Voices in Wellness

Voices in Wellness

*Imaginary names have been used to protect the identity of the healthcare professionals*

Introduction

Welcome to “Voices in Wellness,” presented to you by Kanishka Gandhi, Watanya Aekplakorn, Tanaya Bhalve, and Victoria Chong, students from the Royal College of Art. As part of our college-wide Across RCA unit, we delve into the broader theme of a Caring Society.

The COVID-19 pandemic had been an unprecedented challenge, reminding us of the critical importance of caring for one another. Amidst this global crisis, healthcare professionals emerged as frontline heroes, selflessly dedicating themselves to the well-being of others. However, behind their unwavering commitment lies a reality of immense struggle, sacrifice, and unspoken challenges.

Through “Voices in Wellness,” we aim to shed light on the experiences, struggles, and concerns of these dedicated professionals from both the United Kingdom and India. Our illustrative interview documentations provide a platform for these voices to be heard, urging us all to be mindful and empathetic in our interactions with healthcare workers.

While navigating these interviews, these individuals we encountered are not just interviewees—they are our friends and family members. We shared a collective desire to see improvements in their working conditions and support systems so that they can continue their vital work with greater efficiency and well-being.

Join us in honouring these voices, recognizing their contributions, and advocating for a more caring and supportive society for all. Together, let us strive to uplift and empower those who dedicate their lives to caring for others.

Alice Dong

5th Year

Medical Student

-Anonymous patient

-Anonymous patient

I’ve worked as a receptionist and healthcare assistant at a GP practice in Surrey, primarily as the initial point of contact for patients. However, I found little enjoyment in this role, mainly due to facing patients’ frustrations directed towards me.

How has your journey in the healthcare field been so far?

The demand for appointments, particularly for minor issues, often strained resources, with patients expressing dissatisfaction over wait times and service availability.

What significant challenges have you encountered during your career?

Challenges include dissatisfaction with service delivery, exacerbated by political controversies and strikes, emphasising the need for systemic improvements, including fairer pay and increased training opportunities for medical professionals.

I do understand their frustration but it is not my fault! In the GP, at times the patients expected too much:

“I’ve waited in the queue for 13 minutes. What do you mean there’s no appointments, I called first thing in the morning!”

Sometimes when the waiting room is empty, people will assume that.......

“You’re not very busy, are you? ”

“Doctors shouldn’t have lunch as they should be working!”

How would you assess the efficiency and effectiveness of the healthcare system?

The NHS shows varied efficiency. While the two-week cancer diagnosis system is notable, disparities exist, such as the postcode lottery and technological limitations. Private healthcare often relies on the NHS for critical care. Challenges include dissatisfaction with service delivery, highlighting the need for systemic improvements like fairer pay and increased training opportunities.

The staff shortage results in doctors managing over seven tasks concurrently. Increasing doctors’ salaries is essential for long-term retention. Furthermore, the lack of training positions raises a crucial question: ”What’s the purpose of increasing medical student intake if there isn’t enough infrastructure to support their progression into fully qualified doctors?”

While private hospitals cannot handle A&E (Accidents and Emergency) cases, reliance on paper notes poses challenges due to varied handwriting legibility. Transitioning to a computerised system would be ideal but entails significant expenses for training and maintaining IT departments.

Currently, there is a huge shortage of computers available for doctors.

Cindy Zheng

4th Year Medical Student

As a fourth-year medical student in the UK, I’ve completed placements at Addenbrooke’s Hospital and with GPs across London and South-East England.

How has your journey in the healthcare field been so far?

My experience in the NHS has been predominantly rewarding, particularly in a tertiary teaching hospital equipped with cutting-edge facilities and the chance to learn from top clinicians. However, it has also posed challenges stemming from an overstretched healthcare system, where staff are often overworked and required to take responsibilities beyond their designated roles. Limited resources sometimes impede patient pathways, causing delays in areas like theatres due to logistical constraints such as bed shortages.

What significant challenges have you encountered during your career?

I’ve encountered tough challenges, particularly in regional hospitals where limitations in resources restrict the care available to patients. Additionally, across the NHS, recommended care pathways can be suboptimal due to constrained funding. This often means that the best treatments i.e. IVF., newer imaging techniques or certain drugs, exceed the NHS’s allocated resources, making it challenging for patients who don’t have access to private healthcare and must settle for less optimal alternatives.

