodges' model is no different (sigh!). At what age can people start to use Hodges' model? What mentalization is involved to cognitively engage in use of Hodges' model? 

 

I struggled to obtain a copy of Stebbing's original work from 1930, but see how closely tied the work is to physics. An Internet Archive copy is poor quality. The search will continue, as I suspect there are links to Bill Ross's text on Deleuzian cosmology. It is marvellous that work from 1930 resonates today. There is: 

Janssen-Lauret, F. (Accepted/In press). Directional Analysis in Susan Stebbing’s Philosophy of Physics. In S. Chapman (Ed.), Susan Stebbing on Logic and Analysis Springer Nature. 

https://pure.manchester.ac.uk/ws/portalfiles/portal/338653274/Directional_Analysis_in_Susan_Stebbing_s_Philosophy_of_Physics_Final_.pdf

Gloria Ayob - Flourishing as mental health - was encouraging. 'TASK 1:EQUATION' a slide was titled, including emotional disorder is meta-evaluative; there are negative and positive poles, plus isomorphism between unpleasantness-pleasantness and disorder-health. I think my stomach was protesting I should have paid more attention. There is a blog post by Gloria: https://blog.oup.com/2024/12/the-concept-of-emotional-disorder/

After lunch Richard Hassall - Hermeneutical Injustice and Damaged Intellectual Self-Trust in Psychiatric Service Users, a reminder of the time and effort that needs to be put into public and patient involvement and engagement in mental health service (when this is desired). References included J.L. Austin and J.S. Bruner. A paper:

Hassall R. Sense-making and hermeneutical injustice following a psychiatric diagnosis. J Eval Clin Pract. 2024 Aug;30(5):848-854. doi: 10.1111/jep.13971. Epub 2024 Feb 20. PMID: 38375925.

https://onlinelibrary.wiley.com/doi/10.1111/jep.13971 

Scoping reviews are more common it seems: Lara Calabrese - Exploring epistemic injustice in dementia care: a scoping review and a qualitative study, plus paper [with QR code on the slide]:

Calabrese L, Brigiano M, Quartarone M, Chirico I, Trolese S, Lambiase F, Forte L, Annini A, Bortolotti L, Chattat R. I'm still here and my opinion matters: a scoping review on the experience of epistemic injustice among people living with dementia. Curr Psychol. 2025 Dec 17;45(1):s12144-025-08519-y. doi: 10.1007/s12144-025-08519-y. PMID: 41445984; PMCID: PMC7618523.

 

The paper's title here brought to mind the radio programme "Does He Take Sugar?" Questions followed regards the studies methods. Since leaving I wondered if there has been an evaluation of Dementia Friendly Communities? Are there dots to usefully joined there?

 

The final talk was delivered (with gusto - pepped me up anyway) by Jacob Barlow - Epistemic borders: experts, communities, communication. Jacob's interest in pragmatism was apparent. I look forward to reading future work, and note Liverpool 2025: ‘Problems with Pragmatism in the Philosophy of Psychiatry’.

All in all, a stimulating and enjoyable event.

Joining the digital dots across primary care and integrated care

My partner and I both received a letter today from our respective GPs. An invitation for a 'FREE LUNG HEALTH CHECK'.

Overleaf is an information sheet in landscape about the health check, plus three more sides of A4, similarly formatted - inviting trifold presentation.

After the 'Re. ......' an opening sentence asks: 'Have you ever been a smoker?'

Suddenly, I was dragged backwards through his-tory (some things don't change); not one history, but several:

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My personal and life experience  and not just since my teens . . .

The letter states: **If you have never smoked, you are not eligible for this service**

My mother and father  smoked when I was a child and my siblings.    They got the message early 1980s.    'Society' smoked back then!     Once old enough, I refused to go to the corner shop.   Into the 1990s, patients, smoking (some chain-smoking) on admission, long-stay and other clinical areas. As a community mental health nurse, I learned diplomatic and health promoting skills when in the car, giving a patient a lift to hospital. And, when visiting their home where I was, of course, usually, a guest.

