The evidence base for health and care needs to integrate psychology, sociology, linguistics, neuroscience, computer science, artificial intelligence and philosophy, alongside traditional clinical practice taking into account culture, history and our environment.

Crucially, while processes and metrics work for predictable systems, they fall short in the face of human behaviour, complexity and uncertainty. In these contexts, algorithms alone are not enough. Health and social care must therefore place greater value on experience, empathy, professional judgement and shared decision-making.

From Dr Steve Sucklings blogs – https://themaslow.foundation/category/steves-thoughts/

I have been able to explore that we have four types of knowing;

• Procedural
• Prepositional (facts)
• Perspectival
• Participatory

In health, we have focused on policies, procedures and facts rather than wisdom, life experience, reflection, active open mindedness and situational awareness to enable the balancing of view points, appreciate context and provide the aspiration.

INSANITY – Doing the same thing over and over again and expecting different results. Albert Einstein

We often speak about understanding our patients, yet we rarely extend the same care to our staff. Like everyone else, staff move away from threat and towards safety, connection and belonging. Psychological safety and trauma-informed practice are therefore not optional extras; they shape how individuals, teams and whole systems respond under pressure.

When people feel stressed or unsafe, their thinking narrows. Memory and processing decline. Survival responses emerge — fight (defensiveness or aggression), flight (withdrawal), freeze or compliance. These are human reactions, not professional failures.

By contrast, when people feel safe and valued, they collaborate, think creatively and draw on their experience with clarity and insight.

We recognise financial and workforce constraints, but we must also acknowledge the invisible constraints we create through fear, silence or low expectation. Aspiration and ambition matter. So does making space to talk openly about emotions and how they influence our decisions.Power dynamics are rarely named, yet they quietly shape decisions and determine whether people feel safe.

Differences in role, status and professional identity naturally create imbalances of power. When these are unrecognised or poorly managed, they can leave individuals or teams feeling controlled or silenced and sometimes behaving defensively or even oppressively, often from a place of insecurity rather than intent.

If we want healthier systems, we must pay attention to four foundations of safety:

• Inclusion safety — everyone feels valued and respected.
• Learner safety — people can experiment, make mistakes and share what they are learning.
• Participation safety — everyone feels able to contribute meaningfully.
• Challenger safety — individuals can question decisions and challenge the status quo without fear.

Without these, psychological safety remains rhetoric rather than reality.

We have recognised from The Francis Report about Mid Staffordshire NHS Foundation Trust to the latest Ockenden Report about Shrewsbury and Telford Hospital NHS Trust and their maternity services, that we consistently deliver poor care. We have identified the importance of culture and that this is the bedrock of good practice, but we seem unable to move to a new way of working.

When we try to systemise the unpredictable and eliminate uncertainty, we risk reinforcing systems that already feel fragile and fear-driven. Uncertainty is not failure; it is part of working with people. Ignoring it narrows thinking and limits innovation.

Our organisations were built around single diseases, operating in silos. They were not designed for people living with multiple long-term conditions in complex social environments. As a result, we lack the structures, culture and routines needed for truly collaborative, interdisciplinary and person-centred care.

Partnership working adds further complexity. Health, social care and the voluntary sector each bring different histories, accountabilities and cultures. These differences are often poorly understood, yet they shape our Integrated Care Systems and how they function in practice.

At a strategic level, policy is often launched with optimism but limited attention to how it will be delivered. Politicians may overestimate impact, while local leaders grow sceptical. The result is a widening gap between ambition and reality.

Closing that gap requires shared understanding with co-creation with patients, alignment across partners and honest dialogue between strategy and frontline practice.

Most importantly, improvement should be measured over time, not through snapshots or league tables. Sustainable progress is reflected in continuous self-improvement, not comparison.

With a lens of new understanding, we can build on the foundations of EBM to form a new model of best practice which we have called Participation Centred Care where we merge personalised medicine and participation, organisational development and distributed wisdom and systems theories and philosophy with greater understanding of the totality of the statistical bell curve and celebrate our outliers narrative to inform our practice.