How would you assess the efficiency and effectiveness of the healthcare system?

The efficiency and effectiveness of the NHS system vary. The efficiency of the NHS system varies between hospitals. Regional district hospitals, despite having fewer resources, can be surprisingly efficient by transferring complex cases to tertiary centres. However, logistical issues like poor organisation of emergency theatres and inadequate recovery bed spaces often delay surgeries despite the availability of resources.

What are the current working conditions like for medical professionals?

Medical workers are facing challenging working conditions due to underresourcing and understaffing, leading to overwork and disillusionment. Staffing disparities across wards result in variations in care provision. Junior doctors’ strikes have increased the workload for senior clinicians, impacting patient care and delaying surgeries.

In my view, patients and relatives would benefit from enhanced facilities like bereavement areas and accommodations for overnight stays.

Reflecting on your experiences within GP/ hospital environments, what areas for improvement do you see?

GP and hospital environments vary in terms of layout and facilities. For instance, while some GP practices may be converted houses, others are purpose-built facilities with modern amenities. Patient satisfaction tends to be higher in well-resourced spaces with ample space and a variety of healthcare professionals available. Improvements can be made by creating more welcoming and efficient waiting areas, such as implementing digital sign-in systems.

How do you manage and alleviate stressful situations in a hospital setting?

To relieve stress, hospitals can improve facilities like doctors’ relaxation areas, canteens, and changing rooms. Adding more coffee rooms and addressing working conditions and pay disparities are also beneficial.

Kavita Shinde

Anaesthetist

Consultant

With 26 years of experience as a consultant anaesthetist, mainly in ICUs and operating theatres for elective surgeries, my healthcare journey has been profoundly rewarding. From the outset, I took an oath and I embraced the challenges inherent in this profession.

How would you assess the efficiency and effectiveness of the healthcare system?

Assessing the efficiency and effectiveness of the healthcare system, particularly within NHS hospitals, reveals varying operations across different Trusts. However, a common challenge is the strain on staff due to understaffing, leading to overworked conditions. This demanding lifestyle, coupled with minimal personal time, may discourage younger generations from pursuing this noble profession.

What are the current working conditions like for medical professionals?

The current working conditions within the NHS leave much room for improvement. Daily rotas are demanding, with ICU theatre shifts lasting around 2.5 to 3 hours per patient, and larger operations extending up to 5-6 hours. My son, currently training as a Junior doctor, endures even longer shifts from 8 am to 8 pm due to increased backlog and staffing constraints.

How do you manage and alleviate stressful situations in a hospital setting?

To manage and alleviate stressful situations in the hospital environment, various provisions like gyms, retreat rooms, and planned well-being sessions exist but are underutilised due to time constraints. Personally, unwinding at home with tea, television, and quality time with loved ones serves as my sanctuary. Mandatory annual sessions with managers address career progress and obstacles, while festive gettogethers offer rare moments of relaxation.

How would you describe a day in your life with respect to your practice?

A typical day in my life begins at 8 am, seeing patients and preparing them for surgery with no breaks until the official end of the day at 5:30 pm, often extending to 6:30-7 pm. Evenings are reserved for relaxation, household chores, and muchneeded rest, with on-call duties once a weekend per month adding to the routine.

Priyanka Agashe

Ophthalmologist Consultant

With 15 years of experience as an ophthalmologist at Nottingham University Trust, I’ve been serving across various NHS hospitals within the same trust. Each passing day seems to bring even busier schedules.

How has your journey in the healthcare field been so far?

The current situation, exacerbated by the ongoing COVID-19 pandemic, has only added to the challenges we face. There’s a noticeable shift among junior staff towards part-time roles in private practices, perhaps enticed by the allure of better financial prospects.

How would you assess the efficiency and effectiveness of the healthcare system?

Clinics are perpetually packed, and the backlog of patients seems insurmountable. Despite the strain, I still hold the NHS in high regard for its ability to provide critical treatments to all, a luxury not always available in other healthcare systems, especially back in India where I originated. However, funding constraints have led to the unfortunate removal of specialised surgeries from the NHS roster, further complicating matters.

What are the current working conditions like for medical professionals?

