Case study – Training for practice nurses
Dr Penny Newman, a GP in Ipswich and member of Midlands and East SHA Commissioning Development Team
The health secretary recently described an innovation that would transform the health service – a conversation between clinician and patient. GPs can commission expert patient programmes, medicines management advice, telecare and telehealth to aid self-monitoring, as well as providing advice about diet and exercise. But we also need to have a different approach with our patients in the surgery.
The evidence shows that telling people what to do doesn’t work; to encourage self-care effectively GPs have to motivate people to feel confident and in control.
In 2010, seven practices in NHS Suffolk received £100,000 from the Regional Innovation Fund to train practice nurses in health coaching. Health coaching is used widely in the US and Australia. In the US it has supported self-care for many conditions such as diabetes, asthma, smoking cessation, obesity and cardiovascular disease, transition from hospital, mental health and medication adherence. Savings of between £1.50 and £460 per patient per month have been achieved.
The key is to raise the patient’s self-awareness and responsibility, making them more informed, confident and motivated to look after themselves. It’s useful not only for long-term conditions, but also where patients need to make a change in their lifestyle such as obesity and smoking.
Health coaching prompts a patient to be an active participant and is based on strong clinical communication and negotiation skills, informed, patient-defined goals, conscious choices, exploration of the consequences of decisions, and acceptance of accountability for decisions made. Training for the nurses included understanding potential barriers to change (cognitive, emotional, behavioural) and building on what the patient does well and motivates them, so that advice is perceived as encouraging rather than judgmental – for instance ‘you haven’t given up smoking altogether but you’ve done really well’.
It also covered how to set effective goals.
How does it work?
If a diabetes patient is very dependent on their GP and not managing their disease well, the health coach would start by asking the patient what they want from the session and their treatment, and what would motivate them. It would ask the patient how motivated they are on a scale of 0-10 and what is needed to make it a 10. They might say they wish to go on holiday or talk about how being overweight makes them feel. You could ask where they want to be in six months’ time and then ask them to imagine being at that point and looking back. Then ask what they’ve done to get there.
The pilot evaluation found that this approach helped raised patients’ levels of responsibility and awareness. It showed that when patients leave the session something has shifted in their minds and they feel more confident to do something different than they did when they arrived. In the evaluation we got very high satisfaction scores from patients and significant improvements in self-efficacy scales, which are linked to outcomes. Patients felt more able to manage their condition themselves after this type of consultation.
In the UK, health coaching training for GP registrars has been piloted by the London Deanery with positive results, and will be rolled out more widely. As part of the Health Foundation project Co-Creating Health, some 55 GPs across 21 practices have been trained in motivational interviewing. We are now having conversations with both Sir John Oldham and Steve Laitner, the national leads for long-term conditions and shared decision making, to roll this approach out nationally.
Case study – coaching parents
Dr Martin Kittel, director, Bracknell and Ascot GP Commissioning Consortium
Often nowadays, if people are sick or have a sick child one of the first things they do is look up the symptoms on Google. They then get scared and call a doctor. Previous generations would speak to their mother or neighbour who would know to wait a couple of days before going to the GP.
In the last few years we’ve seen a clear increase in attendance for self-limiting illness, especially by younger patients. Year-by-year increases have been between 7% and 15%. A&E figures show a similar trend. This is beginning to overwhelm practices
and makes it harder to care for those who really need it.
As the self-care lead of my CCG, I had been thinking about self-care initiatives for a long time. When the King’s Fund document Priorities for commissioners was published last year, the first priority was self-care. Andrew Lansley’s comments about the £2bn that could be saved through self-care brought home to me the staggering amount that could be better spent elsewhere. But nobody knows what to do about it.
There are telehealth initiatives for chronic disease management such as heart failure or chronic bronchitis, but beyond that there hasn’t been much thought. We need to push the boundaries.
I believe the key is coaching people. Patients who attend because they are anxious about their children or themselves are not trying to be awkward. We need to teach them that it’s normal for a child to be sick and how to understand their bodies a bit more so they are less dependent on the GP. We need to show them that Google does not always give the right answer.
