Chronic conditions are killing old models of primary care, slowly but surely
Telling patients what to do doesn’t work - new types of conversation are needed, argues Dr Robert Varnam
The soaring prevalence of long terms conditions is a tsunami threatening to engulf the NHS – with primary care suffering the first breach in the sea defences. As the King’s Fund reported last autumn, treatment and care of people with long-term conditions (LTCs) accounts for 70% of spending on health and social care. Half of our appointments as GPs involve LTCs. It is expected that by 2018, 2.9 million people will be living with three or more LTCs – a million more than in 2008.
The time to think differently is now. Instead of wringing our hands in despair, primary care can lead the NHS’s embrace of new ways of working, such as including the use of health coaching. We need to work with patients to develop genuine shared decision-making and care planning, based around patients’ own goals and motivation to change. Telling them what to do doesn’t work - new types of conversation are needed.
The focus on the NHS reforms means we may have been distracted from looking at changing the way we work in response to new challenges - especially in primary care. Research has shown that, perhaps out of an understandable desire to keep the patient safe and manage time effectively, the average doctor interrupts the patient after around 18 seconds, seeking to ‘diagnose and fix’. While having a directive consultation style is helpful in some situations, patients with long term conditions often need a different approach to encourage them to self care.
To motivate patients to become more active participants in their care clinicians need additional skills in behaviour change. Adopting a heath coaching approach sees patients as truly resourceful, as an equal in the clinician-patient relationship, and as the holders of the solutions to the health challenges they face. It sees a clinician’s role as providing expert information when required, but is more about being able to communicate in a way that is empowering and shared based around a patient’s own aspirations and goals and framing consultations in a way, using additional tools and techniques, that supports patients to make decisions about their own health.
Health coaching that supports people with LTCs to self-care - particularly those with multiple conditions - builds on the government’s mantra of ‘no decision about me without me’. The typical patient with an LTC spends around three hours a year with a health professional. Health coaching equips them with the skills, knowledge and confidence to thrive during the other 8,757 hours of the year.
It is to be hoped that the NHS Commissioning Board’s forthcoming national strategy on LTCs will, without being prescriptive, highlight the possibilities health coaching offers both patients and hard-pressed clinicians and NHS budgets.
Robert Varnam is a GP and clinical lead for primary care and commissioning for the NHS Institute for Innovation and Improvement