Within the hospital environment, conditions are far from ideal. Lunch breaks are a luxury I rarely indulge in, and the daily rota keeps me occupied from dawn to dusk. The transient nature of junior doctor positions only exacerbates the staffing issues, placing immense pressure on senior doctors like myself.

Reflecting on your experiences within GP/ hospital environments, what areas for improvement do you see?

If there’s one thing I yearn for, it’s an expansion of our facilities and staff to alleviate the burden of the growing patient load and reduce the backlog. Unfortunately, the shortage of trained doctors coupled with stagnant training posts due to funding constraints presents a significant hurdle.

How do you manage and alleviate stressful situations in a hospital setting?

There are a few initiatives that the hospital trust has created to cope with the street of the hospital environment. Unfortunately we rarely find time to utilise the prayer rooms or the yoga and wellbeing sessions organised.

From your perspective, how have patients and their relatives experienced healthcare services?

From the perspective of patients and their relatives, the experience seems generally positive, with many expressing gratitude for the high-quality care they receive. However, I primarily receive patients referred through GPs rather than directly, so my interaction with them is somewhat limited.

How would you describe a day in your life with respect to your practice?

A typical day in my life often involves me being stationed at the Eye Casualty, our hospital’s 111 emergency service for eye-related issues. Here, I oversee the first aid administered by nurses and provide guidance to the junior doctors.

Despite the challenges and long hours, the recent transition to a computerised system in the Eye Casualty has bolstered efficiency, allowing us to navigate the workload more effectively. On administrative days, I find myself pulled in various directions, from tackling paperwork and patient referrals to overseeing eyelid surgeries in the theatre. It’s a demanding routine, but one I embrace wholeheartedly in service of our patients’ well-being.

Shefali Pathak

Primary Care Consultant

I began working in (GP) general practice in 2007 and have remained in primary care ever since. The working conditions were significantly better nine years ago compared to today.

How has your journey in the healthcare field been so far?

Adapting to the evolving landscape of the NHS, I’ve found myself taking on additional administrative and coordination responsibilities alongside clinical duties. What used to be half-day clinical sessions now often extend to six or seven hours, with the need to manage administrative tasks like checking blood results, making referrals and following up with other [medical] professionals.

Nowadays, nearly all GPs in the UK are working part-time and more than twothirds of trainee GPs are not planning to work full time.

How do you manage and alleviate stressful situations in a hospital setting?

To combat stress, I make it a point to take breaks and engage in activities unrelated to work. However, the workplace pressure and staffing shortages contribute to burnout, affecting one in three doctors in the UK today.

How would you describe a day in your life with respect to your practice?

My daily work routine:

8:00 am-9:40 am

Mornings are dedicated to GP check-ups followed by an efficient staff meeting where we address any challenges and distribute tasks collaboratively.

9:40 am-1:30 pm

After the meeting, I handle on-call cases while concurrently mentoring junior doctors. During lunch breaks, which I spend doing administrative tasks, I rely on pre-prepared meals brought from home which I would have to prepare for during the weekends.

1:30 pm-6:30 pm

There are further check-ups and telemedicine consultations with patients.

6:30 pm-8:00 pm

In the evening, I revisit on-call cases.

8:00 pm-8:30 pm

Every day feels like orchestrating a production! Currently, I hold the manager position, working tirelessly from 8 am until 8:30 pm with no breaks.

Wrapping up the day involves completing administrative duties such as responding to patient inquiries, updating lab results, and managing referrals, prescriptions, insurance matters, and staff schedules.

UK and India Comparison

Comparing healthcare statistics in UK vs India UK

• Personal connections to healthcare professionals drove our creation of this illustrative booklet.

• We aim to increase public awareness of healthcare workers’ daily experiences.

• Addressing increasing violence towards healthcare workers, thereby emphasising their vulnerability.

• We want to humanise healthcare workers by sharing their stories in their own words.

India

Mitali Jain

Dentist

Consultant

Having practised dentistry in the UK for the past two decades, I am deeply committed to providing quality dental care to my patients. With extensive experience and a passion for oral health, I am dedicated to serving the community and promoting healthy smiles.

How has your journey in the healthcare field been so far?

My experience in the NHS has been a challenging yet immensely rewarding journey. Over the years, I’ve gained invaluable knowledge and had the privilege of making a positive impact on many patients’ lives.

What significant challenges have you encountered during your career?

