With clinicians stepping up their leadership skills and patients having increased opportunity to exercise choice in their healthcare, Dr Penny Newman and Dr Andrew McDowell weigh up the benefits of coaching in enabling both groups to make the most of the changes.
The job description for clinicians is changing. It is no longer enough to lead a small clinical team; they are being asked to take responsibility for whole patient pathways and the budgets that follow them, and change their clinical practice through greater shared dialogue and reducing activity.
The aim is to empower clinicians to innovate and improve care. Another intention is for patients to experience more choice and control, fulfilling the mantra of “no decisions about me without me”.
Coaching can help clinicians in the challenge ahead, both in and outside the consulting room. The premise is that “coaching style” interactions can raise awareness and increase levels of responsibility, thus improving relationships and encouraging innovation and efficiency gains.
What is coaching?
Coaching is the art of facilitating the development, learning and performance of another. Key elements include a non-directive style, goal-setting, listening, questioning, constructive challenge and feedback with an aim to empower the coachee rather than tell them what to do.
Research indicates coaching increases performance and provides substantial returns on investment. In the NHS, coaching has been used primarily for leadership development to support managers and teams. Clinicians receiving formal one to one coaching would also experience these benefits.
We ran an online survey in June 2010 with 600 graduates of coaching skills development programmes that were commissioned by strategic health authorities. The aim was to identify the real and potential benefit of the skills they had learnt for application with clinicians and patients.
While the survey may not be truly representative with a 25 per cent response rate and an under-representation of GP commissioners given the embryonic clinical commissioning groups at the time, those who responded perceived the skills to be highly applicable for clinicians in leadership and with patients (see boxes, below).
Coaching for patients
By 2020, three quarters of all deaths are predicted to be from chronic disease. So new approaches to working with patients are required. Self care support is a portfolio of techniques and tools that helps patients choose healthy behaviours and a fundamental transformation of the relationship between the patient and caregiver into a collaborative partnership. Example techniques include expert patient programmes, medicines management and coaching.
Health coaching aims to increase awareness of and encourage greater responsibility for health among patients. While not prevalent in the UK it is used throughout the US where it has achieved savings through improving outcomes such as: medication compliance, physical functioning, self-efficacy and reduced unplanned admissions.
Coaching for patients
Nearly all survey respondents believe coaching is relevant to clinical practice (96 per cent). More than 90 per cent believed that coaching would achieve the following benefits with patients:
- Improve patient motivation and readiness to change
- Address barriers to change
- Increase patient self-management
- Improve compliance
- Improve patient satisfaction
- Improve clinician satisfaction
The patient groups most likely to receive benefit from health coaching interventions were:
- Patients with long term conditions (89 per cent)
- Patients who need to make healthy lifestyle choices (89 per cent)
- Patients with complex problems (82 per cent)
Coaching for practice nurses
To test the concept of health coaching NHS East of England Regional Innovation Fund funded a pilot program with NHS Suffolk. Practice nurses, who are the lynchpin for managing long term conditions in primary care, received five days of health coaching training encompassing core coaching competencies coupled with patient activation, behavioural change, motivational interviewing, and strengths based approaches.
Patients were given longer appointments to establish goals and agree their health plan, and so reduce primary care consultations and hospital admissions. Nurses are now conducting health coaching clinics in their practices to encourage self care. Early results of the evaluation using self care efficacy tools indicate a positive effect.
We believe there are significant advantages to clinicians receiving training in coaching skills as well as formal one to one coaching:
Coaching builds on what clinicians do: Consultation skills for GPs in training includes the use of “two heads”. The “organiser” head manages the consultation process, while the “responder head” watches, logs and responds to the emotional, visual and physical cues and relationship evolving between the doctor and patient. Similar processes are used in coaching, which builds on clinicians’ core skills and values.
Coaching is a good way to manage clever people: Research describes a specific group of highly talented, uniquely skilled, confident and autonomous employees as “clevers” – attributes that could apply to clinicians. “Clevers” do not like being told what to do – a coaching approach is considered effective as it requires them to generate their own options and solve problems for themselves.
Coaching is a desirable leadership style: Good leaders match their style to the situation to encourage interaction by the “follower” in the decision making process, and clinical commissioning groups will require “delegated leadership” to engage their constituent practices. A coaching style will be useful in these complex non-hierarchical relationships, and is recognised as one of seven that good leaders can adopt to improve performance, develop strengths in employees (or peers), with a positive impact on organisational culture.
Coaching supports self-care and a shared dialogue: Early evidence from the US indicates coaching with patients can increase responsibility and motivation to self-care, producing significant savings.
Coaching for clinicians
Survey respondents reported they would apply coaching in:
- Management conversations (96 per cent)
- Appraisals (92 per cent)
- Education and training (89 per cent)
- Formal one to one coaching (82 per cent)
- Commissioning (71 per cent)
Over 95 per cent of respondents agreed coaching would deliver the following benefits to clinicians:
- Improved problem solving
- Better relationships with colleagues
- Greater self-awareness and new perspectives
- Greater adaptability to change
- Improved managerial and interpersonal skills
- Identifying and acting on development needs
Coaching, including health coaching skills, is one of a range of techniques that will be useful for clinicians in the challenge ahead (see diagram, attached right). Coaching training for clinicians delivers the double benefit of skills that can be used with peers and patients. Such training could be delivered separately or together. The National Leadership Council has offered coaching training to a small number of GPs as commissioners; training to encourage self care is minimal.
Coaching is not a panacea, but it builds on what clinicians already know and provides an option for different types of conversations. Many clinicians will use these skills to improve consultation with patients and realise the benefits for other types of conversations including leadership.
The benefit of coaching has already been recognised for managers and substantial investment made across the country to develop a coaching culture. As clinicians take up the leadership mantle, this development could be more widely applied.