I wondered what has happened to the GP's records? To the primary care clinical record ? The custodians of my health record, that they should need to ask that question?    Or, does confidentiality tie some bureaucratic knots?   Where is 'integrated care' and its driver 'clinical informatics'?  The letter included the NHS Number.    Don't get me wrong, I/we appreciate the obvious effort here, even if the chronology is confusing, or,  speaks of afterthought? The letters are dated 19/06/2025. I must admit I haven't accessed my GP record, checking it for accuracy.   If anything, this is a prompt to do so. And seek a general medical.

Previously: 'smoking' : 'winwick'

'Drama classes help GPs handle difficult patients' c/o BBC

'Hull Truck Theatre has just won the Innovation prize at the Stage Awards for their new training scheme for GPs. Associate Director Tom Saunders and GP Dr Eman Shamsaee discuss why drama classes are helping doctors treat patients.' 

BBC Radio 4 'Front Row' https://www.bbc.co.uk/sounds/play/m002q2jz (15 mins ...)

◇

Holly Phillips, East Yorkshire and Lincolnshire and Ian Youngs, Culture Reporter

Published - 21 January 2026

'A theatre company is using drama training to help doctors deal with challenging patients.

Hull Truck Theatre's classes feature actors performing difficult GP consultations, with GPs giving feedback before taking over the consultation themselves.

The theatre recently won the Innovation Award at the Stage Awards for the programme.

Dr Eman Shamsaee, who has taken part in the training scheme, described it as a "really creative way of doing GP training".'

BBC News:  Drama classes help GPs handle difficult patients

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HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

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The training programme has completed its pilot stage and is now in the delivery phase

A reminder of co-working to deliver STORM training with a Clinical Psychologist colleague. 

See also: 'communication' : 'primary care' : 'GP' : 'drama'

iii Book: Bill Ross - 'Order and the Virtual'

'The Philosophy and Science of Deleuzian Cosmology'

My book 'reviews' are unconventional in that they are not journal fare (format and quality-wise...); the book, or my reading of it - invariably refers to Hodges' model. I could argue that is not my fault, but a quality, something built in to the model. Anyway, what of the physical book itself?

The cover image is a marvel: Stone Quartet 1 by Patrick Haughton. 
[ Did someone say 'quartet'!* 😉]

Cover design by www.paulsmithdesign.com

Typeset in 10.5/13 Sabon, the fonts and styling through the book is clear, and easy to read (without regard to the technical content). The paper is thick, the quality contributing to a high contrast. 

The contents:

Abbreviations
Preface by Robin Durie and David Webb
1. Chaos
2. Entropy and the Complete Concept in Leibniz and Deleuze
3. Order
4. Order as Complexity
5. Sufficient Reason as Dissymmetry and the Evolutionary Paradigm
Conclusion
Notes
Bibliography
Index

The EUP website only lists four chapters for Order and the Virtual, but the book clearly has five. The conclusion is similarly omitted online: running from pp.175-181, I wish I'd written it.

That nursing and healthcare practice are bound up in philosophical considerations, values and ethics is fairly obvious. Care dilemmas would arise, calling for a multidisciplinary approach, and cross-disciplinary advice. Through this book, Bill Ross keeps highlighting for me, the way that once the uniform is donned, or the clock denotes an inbetweenness '0900-1700' for community staff, philosophy goes on the back-burner. The heat of the issue, and first rule of first-aid is felt, but it is not the primary concern. There is an international group of scholars for philosophy in nursing (and journal), but practitioners have, by definition - a job to do. If time is chaos and complexity (or appears as), then in health it is continuity, avoiding disruption and more often trying to 'heal' it.

Although Hodges' model presents as a symmetry; it is anything but. If we wish to symmetry-break, Hodges' model may assist. The flux and dynamics of care [insert your context] means that Hodges' model constantly changes its shape, form. Not as an objective statement, but an interpretation. Bill Ross's discussion on Nietzchean chaos and the superior principle of sufficient reason, demands and rewards a close reading (as does the whole text). Whether it is chaos, equilibrium, law and possibility cognitive - conceptual spaces invite ergodic (a cyclic) exploration. The mix of Deleuze and Leibniz's system makes for complex ideas, one probably needs to swim in. The book's first chapters are deep, technical but also inviting. There are encouraging links to psychotherapeutic thought, in the philosophy of difference, and how this is recognised, and change negotiated.