Navigating through challenging cases requiring complex treatments, coping with staff shortages, and enduring the lengthy training pathways have been notable hurdles.

How would you assess the efficiency and effectiveness of the healthcare systems in both India and the UK?

While both healthcare systems are effective, there’s room for improvement in terms of efficiency, especially in streamlining processes and reducing waiting times.

What are the current working conditions like for medical professionals?

Working conditions for medical professionals are incredibly demanding, with increased workloads, stagnant pay, and persistent staff shortages exacerbating the challenges.

Reflecting on your experiences, what areas for improvement do you see?

Improving accessibility to GP appointments is paramount, as quicker access to care can significantly enhance patient outcomes and satisfaction.

How do you manage and alleviate stressful situations in a hospital setting?

Although stress relief is limited, having supportive colleagues and a strong team provides invaluable assistance during challenging times.

From your perspective, how have patients and their relatives experienced healthcare services?

While patients generally receive good treatment in the NHS, there’s room for improvement in areas like reducing waiting times and enhancing communication and transportation services.

How would you compare and contrast the experiences of doctors, staff, patients, and relatives within the healthcare systems of India and the UK?

In the UK’s NHS, healthcare is accessible to all taxpayers, whereas India offers both government and private healthcare options. While the value for life may be perceived as higher in the UK, India often boasts quicker access to tests and satisfactory treatments.

Divya Joshi

Anaesthetist Consultant

Hello, I’m an anaesthetist with a diverse background in healthcare spanning across India, the Middle East, and now the UK.

These experiences provided ample opportunities for growth, emphasising teamwork, effective communication skills with everyone, and organisational skills crucial for becoming a Consultant.

How has your journey in the healthcare field been so far?

Starting from the bottom with a clinical attachment, navigating the NHS was a learning curve. The process of completing PLAB exams and relocating frequently for training were significant hurdles. This was compounded by having to prepare for the fellowship exams while undergoing training.

What significant challenges have you encountered during your career?

Restarting training as a junior, balancing exams with on-call duties, and adapting to frequent relocations posed notable challenges. Understanding the NHS’s policies, guidelines, and communication practices were additional hurdles, along with managing patient documentation efficiently.

How would you assess the efficiency and effectiveness of the healthcare systems in both India and the UK?

While the NHS offers excellent services, high demand and limited resources result in long waiting times and delays in accessing care. India’s healthcare system, with shorter wait times and ample professionals, contrasts with the UK’s more streamlined training pathways and career progression opportunities.

What are the current working conditions like for medical professionals?

The demanding nature of the job, coupled with limited resources, creates a challenging and stressful environment. Shift patterns, on-call duties, and the pressure to fulfil multiple roles within tight timeframes add to the strain. Support systems for junior doctors and better workload management could alleviate these challenges.

Reflecting on your experiences within GP/ hospital environments, what areas for improvement do you see?

Enhancing patient experiences by improving facilities, reducing wait times, and offering free parking could boost satisfaction levels. Additionally, maintaining well-being initiatives like wellbeing days and social gatherings fosters a supportive work environment.

How do you manage and alleviate stressful situations in a hospital setting?

Utilising hospital facilities like doctor’s mess, restaurant areas, prayer rooms and organising social events can provide much-needed stress relief. Prioritising staff well-being through initiatives like coffee mornings and outdoor activities can promote a healthier work-life balance.

From your perspective, how have patients and their relatives experienced healthcare services?

Improving patient experiences through reduced wait times, enhanced communication, and better facilities can significantly impact satisfaction levels. Addressing stressors in hospitals, such as parking issues, can further enhance overall experiences.

How would you compare and contrast the experiences of doctors, staff, patients, and relatives within the healthcare systems of India and the UK?

While the UK offers free healthcare services and structured career pathways, India provides shorter wait times and a higher density of healthcare professionals. Facilities like NHS pension and sick pay in the UK contrast with India’s predominantly private healthcare model.

Mihir Mehta

Surgeon Consultant

Currently, I practise as a laparoscopic, gastrointestinal, and general surgeon in Mumbai, while also being affiliated with corporate hospitals.

As an MBBS student at D.Y.Patil University in Navi Mumbai, I faced challenges commuting to college and adapting to evolving departments. Post-graduation, I was trained in surgery at municipal hospitals under senior surgeons, and later specialised in laparoscopic surgery in India and the UK. Upon returning, I established my own hospital, now thriving for 20 years. Additionally, I attended a week-long Robotic Surgery workshop in Italy.

