On the day of John’s consultation, our new GP trainee sat in with me for the first time. Before clinic, we had been chatting about each other’s interests, and I told him my career had been transformed by using health coaching. I explained how it had enabled me to have new ‘partnership’ relationships with my patients. Hot off the medical ward, I could sense his scepticism. In walked our first patient.
John, 38 years old with one year’s history of type two diabetes, was back a month after our last consultation. ‘I took on board what we talked about last time, doc. I read that book, and I’ve started a low carb diet,’ he said.
‘I’ve got my wife on board and we’re having a lot of fun with new recipes. I’ve lost 8kg so far and have so much more energy. I know I’ve got to stop smoking, but work is still really stressful, so that’s the next step. Now I’ve achieved this I know I can do it; I’m in a much better place mentally than when I last saw you. I decided to stop gliclazide because of what I read about associated weight gain, but I think metformin is a good idea. Is that alright with you?’
When John left, the trainee and I were both grinning. ‘Did you set that up?’ the registrar asked.
‘Yes,’ I replied, ‘the conversation we had a month ago set that up.’
The Patient Activation Measure
I knew John had good self-care capabilities; I had formally measured this using the Patient Activation Measure. Activation is people’s confidence, skill and knowledge to self-manage their care. It’s a key parameter we now capture in people with long-term conditions, and we focus on increasing it. We tailor our conversations and support to draw out this sort of response.
I was able to listen to what mattered most to John and be open to his ideas on the changes he could make. We then made a plan together that he knew he could make work and thought would be helpful. For others, it takes much more support to get to this stage, so it’s often non-clinical staff like health trainers who support these first small steps.
Supporting people to self-care must start with a new belief model. It’s a model drawn from coaching and, at its heart, is about believing that everyone is resourceful, and given the right support, able to do more than they think they can. In a health context, this means learning to understand and contribute to the things that help them attain and maintain good health. It’s a belief model that will not only create better health care but also help save our burnt-out staff and overstretched system.
Shaping a new system
In a recent co-production meeting, one of the patients in our group said, thoughtfully, ‘we need to move on from the long-held belief that doctors know best.’
For many years I studied and trained to build confidence in the fact that I would always know best. I thought that being a good doctor was about solving the problem and telling people how to deal with it: ‘my great ideas, you stick to the plan.’
15 years of general practice later and I’m coming to my senses. I’m exhausted from the effort of trying to solve everyone else’s problems, and I’ve realised that teaching people to understand and think for themselves is more beneficial for everyone involved. Now I coach people according to their level of activation, moving at their pace and drawing out a plan that they develop and own.
People play a huge part in solving their own problems. Very often, this doesn’t involve as much medicine as we think. We know from studies that as little as 10% of our health is determined by health care. It is the wider social and behavioural factors that matter most, and often these are the best place to start.
Health coaching involves a whole new set of skills, and it’s a fine art knowing when to input appropriate medical expertise. I couldn’t do it without the background knowledge and experience that I built up in medical training, but this is most effective when combined with the coaching skills I’ve developed.
The biggest challenge I see now is shaping our systems to make time for important conversations. My experience so far tells me that we can make this time by avoiding wasted medical input when people are either not ready, or already doing fine on their own. This will mean some changes in our expectations, but we are getting there.
Ollie Hart is GP partner at Sloan Medical Centre and clinical lead for person-centred care at NHS Sheffield.
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