The scale is cosmological, with a section on ergodicity; and (inevitably) time, as per the quotation (p.10):

'Everything which happens and everything which appears is correlated with orders of differences: differences of level, temperature, pressure, tension, potential, difference of intensity. Carnot's principle says this in one way, Curie's principle in another, Gilles Deleuze (DR, 222)' (DR - Difference and Repetition).

There is a ponderous sense when assessment is routinized: assessment must be comprehensive. Do: tick all the boxes. Don't miss anything! How many levels of assessment should there be? If you want this number of assessments, what should I leave out? It is fascinating how we can frame time, not just 'set' against the axes of  Hodges' model, but a product of lifestyle, bio-physics, and even bio-psycho-social-politics. Is back to Earth - back to the individual? Not now. Contrast chronological and pathological time and not just for humanity. Ross follows Deleuze, Poincare, Neitzche and others in the long-term diagnosis of the universe, no less. A heat-death: the anti-fever. Now there's the collective, while in mental health, a diagnosis (or two ...) is still (often) contested, at least on twitter/X.

'The distinction for me is that metaphysics lives in that plane above where the concepts are not tied specifically to one field, but remain free to mobilise the salient questions as they play out among several fields.' p.15.

I don't think this just applies to metaphysics, but the extent (now) to which problems (clinical and generally) are multi- inter- and transdisciplinary (Ross acknowledges the pragmatic). Otherwise, with each step across a disciplinary boundary, our concepts lose their meaning, and the ergodic action (the around and around, back and forth ... our models and frameworks) is more akin to a drunken random-walk.

More to follow ...

Bill Ross (2024) Order and the Virtual: The Philosophy and Science of Deleuzian Cosmology. Edinburgh: Edinburgh University Press. 
https://edinburghuniversitypress.com/book-order-and-the-virtual.html

*And is that the fifth domain floating above?

The preface is titled 'Playing Cortázarian Hopscotch':
https://en.wikipedia.org/wiki/Hopscotch_(Cort%C3%A1zar_novel)

There is also a brief  'Series Editor's Preface'

Primary & Secondary Health Care - How long...?

THE DAWSON REPORT

MINISTRY OF HEALTH.

CONSULTATIVE COUNCIL ON MEDICAL AND ALLIED SERVICES.

Presented to Parliament by Command of His Majesty. [... selected extracts]

3. The general availability of medical services can only be effected by new and extended organisation, distributed according to the needs of the community. This organisation is needed on grounds of efficiency and cost, and is necessary alike in the interest of the public and of the medical profession. Measures for dealing with health and disease become, with increasing knowledge, more complex, and, therefore, less within the power of the individual to provide, but rather require combined efforts. Such combined efforts to yield the best results must be located in the same institution. As complexity and cost of treatment increase, the number of people who can afford to pay for a full range of service diminishes. Moreover, enlightened public opinion is appreciating the fact that the home does not always offer the best hygienic conditions for dealing with serious illness, which requires special provision in order to give the patient a full chance of recovery.

4. In days gone by such conditions as appendicitis were treated with poultices and drugs in the patient’s home. Now they are treated by operation, which is more effective, but requires more equipment, a team of workers, and a larger expenditure. Such conditions as diseases of the lungs formerly received clinical examination and treatment by drugs. They now may require, in addition, the attention of the pathologist and the radiologist. This means greater efficiency, but more organisation and higher cost.

5. Preventive and curative medicine cannot be separated on any sound principle, and in any scheme of medical services must be brought together in close co-ordination. They must likewise be both brought within the sphere of the general practitioner, whose duties should embrace the work of communal as well as individual medicine. It appears that the present trend of the public health service towards the inclusion of certain special branches of curative work is tending to deprive both the medical student and the practitioner of the experience they need in these directions.

6. Any scheme of services must be available for all classes of the community, under conditions to be hereafter determined. In using the word “available,” we do not mean that the services are to be free; we exclude for the moment the question how they are to be paid for. Any scheme must further be such that it can grow and expand, and be adapted to varying local conditions. It must be capable of comprising all those medical services necessary to the health of the people.