My hospital operates 24/7, enabling continuous patient care. I schedule surgeries primarily in the mornings and coordinate outpatient consultations at other hospitals on specific days, carefully considering factors like theatre availability and patient urgency.

How has your journey in the healthcare field been so far?

My journey in healthcare has been deeply fulfilling, albeit demanding and requiring significant personal sacrifices, especially in terms of time with my family. While I’ve managed to strike a balance between my professional and personal life, I recognize that not every doctor may have the same opportunity. Performing surgeries has been particularly rewarding for me, especially seeing the positive impact on patient satisfaction.

What significant challenges have you encountered during your career?

Throughout my career, I’ve faced numerous challenges, from student life to establishing my own practice. Travelling to college was arduous, and setting up a clinic was financially daunting. Despite initial setbacks, I persisted, eventually building a successful practice. Navigating licensing hurdles was tough, with corruption rampant, but I remained committed to integrity, avoiding bribery and meeting all regulatory requirements.

How would you assess the efficiency and effectiveness of the healthcare system?

The healthcare system, particularly in private settings, has proven to be highly efficient and effective, yielding commendable results. However, government-run hospitals often grapple with long waiting times and inadequate facilities, leading to patient dissatisfaction with treatment outcomes.

What are the current working conditions like for medical professionals?

Medical workers’ conditions, especially those in government setups face notably poor working conditions and are often underpaid, a disparity not observed in private establishments

Reflecting on your experiences within GP/ hospital environments, what areas for improvement do you see?

To foster a more welcoming environment for patients and their relatives, there’s an imperative need for reception areas to exude customer-friendliness and for basic information to be readily accessible.

How do you manage and alleviate stressful situations in a hospital setting?

Stress is an omnipresent factor during my time at the hospital, given the multitude of responsibilities I juggle between patient care and hospital management. Personally, I find relief from stress by stepping away from the hospital environment during my free time and engaging in sports activities like hockey, swimming and lawn tennis.

From your perspective, how have patients and their relatives experienced healthcare services?

The implementation of digitization initiatives, such as medical records and streamlining information dissemination, holds promise for enhancing the patient experience. Moreover, efforts to reduce waiting times are imperative.

How would you compare and contrast the experiences of doctors, staff, patients, and relatives within the healthcare systems of India and the UK?

Addressing the issue of undefined working hours for medical professionals in India requires urgent attention. Additionally, patient education on adhering to medical advice is paramount. Financial stability across all stakeholders is pivotal for delivering superior healthcare compared to the UK. Furthermore, prioritising counselling services for doctors’ mental and physical well-being is essential.

Tanya Shah

2nd Year

Surgical Resident

I am currently serving as a 2nd surgical resident at Sion Hospital, Mumbai, where I also completed my MBBS. My aspiration is to specialise in Paediatric Surgery in the future.

How has your journey in the healthcare field been so far? My journey in healthcare has been deeply gratifying, with the ultimate reward being patients returning home healed and healthy.

What significant challenges have you encountered during your career?

Communicating sensitive information to patients and their families has proven to be a significant challenge, as is navigating the bureaucracy and workload in a government healthcare setting.

How would you assess the efficiency and effectiveness of the healthcare systems in both India and the UK? Both systems exhibit remarkable efficiency, with excellent patient survival rates and minimised mortality and morbidity rates.

What are the current working conditions like for medical professionals?

Medical professionals often contend with challenging working conditions characterised by sleep deprivation, limited breaks, poor dietary habits, and chronic stress.

Reflecting on your experiences, what areas for improvement do you see?

Enhancements in hygiene standards and the inclusion of soothing artwork and informative posters in multiple languages could significantly enhance the hospital environment.

INDIA

Nimit Gandhi

2nd Year

Surgical Resident

I am currently a 2nd year surgical resident at JJ Hospital, Mumbai. I have completed my MBBS from Sion hospital, Mumbai. I plan to become a Urologist in the near future.

In my current role as a student studying and working at a government hospital, my days are filled with diverse patient encounters. Beyond providing treatment, I engage in counselling relatives during complex cases and strive to balance personal obligations with my professional responsibilities. Occasionally, my hectic schedule results in unconventional meal times, such as having lunch for dinner. Moreover, due to time constraints and hygiene concerns, I faced challenges with infections.

