Initiatives for self-management are placing the individual at the hub of care. In line with one of Simon Stevens first statements as NHS Chief Executive, the NHS has become “serious about patient power” and has “boost[ed] the critical role that patients play in their own health and care.”
In its publication Supporting People to Manage their Health the King’s Fund states “With 60 to 70 per cent of premature deaths caused by detrimental health behaviours, it is vital that people engage more with improving their own health”. Although not a replacement for investing in service improvement, it has been shown that supporting people to manage their own health, wellbeing and care results in both a better experience of care, and a reduced demand for high-intensity acute services.
We find ourselves in an era where the clinician-patient relationship is, by necessity, an increasingly collaborative one. Dr Martin McShane, NHS England’s National Medical Director for Long Term Conditions says: “Helping people to help themselves is a two-way partnership between individuals and the NHS to provide information, tools, support and care to allow people to stay well and use health services appropriately.”
The King’s Fund defines patient activation as “a concept describing the knowledge, skills and confidence a person has for managing their own health and healthcare”. These factors have been shown to be key determinants in a person’s health outcomes, as people who are more activated are significantly more likely to:
- attend screenings, check-ups and immunisations
- adopt positive behaviours (e.g., diet and exercise)
- have clinical indicators in the normal range (body mass index, blood sugar levels (A1c), blood pressure and cholesterol)
And people who are less activated are significantly less likely to:
- prepare questions for a medical visit
- know about treatment guidelines
- be persistent in clarifying advice
Cost implications and interventions
Levels of patient activation have significant cost implications for the health service. As NHS England explains: “Evidence shows that supporting people to increase increasing their activation can help with reducing costs for the NHS, as less activated patients engage less with preventative healthcare and are involved in more costly emergency care episodes.” Increased activation will help to improve their outcomes, their patient experience, plus reduce their rates of hospitalisation and visits to A&E.
Studies show that certain targeted interventions can increase activation by boosting people’s knowledge, skills and confidence, and thereby their capacity to self-manage their condition more effectively. The Realising the Value programme, funded by NHS England and led by the Health Foundation and Nesta, identifies five evidence-based approaches which engage people more in their own health and care: self-management education; peer support; health coaching; group activities that promote health and well-being; and asset-based approaches in a health and well-being context (i.e. approaches which build on the existing strengths of individuals and communities).
Clinicians’ evolving role
So, what will these efforts towards higher patient activation mean for clinicians, the way clinicians communicate with increasingly activated patients, and the evolving role of staff in the healthcare dialogue? As patient activation levels rise and they take greater ownership of their health, they may no longer be looking to clinicians to just be an encyclopedic source of information about a given condition; patients will instead be prepared to engage in an informed, two-way dialogue about health.
When patients arrive at clinics with some level of information – for example, an awareness of the long-term impact that smoking can have on their health – rather than seeking simply prescriptive imperatives or didactic lectures, they will be looking for a conversation about options and a healthy dialogue to process conflicting information that they may have found.
The position of conduit
This, more than ever before, places the clinician in the position of conduit to reliable information. Via the internet, patients have access to limitless health information, from NHS Choices (now getting 40 million hits per month) and reliable peer-reviewed medical journals, to online sources of health information like WebMD or pop culture articles on medical topics. More activated patients might no longer be looking for clinicians to be the only source of information, but rather to direct them to the most trustworthy information.
Technological advancements mean that clinicians might also be called upon by patients to engage in conversation about apps or other new tools to support ongoing self-management. Wearables like the Fitbit or weight-loss apps like LoseIt! are examples of the many technologies now on offer which could support self-managed health and care, dependent on accessibility. And the NHS Five Year Forward View commits to: “an expanding set of NHS accredited health apps that patients will be able to use to organise and manage their own health and care; and the development of partnerships with the voluntary sector and industry to support digital inclusion”.
To truly deliver person centered care, all healthcare staff have a responsibility to be aware of resources available to patients and capable of guiding them to it, whether it is a new mental health app available through the council, or wrap-around services to assist with getting the heating turned back on. This should not sound unfamiliar, as it aligns with the Making Every Contact Count (MECC) initiative that calls on staff to have the competence and confidence to deliver healthy lifestyle messages as well as to direct them to local services that can support them.
An interpretive dialogue
Communication skills are of course a vital component in the effective provision of such information. As NHS England states: "Improved communication skills for clinicians and training in areas such as motivational interviewing can support them to address the individual needs of patients at different levels of activation more effectively".
While motivational interviewing has been part of the standard curriculum for junior doctors in recent years, reviewing and maintaining a competence in this skill is key to ensuring patient buy-in and behaviour change. Having a conversation to understand a patient’s motivations, and agree upon items of change is paramount to driving population health outcomes. In this way, the importance of motivational interviewing in patient dialogues cannot be overlooked, and clinicians can benefit from adding this to their revalidation assessments or reflections to ensure that this remains a staple skill.
Are you a leading expert in motivational interviewing for healthcare, or are you a clinician whose organsiation has a need for training in this area? If so, please contact Katrina Ong: email@example.com