7. The foregoing are some of the considerations which have guided us in drawing up the scheme outlined below.

The services maybe classified into-

Those which are Domiciliary as distinct from those which are Institutional.

Those which are Individual as distinct from those which are Communal.

1. We begin with the home, and the services, preventive and curative, which revolve round it, viz., those of the doctor, dentist, pharmacist, nurse, midwife, and health visitor. These we style domiciliary services, and they constitute the periphery of the scheme, the remainder of which is mainly institutional in character. A Health Centre is an institution wherein are brought together various medical services, preventive and curative, so as to form one organisation. Health Centres may be either Primary or Secondary, the former denoting a more simple, and the latter a more specialised service.

2. The domiciliary services of a given district would be based on a Primary Health Centre -an institution equipped for services of curative and preventive medicine to be conducted by the general practitioners of that district, in conjunction with an efficient nursing service and with the aid of visiting consultants and specialists. Primary Health Centres would vary in their size and complexity according to local needs, and as to their situation in town or country, but they would for the most part be staffed by the general practitioners of their district, the patients retaining the services of their own doctors.

3. A group of Primary Health Centres should in turn be based on a. Secondary Health Centre. Here cases of difficulty, or cases requiring special treatment, would be referred from Primary Centres, whether the latter were situated in the town itself or in the country round. The equipment of the Secondary Centres would be more extensive, and the medical personnel more specialised. Patients entering a Secondary Health Centre would pass from the hands of their own doctors under the care of the medical staff of that centre. Whereas a Primary Health Centre would be mainly staffed by general practitioners, a Secondary Health Centre would be mainly staffed by consultants and specialists. It would be a consultant service in function and would be carried out by specialists or by general practitioners acting in a consulting capacity.

4. Secondary Health Centres must of necessity be situated in towns, where alone an efficient consultant service and adequate equipment could be expected, and the necessary means of communication exist. The selection of these towns will need careful consideration, and full information will be required as to the extent of existing provision of hospital and allied facilities, and of its distribution in relation to population and means of public conveyance. In rural areas the natural currents of traffic and business and existing medical facilities will usually indicate the town or towns in which a Secondary Health Centre may best be placed. In this connection we would like to point out the importance of carrying out a “Hospital Survey” at an early date. The results of this survey would afford data for recognising the areas in which the existing provision is inadequate, and the degree of the inadequacy. The Secondary Health Centres would vary in size and elaboration according to circumstances.

5. Secondary Health Centres should in turn be brought into relation with a Teaching Hospital having a Medical School. This is desirable, first in the interest of the individual patient, that in difficult cases he may have the advantages of the highest skill available, and secondly in the interest of the medical men attached to the Primary and Secondary Centres, that they may have the opportunity to follow the later stages of an illness in which they have been concerned at the beginning, to make themselves acquainted with the treatment adopted, and to appreciate the needs of a patient after his return to his home. In those towns where Teaching Hospitals exist, Secondary Health Centres would sometimes be merged in them. 

Continued at: 

https://sochealth.co.uk/national-health-service/healthcare-generally/history-of-healthcare/interim-report-on-the-future-provision-of-medical-and-allied-services-1920-lord-dawson-of-penn/

LONDON PUBLISHED BY HIS MAJESTY'S STATIONERY OFFlCE

1920. Price 2s. Net. Cmd. 693

See also:
https://www.adph.org.uk/resources/175th-anniversary-timeline/ 

My emphasis.

ii Learn your lines and the hyperplanes will follow

With these lines, partitions, axes and domains in mind, when a clinical practitioner is presented with a new person, whether as a patient, client, or carer ... they can, using Hodges' model (and other tools!) approach their assessment in an open and receptive manner.

This means that the information provided by the 'patient' can be readily fielded, captured whatever the context and situation.

As noted previously, my study of Hodges' model began in the late 1980s. Application in my work as a community mental health nurse, with an interest in informatics followed quite naturally(?). Primed as I was, for various reasons to carry this forward, I also carried a mathematical learning disability. At the risk of getting bogged down in my thought, use and approach to Hodges' model I need a challenge.