How has your journey in the healthcare field been so far?

My journey in healthcare has been enlightening to say the least, allowing me to witness both the miracles and fragility of life up close.

What significant challenges have you encountered during your career?

One of the most formidable challenges has been to convey the gravity of near-death situations to patients’ relatives, who are deeply invested in their loved ones’ care but may struggle to grasp the practical realities of the situation.

How would you assess the efficiency and effectiveness of the healthcare system?

The healthcare system is yet to achieve peak efficiency, particularly in embracing recent advancements like AI, which still faces resistance within the current system.

What are the current working conditions like for medical professionals?

Medical professionals often endure substandard living conditions in cramped hostels lacking ventilation, lighting, and adequate sanitation facilities.

Reflecting on your experiences within GP/ hospital environments, what areas for improvement do you see?

Hospital environments, while plain and functional, could benefit from aesthetic enhancements such as vibrant paintings or wallpapers, particularly in areas like paediatric wards to create a better atmosphere.

How do you manage and alleviate stressful situations in a hospital setting?

Managing stress involves various strategies, but prioritising rest after completing daily tasks is paramount. Additionally, I find solace in activities like listening to music or playing cricket during free time.

From your perspective, how have patients and their relatives experienced healthcare services?

Patients’ experiences vary based on the duration of their stay, with shorter stays generally resulting in higher satisfaction. However, relatives often face challenges while balancing care responsibilities with that of household duties, leading to mixed experiences.

Chetan Anand

Ophthalmologist

Consultant

I am an eye surgeon and a clinician. My dedication lies in providing personalised treatment approaches to address the unique vision needs of every patient. For 20 years, I have overseen my clinic with a steadfast commitment to eye care.

Navigating the dual roles of an entrepreneur and a surgeon has been a notable challenge.

How has your journey in the healthcare field been so far?

My journey in healthcare has been immensely gratifying and fulfilling.

How would you assess the efficiency and effectiveness of the healthcare systems in both India and the UK?

While I had a brief experience in the UK, I found the waiting times to be unreasonably long. Access to healthcare should be timely and convenient for patients.

What are the current working conditions like for medical professionals?

Personally, I find the working conditions for most seniors in this field to be satisfactory. However, I acknowledge the demanding nature of the job for junior medical professionals. They must have sufficient rest and time for personal care.

Reflecting on your experiences within GP/ hospital environments, what areas for improvement do you see?

There is ample opportunity for educational initiatives within GP/hospital settings.

Addressing the mental health concerns of emerging doctors should be a priority for improvement.

How do you manage and alleviate stressful situations in a hospital setting?

As most surgeries are planned, I often encounter limited emergency cases. I manage stress through activities like walking, sleeping, reading, and spending quality time with family.

From your perspective, how have patients and their relatives experienced healthcare services?

Patients often find the healthcare journey stressful, and compassionate care from doctors can significantly alleviate their concerns.

How would you compare and contrast the experiences of doctors, staff, patients, and relatives within the healthcare systems of India and the UK?

While my experience with the UK healthcare system is limited, I can attest to the world-class expertise of top Indian doctors.

How would you describe a day in your life with respect to your practice?

Though hectic and sometimes stressful, I am fortunate to maintain a decent worklife balance. Satisfying interactions with patients make each day fulfilling.

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Step into the world of healthcare through the eyes of those who dedicate their lives to healing and compassion. “Voices in Wellness” is not just a collection of interviews; it’s a testament to the resilience, struggles, and unwavering commitment of healthcare professionals in the United Kingdom and India.

This book is a beacon of empathy and understanding and sheds light on the challenges faced by doctors and healthcare workers by offering a glimpse into their daily realities. Through candid conversations and heartfelt reflections, this book invites readers to step into the shoes of these unsung heroes, to empathise with their struggles, and to honour their tireless dedication. Each interview is a poignant reminder of the sacrifices made by healthcare professionals, and a call to action to support and uplift them.

Placed in waiting rooms, it serves as more than just reading material; it’s a reminder of the humanity behind healthcare, and a tribute to those who tirelessly serve others. May these voices inspire compassion, ignite conversations, and pave the way for a more caring and supportive society in healthcare.