Clinicians are changing the way they work with patients and acknowledging that it is a partnership, says Natalie Grazin
In hospitals and general practices across the UK, a pioneering group of clinicians is leading a quiet revolution that is turning on its head the way clinicians approach their consultations with people who have long term conditions. Co-creating Health is an ambitious three-year Health Foundation initiative running in eight health economies across the UK. Its aim is to test the feasibility of putting self-management support at the heart of mainstream care. Moving away from standalone self-management courses for patients, Co-creating Health's goal is that self-management support will be embedded throughout the healthcare system - and nowhere is this more challenging than in the classic 10-minute consultation.
As health economies across England grapple with the new challenges presented by the next stage review's commitments to patient partnership and care planning, the Co-creating Health approach provides valuable pointers. The initiative is based on the evidence that change of this nature requires a whole-system approach - clinicians, patients and service models all need to adapt - and in turn, they each need support with the change required of them.
Co-creating Health offers clinicians an advanced development programme designed to strengthen the skills and knowledge health professionals need to provide self-management support.
One of the eight NHS teams involved in Co-creating Health is NHS Ayrshire and Arran. Its ambitious goal is to transform care for people with chronic obstructive pulmonary disease. Consultant respiratory physician Hans Hartung is joint clinical lead for the team and was in the first wave of clinicians to go through the programme.
"It was a real eye-opener for me - almost a shock," says Dr Hartung. "I hadn't expected that there was such a different way in which we could conduct a consultation. It had never even crossed my mind before.
"It showed me a completely new way of interacting with patients - one that is more meaningful, effective and satisfying."
The nine-month programme consists of action learning sets, web-based learning and three half-day workshops co-facilitated by a local health professional and a local patient. The clinical and patient co-facilitators have equal status as tutors.
"There are very few examples of patients co-delivering clinician training," says Larry Baker, associate professor from CFEP UK Surveys, which designed Co-creating Health together with the Health Foundation and now delivers the programme on its behalf. "Patients and clinicians co-delivering training is also symbolic of what we are trying to achieve. It gives an example to the participants of partnership working in practice."
Clinicians are encouraged to co-create with their patients an "agenda" at the beginning of each consultation, based on the question "what will make this consultation successful for you?" They also act as facilitators for patients' goal-setting, helping them to set goals that are relevant to them and which will build their confidence in their ability to make a contribution to their health, rather than depending on the professional. Clinicians also learn to plan with patients how they will receive continuing self-management support in a way that suits that individual.
The workshops for clinicians are full of active learning methods such as role play and video. They give clinicians a safe environment to try this new approach to their consultation, with trained actors playing patients. They can practise and "rewind" their consultations to make improvements in real time. Then the clinicians take back their learning and put it into practice in their consultations.
For Carol Nixon, the nurse lead for Co-creating Health in NHS Ayrshire and Arran, the key learning has been the emphasis on building patients' belief in their ability to make a difference to their health and the investment in building up their self-management skills. "Consultations are much more constructive now. It's so inbuilt that we solve our patients' problems - that's the way we were taught and that's the way we've always acted. You have to change your whole way of thinking, but I'm now a lot happier at the end of each consultation."
Another component of Co-creating Health works to reshape the service itself so that it better supports self-management. Staff and patient representatives are given the time, space and help to explore and imagine how the service could better aid patients to play a more active role in optimising their own health.
Other Co-creating Health sites have introduced drop-in self-management support sessions and email and telephone consultations and have joined forces with local voluntary sector organisations such as the Ramblers Association in order to provide peer support beyond the limits of the NHS. The challenge of providing truly personalised care brings change on a scale most of us do not yet appreciate - but experience so far suggests that for both clinicians and patients, it is a change for good.
On the front line: co-facilitation in practice
Joni Inniss is patient co-facilitator, advanced development programme for clinicians, Whittington Hospital trust
As patient co-facilitators, we help clinicians to reflect on the aims of their consultations with patients, to clarify their learning and to think about how to set agendas with their patients. Most importantly we give some insight to clinicians to see what it is like from our perspective.
I've now participated in my first sessions as a patient co-facilitator. I enjoyed the feeling in the room - the clinicians were interested to know what they could do to develop themselves and the way they worked. They shared stories and concerns and it gave me insight into some of the difficulties they face to make this shift in approach.
The old school clinicians is not quite dead, but there are people who are prepared to take on new concepts and to recognise that the previous way of working was not as effective as it could be.
Learning so far
Until now, the focus of effort in self-management support has been at the patient level. But when clinicians encourage patients to take an active role in managing their condition as part of a routine consultation and the service is reorganised around self-management support, patients' perception of the importance of their own actions is far greater.
Effective clinical leadership is critical to implementing self-management support successfully. Clinicians need to feel confident that their clinical leaders have themselves participated in the Co-creating Health initiative and are exploring the implications of new ways of working with their patients as a result.
Clinicians, particularly doctors, are trained to solve patients' problems, to "fix and cure". This is very different from the partnership approach needed between lay people and clinicians over a range of aspects of self-management. Making routine consultations truly collaborative is a challenging shift, demanding changes not only in attitude but also in technical and ingrained consultation skills.
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