Mathematics is the challenge for me. It's fascinating how we have in-built 'calculators' that can help us catch a ball, and judge fairly well where to throw a ball for interception. There seems then to be an informal or naïve  mathematics, at work unconsciously. Does the same apply to Hodges' model? If so, how can I isolate, and identify it?

• Is it represented somewhere, implicit in Hodges' model itself?
• Is it (once again) to be found in the user of the model?
• Is it (more likely, and obviously) a combination of these two?
• Or, is it a product of the system, or a series of systems? 

I was reminded of what is a Sober toy, several years ago:

Is Hodges' model a selection machine?

All four original purposes of Hodges' model:

1. Person-centred, integrated and holistic care;
2. To bridge the theory - practice gap;
3. To facilitate reflection and reflective practice;
4. To support curriculum development;

- are concerned with conjunction and choice, selection. So is life itself through distinction, difference, and differentiation.

Hodges' model is a selection machine, that is both fhuman and machine driven.

A clinician may obtain the referral information through an email, a history of previous contacts can be retrieved from a clinical information system; the context and purpose supporting access to the information.   

A whole series of blog posts describe the role of Hodges' model to help assure parity of esteem across mental and physical health. What does this mean in practice?

For the practitioner, they take selected data from the referral, a history - if available, an initial telephone contact, a conversation with a colleague who remembers the person re-referred and starts to populate Hodges' model. What are the psychological concepts that arise? What are the physical?

If a referral in whatever form, or a database record can be viewed as a bag-of-words, then Hodges' model is a collection of care concepts. Four bags then. Sets or classes. An experienced user of Hodges' model may position care concepts that throws attention on the INDIVIDUAL↔GROUP axis. Lying between the INTRA- INTERPERSONAL and SCIENCES domains, this axis (like all the others) earns its keep. There is work to be done that is also of interest in machine learning:

'A support vector machine (SVM) is a supervised machine learning algorithm that classifies data by finding an optimal line or hyperplane that maximizes the distance between each class in an N-dimensional space.

SVMs were developed in the 1990s by Vladimir N. Vapnik and his colleagues, and they published this work in a paper titled "Support Vector Method for Function Approximation, Regression Estimation, and Signal Processing"¹ in 1995.' 

https://www.ibm.com/think/topics/support-vector-machine

Strange to think that perhaps the VERTICAL axis and others in Hodges' model are not precisely S-N-E-W in their bearing? There may also be several vectors at work in fact?

Image: c/o https://www.ibm.com/think/topics/support-vector-machine

The word 'naïve' has been bubbling away for a good-many years. A close colleague Silvana Bettiol, Univ. of Tasmania kindly read my draft on Hodges' model as a mathematical object, and mentioned the introduction points to Bayes theorem even if informally. Even in those initial 'clinical' encounters (and social meetings, that attend to empathy, rapport and engagement...) complex judgements are being made, beliefs tested, from what is often partial and disparate sources of information.

Checking other leads led to Frequentist and Bayesian Approaches

'Statistical inference is a series of methods used to make decisions and draw conclusions based on available data. There are two primary approaches for inference: Frequentist and Bayesian. Each framework relies on a different philosophical perspective on probability and modeling, leading to different techniques and interpretations. Each has its own strengths and drawbacks, so understanding the distinctions between them is vital for researchers, data scientists, and statisticians who aim to choose the most suitable approach for their specific analysis.'
https://www.statology.org/comparing-frequentist-and-bayesian-approaches/

More reading required and threads to run.

Earlier this week I posted re. Cromer's book -

Cromer, A. (1997) Connected Knowledge: Science, Philosophy, and Education, Oxford: Oxford University Press

Before passing the book on, p.198, Chapter 8 notes, #4:

'"Understanding" is a commonly used English word which has no precise meaning. It's sometimes taken to mean the ability to apply knowledge to new situations. In this sense, it is a very high-level skill. Benchmarks for Science Literacy says, "Learning to solve problems in a variety of subject-matter contexts, if supplemented on occasion by explicit reflection on that experience, may result in the development of a generalized problem-solving ability that can be applied in new contexts' (American Association for the Advancement of Science, 1993)." The key word here is "may." 'We really don't know how to help students develop a generalized problem-solving ability, or whether there is such an ability apart from mere knowledge of many different problem-solving strategies. Whatever the case, since we do know how to teach students to solve specific, problems. this should be the primary focus of science education' p.198.

