Guest Blog by Dr Ollie Hart
I am honoured to be asked to speak at the Inaugrial World Health Innovation conference in Cumbria in Spring. I’m a GP working in Sheffield. Like most in the NHS I constantly juggle with the many conflicting demands and pull on my time and energy. However I always have an eye open for innovation- especially if I think it will make mine and my patients lifes better. I have recently become especially interested in person centred care, and measuring ‘activation’. I see it as a really positive and innovative way to shift the ethos of health (and social) care, helping it feel in more right to patients, and more manageable to health care professionals (HCPs)
It is now pretty much beyond doubt that people who feel in control, empowered and confident to take a lead role in their health care have better outcomes. This is the central ethos of person centred care. This approach is a lead feature of Simon Steven’s five-year forward view for the NHS, a key priority for the Health Foundation, and a feature of most manifestos and policy guidance from leading patient groups.
So whilst the aspiration of building patient centred care is fairly universal, how to do it is less well understood, and consequently we rarely do it. The Health foundation identifies 3 particular activities that support PCC- supported self management, shared decision making, and collaborative careplanning.
Each of these activities is new, especially to GPs, and often require very different approaches in how we think about, and organise, our services. This might mean longer appointments with more of a coaching approach to healthcare, or changing the balance of what data and information people have access to. This might mean helping patients to see and understand their health records, or their results, before meeting a clinician to discuss them.
Speaking as a GP and Commissioner I am acutely aware that our current systems, in the main, do not support such an approach. Contracts do not prioritise person centred processes, so GPs continue to run 10 min appointments for most patients, and efforts to give results in advance of appointments rely mostly on pockets of innovative enthusiasts.
In order to move towards systematic adoption of person centred care we need a culture change. Culture change is never easy and never quick. It requires patience, persistence and a plan. I’ve had first hand experience in my CCG of trying to introduce the concepts of person centred care in both primary and secondary care over the last 2 years.
There is plenty written about system change. I particularly like Kotters 8 steps
I wouldn’t suggest to reinvent the wisdom of such tried and tested models of change however I have come realise how important measurement is in changing our systems. It is a key feature of an improvement science model. If something matters and we are going to try and change it for the better, we need someway of measuring it. Just as we now know how important the pressure in our blood vessels is to our longterm health, if we think person centred care is important we need some way of assessing how we are doing.
If we are going to aim to change the way a patient is involved in their own care we also need to have a good way of supporting them learning how to do this- supported self management. The first rule of education is ‘find out what your student already knows, and can do’.
I’d like to draw a parallel with learnging to dance.I recently decided that learning to salsa dance with my wife was going to be a good way to enhance our relationship. We went along to a local class, but I quickly realised it was way too advanced for me, I couldn’t keep up and felt stupid. I realised I was a beginner, and needed to be in a class that was pitched at the right pace for me. My wife however already had a bit of experience, not quite an expert, but more of an intermediate. She would be bored and frustrated to be returning to a beginners class. Just so for self management. We need a way of measuring where people currently are so we can pitch the training and support at the right level.
Sheffield is part of a national pilot to trial the Patient Activation Measure (PAM) as just such a measurement tool. It uses 13 questions to help establish whether people are Level 1-4 activation. ‘Activation’ is defined as the level of skill, knowledge and confidence a person has to self manage. In Salsa terms you could translate this into level 1 = not currently thinking about learning, level 2= beginner, level 3= intermediate, level 4= expert. We are then encouraging ways of the local systems and HCPs, to tailor their approaches to supporting self management according to the level of activation of their patients.
The PAM has a strong and established evidence base. Interestingly it suggests that moving someone from a level 1 to a level 2, from not seeing a role in managing their own health, to just being a beginner, has the biggest affect on health outcomes. Ironcially I think we are very poor at picking up this subtle change as HCPs. We often set our success criteria around significant behaviour changes like giving up smoking, or increasing our exercise levels. The PAM helps us to track these early, often impercievable, changes. Knowing you are making a difference is a key motivating factor for many HCPs and patients.
We don’t have much spare capacity in any of our health systems, and lack of time so often limits our ability to embrace new ideas, and especially if these ideas include giving longer appointments to some people. However what I have found especially helpful about PCC is that it can be a safe way to help free up time. I know from talking to our patient group in the practice that we all spend a huge amount of time and effort giving people advice that is too complicated for them. We think it is the right thing to give diabetics all the advice about eating well, exercising, taking medication etc, but if like in the Salsa example they are just a beginner, then expecting them to thrive in an expert setting is probably more harmful than helpful. It certainly put me off Salsa.
So if we understand their level of activation – we can stop doing the things that really aren’t going to help at that time. It saves us wasting time doing the things we think should be helpful, but are actually harmful. Eliminating waste from our systems is the only way we will ever claw back time to do new things.
In my experience, for people who have low levels of activation, HCPs are often not the best people to help. Our training means we can’t help but offer ‘too much information’. Often expert patients, lay health trainers, or voluntary groups are better placed to help people deal with the issues that are overwhelming them and stopping them from prioritising their health. It is hard to think about your health when you dealing with debt or a housing crisis. When you are just starting to consider your role in self-management it is often much less intimidating to chat to a peer than an expert. This can lead into accessing expert advice later, when that person is ready, and at a pace that they can control.
So I remain realistic about the level of persistent effort it will take before measuring and responding to levels of activation becomes an automatic feature of our health care systems. However I remain optimistic that this approach will eventually liberate us from wasting time doing the wrong things, in the wrong way, and help us to shape our systems around what our patients need at that stage of their life. It can form part of a journey towards systematic person centred care.
When it comes to Salsa, a few months on from my beginner classes and me and my wife are twirling the night away. I still have 2 left feet, but we know enough to have fun, and are learning all the time!
I really hope I get the opportunity to explore these ideas and concepts with many of you in March 2016.
*The opinions expressed are the guests own and do not necessarily reflect the views of the World Health Innovation Summit.