Bid to improve health care through ‘better conversation’

Health staff are being offered advice and training to change the way they talk to patients.

 It follows research which shows that patients often don’t take their medications or change their lifestyle after visiting a doctor or nurse, while only about 60 per cent of patients feel they are sufficiently involved in decisions about their care.*

A set of resources has been developed as part of a ‘Better Conversation’ campaign which aims to empower patients to become more active in managing their health.

A new website www.betterconversation.co.uk includes information, evidence and tips for clinicians and health and care leaders on how to introduce a health coaching approach, so that patients are treated as partners in their care rather than passive recipients.

NHS Medical Director Professor Sir Bruce Keogh, who wrote the foreword to the resource guide, described health coaching as an essential part of the plan to transform the way health care services are provided, to make them sustainable.

The materials were put together by a collaboration of health organisations, led by NHS Innovation Fellow Dr Penny Newman. Penny said: “The conversation between any clinician and patient is paramount. I am passionate about us having conversations that enable people to thrive by feeling more motivated, confident and in control of managing their own health and care.

“Only by understanding what’s really going on and putting patients more in the driving seat can we enable them to better manage their own health and adopt more healthy behaviours. Since 2010 I have been gathering the evidence and developing resources to support colleagues to work more in partnership with patients”.

“People often know they need to improve their health they just don’t know how.  Behaviour change science shows that just telling people what to do often doesn’t work – as clinicians we have to become more empowering.  If we ask patients what matters to them, and work together to create plans that motivate them and fits in with their life, we will improve their health and well-being.”

“A different or health coaching approach not only means people feel really listened to, which improves their whole experience of care, it also achieves efficiencies. It is my ambition and that of all our partner organisations to transform health care through enabling better conversation.”

A pilot programme of health coaching developed in the East of England has now been rolled out to over 3000 clinicians across the country. The work is backed by the NHS Innovation Accelerator initiative along with the Academic Health Science Network, Health Education England and the Coalition for Collaborative Care.

The purpose is to give clinicians the tools to help patients to feel more motivated, confident and in control of managing their health and care through better conversations. These health coaching skills can also be used by lay people.

Examples of impact
An evaluation in an older persons rehabilitation ward found that, by using the techniques of health coaching, patients became more engaged in their recovery. The local service provider’s data showed the resulting average length of hospital stay was reduced by 17 hours per patient, while eight per cent of patients in the intervention group were discharged to residential care homes, compared to 27.3 per cent in the control group.

Using these findings an economic evaluation found the intervention to have been very cost effective with a net benefit value per patient of £4,973 or savings of about £3million over a one year period for the rehabilitation ward.

Other examples include hospital pharmacists who after training in health coaching significantly reduced the number of people returning due to medication problems such as drug reactions. Health coaching has also been shown to reduce smoking and increase physical activity, weight loss and mood in Salford when used by practitioners in the community and outside hospital settings. For people with diabetes, after coaching they were more likely to take their medications correctly which improved their blood sugar and hence risk of complications.  

What patients say:
Evidence of the need for health coaching came from an analysis of patient feedback on the public website Patient Opinion. (full report available)

One hundred and sixty two stories reported over a two year period between January 2014 and December 2015 were analysed and key themes identified to understand what happens when people feel listened to and involved in their care, and when they don’t – and how this impacts on their health and wellbeing, and future use of services.

The vast majority of stories - 84 per cent - recounted positive experiences of being listened to, empowered or engaged in decision-making about the patient’s health care.

Of the remaining 16 per cent, the negative experiences were categorised under the following headings: a felt lack of respect; having one’s own concerns and priorities ignored, dismissed or contradicted; and a lack of involvement in decisions about one’s care.

The mother of a 16 year old boy with cystic fibrosis, Mandy Rudczenko said: “Health coaching has enabled myself and my son to find ways of managing his relentless treatment regime, without the negative baggage which comes with telling someone what to do.

“Health coaching isn’t a luxury or an extravagance. It’s the only option for positive, humane health and care relationships.” (full version of A carer’s story is below)

Patient Opinion Chief Executive Dr James Munro said: “The stories that people share with us online give a rich insight into the issues that matter most when using healthcare. Communication with health professionals is by far the most important.

“When communication works well, people feel treated as equals, their knowledge and experience is respected, and they are given clear and relevant information. The result is trust, confidence, better decisions – and people feeling more in control of their health.

"But when a person’s concerns are ignored, and their experience is dismissed or contradicted, they become excluded from decisions about them. This leads to a loss of trust, less interest or confidence in maintaining their own health, less adherence to medication, and poorer health.

“Better, more equal and respectful conversations between clinicians and patients are essential to improving care.”

A carer’s story:
Mandy Rudczenko said: “As a carer for my son with cystic fibrosis, I used to see this as a passive role, in which I was the mechanism by which the  treatment decided by clinicians was carried out. Health coaching has come as a breath of fresh air, which has enabled me and my son to engage with the management of his condition in a much more positive way.

“Cystic fibrosis requires a heavy, relentless treatment burden to stay alive. Traditional methods of ensuring treatment adherence include nagging, criticism, bullying, threats of hospitalization, and a default mode of assuming non-adherence.

“These approaches create dysfunctional working relationships between clinicians and families, resulting in resources being wasted on over-medicalisation and misdiagnosis. The critical patriarchal approach also disengages children and teenagers, often resulting in declining health during adolescence.

“I instinctively knew this approach wouldn’t work for my son. I also know that I don’t want to go to my son’s funeral – the average predicted survival age is 41 according to the CF Trust.  When health coaching came into my life I knew I had found the answer. Health coaching has given me permission to do what I had always wanted to do, but thought that it wasn’t allowed.

“I allow myself to listen to my son and enable him to set his own treatment goals. The traditional fear is that the patient, especially a child or teenager, will opt for low or zero goals; this is a myth. My son wants to carry out treatments in ways which mean something to him. He uses a nebuliser three times a day. The relentless burden of doing this every day means that the average adherence is 40 per cent. Factors affecting adherence are obviously very complicated.

“My son’s average adherence is 80 per cent because he set himself a goal to avoid having intravenous antibiotics – a regular treatment for CF – as long as possible. He knows that one way of avoiding this treatment is to keep up with the nebuliser which prevents chest infections, thus giving him the internal motivation.

“People with cystic fibrosis struggle to put on weight and are often threatened with tube feeding. They are often given a target weight to achieve by a certain date. This target can then become a disempowering obsession. Instead, my son set his own goal of taking a certain number of digestive enzymes a day, which translates into eating a certain number of grams of fat per day. He has managed to stick to this without developing an unhealthy relationship with the bathroom scales.

“Health coaching has enabled myself and my son to find ways of managing his relentless treatment regime, without the negative baggage which comes with telling someone what to do. Health coaching isn’t a luxury or an extravagance. It’s the only option for positive, humane health and care relationships.”

Her son Leo said: “I think the most helpful thing a health professional can do in a conversation is listen to me and believe what I say.”

Only about 60 per cent of patients feel they are sufficiently involved in decisions about their care:

* Responses from 83,116 people and 159 Trusts indicate only 60% were definitely involved as much as they wanted to be in decisions about their care and treatment and 9% felt that they hadn’t been involved at all. 

Source: CQC in-patient survey 2015 http://www.cqc.org.uk/content/adult-inpatient-survey-2015