Ack. IBM.

Hodges' model - Locus of Care & Control?

Draft notes:

There are obvious geometric features (Stewart, 1981) in Hodges’ model. Application of the model is a holistic affair. The centre of the model is its centre (as a template), but in application it is not fixed. There are several degrees of freedom, determined by the context of application. Consider figures 4a, 4b and 4c. Perhaps it can be argued there is what amounts to a care locus? As Persons (2025) notes:

‘Primary care is considered the first line of defense in health care, and it is the locus of the maintenance of both individual and population health.‘ p. 15.

 Emphasis can be placed on selected domains, as the situation dictates:

Stewart, I. (1981) Concepts of Modern Mathematics, Harmondsworth: Penguin Books.

Persons, G. A. (2025). Health Care Safety Nets: Vital Participant Roles and Varying Policy Contexts. Phylon (1960-), 62(1), 5–30. https://www.jstor.org/stable/27396595

c/o HIFA - Publications re. primary health care & community health

Dear [HIFA] friends and colleagues with an interest in primary health care and community health:

Since my last communication with you more than 6 months ago, the entire field of global health has continued to be upended by our US government, with unconscionable effects on millions of people around the world, on advancements in global health research and its ethical foundations, and on the careers of thousands and thousands of people working around the world in the field of global health. As I said before, and I repeat now the obvious, it will take decades to build back what has been destroyed and to regain respect from the rest of the world for the United States and the values that most of us hold dear.

William Foege, eminent global health leader and former Director of the Centers for Disease Control and Prevention wrote this biting editorial <https://www.statnews.com/2025/08/18/rfk-jr-public-health-threats-william-foege-smallpox/> in which he said, among other things, 

"We will live through this drought of values, principles and facts and again apply our talents to improving global health and happiness. Do not back down.”

Atul Gwande, now one of the foremost champions of primary health care and community health of our time (even though he is, like me, an erstwhile surgeon!) and former Director of the USAID Bureau of Global Health during the Biden administration, gave an eloquent presentation of his perspective on the aftermath of the destruction of USAID on 28 April 2025 at the Harvard School of Public Health.

You can watch this here:
<https://www.bing.com/videos/riverview/relatedvideo?q=Atul+Gwande+presentation+at+Harvard+School+of+Public+Health+April+28%2c+2025&mid=26DA144398CF1F613D0A26DA144398CF1F613D0A&FORM=VIRE>.

Here are a few items of possible interest:

The Fourth International Symposium on CHWs will be held virtually next week.

I was most fortunate to be able to attend the second International Conference on Primary Health Care was held in Addis Ababa, Ethiopia, from October 6-10. It was a glorious event, with 750 attendees, mostly from Africa but with strong representation from UNICEF, WHO, Africa CDC, and other international organizations. 

The conference was sponsored by the International Institute for Primary Health Care – Ethiopia. <https://iphce.org/> Directors of PHC from 45 different African countries were present along with at least 50 community health workers from across Africa. There was palpable enthusiasm for the growing momentum for PHC across Africa.

Abhay and Rani Bang are world-renowned champions of community-based primary health care through their work with SEARCH <https://www.searchforhealth.ngo/> (Society for Education, Action, and Research) in Gadchiroli, India, with tribal people. Their seminal publications on the effectiveness of community-based primary health care and community health workers as well as their contributions to India’s national program for reducing neonatal mortality through home-based neonatal care, among others, have gained for them global recognition. Attached is an English translation of an article about their life’s work that was published in April Der Spiegel in the leading German magazine, Der Spiegel.