In our practice we organised an evening workshop and invited the 100 most frequently attending parents of children of primary school age. Some 30 of them came, and we gave them information about how to recognise and deal with minor and self-limiting illnesses and injuries. We were delighted by the feedback. They all felt far more confident. I’ve since organised another to cover patients of all the CCG’s practices.
We are also running a telehealth initiative. We have 20 heart monitors for our sickest patients measuring blood oxygenation and heart rate. If they go outside certain values the practice is alerted and a nurse will investigate. This has been shown to reduce hospital admissions by about a third, nationally.
We have other pilots under way. We are working with Bracknell Borough Council to tackle childhood obesity. I’d also like to pursue online checks for blood pressure or certain repeat prescriptions so patients can self-review at home.
Our CCG is currently designing new urgent care pathways and we will put self-care education for patients in the specification of new contracts with providers.
One of the main stumbling blocks is that technology has not caught up with what we want to do. We cannot send out emails or text messages to our patients without complicated third-party products. We’d like to be able to send patients targeted information about local health issues and advice on how they can protect themselves.
We’d like to be able to target groups in this way to help them help themselves. It’s a lot cheaper than sending letters, which can cost thousands of pounds. Also, patients like receiving information in this form. The technology-based self-care schemes do not only appeal to the young and working-aged population of our consortium, who are the group who most frequently attend surgeries for self-limiting conditions, but older patients are also getting increasingly web and email savvy.
Case study – getting the right information to patients
Rod Marshall is practice manager at Parkside Medical Centre, Milton Keynes
In April 2008, we set up a patient empowerment and information project in our practice.
The idea was to ensure every patient
was given the information they needed to enable them to improve their quality of life, health and wellbeing, and to be more independent.
We received £2,850 from the local commissioning group and £1,000 from Quality:MK – a Health Foundation project involving NHS Milton Keynes, the local patient forum and the centre for evidence-based medicine at the University of Oxford. We also aimed to guide patients to reliable sources of information about their condition and support groups.
We did this by providing:
• a dedicated information zone in the waiting room with PC terminals for internet access
• printed leaflets giving patients their diagnosis, telling them where to get information on their condition – including websites, libraries, phone numbers, local and national support groups, and welfare and social care organisations
• tear-slips on the leaflets to enable patients to request an ‘information prescription’
• trained health information advisers in the practice to help with the new resources
• small library of recommended books (in the information zone) on a wide variety of conditions for patients to use and borrow.
The project ensured the information given to patients was accredited by use of appropriate websites, publications and books.
Patient information leaflets are provided by PatientUK, which is accredited with the Information Standard.
Books were selected from the Core Collection of Health Care Books for Patient and Public, endorsed by the RCGP.
Patient representatives from the Milton Keynes LINk group and the practice patient participation group were an active part of the project group. A practice open evening and an open day were staged to promote self-management and the information zone. The information zone and health information advisers are publicised in the practice newsletter. Long-term savings will be made through the reduction of inappropriate referrals.
Local support groups have seen an increase in numbers attending meetings.
The outcomes were fed to other practices in Milton Keynes via presentations at the Health:MK AGM and support is available to enable others to establish similar schemes.
The information zone will be maintained and the provision of information by GPs
and health professionals will continue, with the support of the health information advisers.
To ensure uptake, there needs to be continual reinforcement of the message – to clinicians, patients and carers. There also needs to be a culture shift in the practice for GPs and patients that information can empower, and that that information can be provided by a variety of people and means.
In 2009 we carried out a patient survey:
• 62% (35/56) used books in the waiting room
• 30% (17/56) had talked to a health information adviser
• 50% (28/56) accessed the internet sites on the leaflets
• 72% (41/56) had been given printed information by their GP
• 64% (36/56) had a better understanding of their condition
• 49% (27/56) felt better able to cope
• 45% (25/56) were able to have a more meaningful consultation with their GP.