Nicholas Kristof has continued to share with the world some of the heart wrenching effects of the collapse of the United States Agency for International Development. The New York Times opinion columnist wrote <https://www.nytimes.com/2025/09/20/opinion/trump-usaid-cuts.html> on 20 September 2025 on the human dimension of the shutdown of USAID, citing estimates that 690,000 will die in 2025 and 829,00 will die in 2026 as a result of cutbacks in USAID funding, and 3.1 million children will die during Trump’s second term from these cuts (a PDF is attached if the link doesn’t work for you [mod: HIFA does not carry attachments]).

Two recent publications on novel approaches to reducing child mortality have gained widespread attention.

One study <https://www.nber.org/system/files/working_papers/w34152/w34152.pdf> in Kenya provided a one-time transfer of $1,000 to poor families and observed a decline of nearly half in under-5 mortality as well as in infant mortality. Another study reported that wrapping

A recently reported study <https://pmc.ncbi.nlm.nih.gov/articles/PMC12462887/> from Uganda found that giving mothers fabric treated with permethrin, a long-acting insecticide to protect against mosquito-born illnesses, as a baby wrap dramatically reduced malaria infections in the infants carried in them. There were 66 percent fewer cases among those children compared with babies in the untreated wraps. By the end of the six-month study, only 16 percent of children in the treated wrap group had been sick with malaria, compared with 34 percent in the untreated wrap group, many of whom had multiple malaria episodes.

Now available for purchase on Amazon.com are several important publications related to community-based primary health care and community workers.

Feel free to share this email and these resources with anyone else or with any relevant listserve you may have access to.

You are receiving this email because of your interest in primary health care and community health.

If you know of anyone that you think would like to be included in the listserv, just send me the person’s name and email address.

Warm regards, Henry

Henry B. Perry, MD, PhD, MPH Senior Associate, Health Systems Program Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore, MD, USA 21205 Hperry2 AT jhu.edu

HIFA profile: Henry Perry is a Senior Scientist at the Johns Hopkins Bloomberg School of Public Health, USA. Professional interests: Community health and primary health care. hperry2 AT jhu.edu

Julian Tudor-Hart 'The Inverse Care Law' - c/o The Lancet

On the bottom of my notes re. Giarchi and 'distance decay' I'd written:

'Inverse Care law - p.60. - Giarchi. "those who suffer more ill health are less likely to be assisted."

It made me wonder about the origin of this law having posted about it in 2020.

The Lancet has an editorial and an associated podcast:

50 years of the inverse care law. The Lancet, Volume 397, Issue 10276, 767. February 27, 2021.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00505-5/fulltext

'“The availability of good medical care tends to vary with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”

These understated opening lines of Julian Tudor Hart's paper, The Inverse Care Law, are as relevant now (50 years to the day since publication) as in 1971. The paper is one of the landmark publications in The Lancet's near 200-year history, and the resonance of Tudor Hart's definition of the inverse care law has global and timeless importance. Simply expressed, Tudor Hart observed that disadvantaged populations need more health care than advantaged populations, but receive less.

Tudor Hart's life and career took him from highly privileged beginnings in London and Cambridge to decades spent in the deprived and deeply socialist Welsh valleys. His experience and work has inspired a generation of influential health-care leaders including Andrew Haines, Allyson Pollock, Cesar Victora, and Graham Watt. Today's anniversary issue of The Lancet explores both the global reach of the inverse care law and primary care initiatives in deprived areas around the UK.

Although inequality in health and its many causes are widely understood, inequity in health-care service provision is enduring and fundamental: an intractable concept that lies at the heart of the inverse care law. The inverse care law is primarily about inequity (injustice) in health care that results in unfair social inequalities (imbalances) in health. Since the inverse care law was published, the UK's National Health Service (NHS) has strived to reduce inequity with mixed success. Notably, long-lasting progress was achieved through the 1970s resource allocation formula, which reduced geographical inequality in hospital and institutional expenditure. In the early 2000s, the NHS strengthened primary care provision in disadvantaged areas, leading to a temporary reduction in social inequality, although this progress has reversed following shifts in funding, a slowing of spending, and years of living with austerity.'

See also: 

https://en.wikipedia.org/wiki/Julian_Tudor-Hart

https://www.chpi.org.uk/blog/julian-tudor-hart-and-the-essence-of-primary-care/