Travelling on the journey of change with
people with long-term conditions
1
When people self-manage, they are more likely to:








Experience better health and well-being;
Reduce the perceived severity of their symptoms, including
pain;
Improve treatment adherence;
Prevent the need for emergency health and social services
input;
Prevent unnecessary hospital admissions;
Have better planned and co-ordinated care;
Remain in their own home;
Have greater confidence and a sense of control.
2



Self-Management, by definition, is led, owned and
done by the people themselves.
The NHS cannot do self-care to people, but what it
can do is create an environment where people feel
supported to self-care.
This is not just about a change in service provision,
but about a cultural change, allowing patients to be
partners in their care, letting them decide what
support they need, when they need it and how.
3

In 2008/9 in England, 49% of all inpatient bed
days were occupied by just 5% of patients

The treatment and care of people with
Long-Term Conditions accounts for
approximately 69% of the primary and
acute care budget in England

4


People with LTCs are far higher users of health and
social care services than average, accounting for
approximately 50% of General Practice consultations,
65% of out-patient appointments and 70% of inpatient
bed days.
At the current rate of growth, expenditure on LTCs will
increase by 94% by 2022 – whereas the NHS budget
won’t
Source: Improving the Health and Well-being of people with Long-Term conditions DOH
5
The biggest ‘Efficiency Frontiers’ are
where the major costs in healthcare
are:
• Management of people with long-term medical
conditions
• Care of older people
• Reducing avoidable emergency admissions
• Care for people at the end of their lives
Source: Nuffield Trust (2010): Making Progress on Efficiency in the NHS in
England – Options for System Reform
6

SMP – Self-Management Programme for patients

ADP – a clinician training programme based on
motivational interviewing techniques

SIP – service improvement programme; designed to
make system changes that promote self-care
7




Self-care needs movement from both sides
Move away from traditional doctor-patient relationship
Meeting between two experts sharing different knowledge
Better doctor-patient communication leads to better health for
the patients, measured either:
◦ Physiologically e.g. blood pressure, blood sugar
◦ Behaviourally (functional status)
◦ Subjectively (beliefs about overall health status)
Source: Med Care (1989): 27S110 – S127
8
Traditional vs. Collaborative
Interactions
Traditional Interactions
Collaborative interactions
Information and skills are taught based on the
clinician’s agenda
Patients and clinician share their agendas and
collaboratively decide what information and
skills are taught
There is a belief that knowledge creates
behaviour change
There is a belief that one’s confidence in the
ability to change, together with skills and
knowledge, creates behaviour change
The patient believes it is the clinician’s role to
improve health
The patient believes that they have an active
role to play in changing their own behaviours
to improve health
Goals are set by the clinician and success is
measured by compliance with them
The patient is supported by the clinician in
defining their won goals. Success is measured
by an ability to attain those goals
Decisions are made by the clinician
Decisions are made a patient-clinician
partnership
9
Source: University of Oregon
10

Use activation level to determine what are realistic “next
steps” for individuals to take

Many of the behaviours we are asking of people are only
done by those in the highest levels of activation

When we focus on the more complex and difficult behaviours,
we discourage the least activated

Start with the behaviours more feasible for patients to take
on, increases individual’s opportunity to experience success
Source: University of Oregon
11
Level 1
Develop basic knowledge, self-awareness and confidence
Individual becomes self-aware of own behaviours and symptoms. Focus coaching
on the relationship between symptoms and behaviours, building self-confidence and
awareness. The individual should choose the areas they want to work on
Level 2
Increase in knowledge, initial skills development
Individual develops the knowledge, skills and confidence needed to master new
self-management competencies. Coaching should focus on helping the individual
learn to monitor symptoms, behaviour and adverse triggers – and adjust
accordingly. Focus on taking small steps.
Level 3
Initiate new behaviours
Individuals initiate new health promoting behaviours and work to further refine
techniques to monitor and adjust. Coaching should focus on providing
encouragement, noticing successes and problem solving.
Level 4
Maintaining behaviours and techniques to prevent relapse
Individual strives to maintain desired health-related behaviours over time and learn
to anticipate difficult situations that will arise. Coaching should focus on the issues
that make it hard to stick to correct behaviours and to help the individual troubleshoot.
Source: University of Oregon
12
Importance
Confidence
Use of
Problem-Solving
Level 1
Low
Low
Low
Level 2
Increasing
Low
Low
Level 3
High
High for some
Low
Level 4
High
High
High
13

Clinicians can’t do it alone

Patients don’t have all the knowledge and
technology

Clinician-patient partnership yields best health and
quality of life

Skills are needed to foster clinician-patient
partnership
14

Agenda Setting - skills for exploring and agreeing the
agenda

Goal setting – skills for collaboratively planning goals
and action plans with patients

Follow-up – skills for arranging and discussing what
action has been taken and developing collaborative
problem-solving with patients
15

Inviting patients to contribute their beliefs, knowledge
and values that are critical to co-creating an approach to
their health and well-being
16

Clinicians and patients collaborating on the goals of
treatment and action steps that each will pursue to
address health and well-being
17

Patient and clinician supporting self-management by
arranging to learn from the results of an action plan
18

Clinician and patient examine challenges to selfmanagement and collaboratively identify possible
solutions to try out
19
20
Skills for learning the patient’s perspective



The power of the patient’s perspective
A strong relationship
Key skills
◦ Open-ended questions
◦ Reflection
◦ Empathy
21
Open-ended questions



Begin with:
“How?”
“Who?”
“Where?”
“When?”
“What?
“Tell me..”
Avoid:
“Why?” - can be risky
Questions that invite many possible answers, not
yes/no answers or a number
22
Words to start reflection:

“So, you are saying…”

“It sounds like…”

“You are wondering if…”

“ I hear you saying…”
23

Reflection:
“You seem [frustrated, worried, sad]…”

Validation:
“Anyone would feel…”

Partnership:
“I’d like to help…”

Respect:
“I’m impressed by how you…”
24
Exercise:
 Think of a change you are considering

Groups of 3
◦ Interviewer, Observer, Interviewee

Explore colleague’s thoughts on change

Observer tracks open-ended questions,
reflections and empathic statements

Switch roles
25
26
The patient’s perspective

Agenda, priorities

Level of activation

Importance and confidence
27
The clinician’s perspective

Patient health status

Take a long-term view

Supporting autonomy and choice
28







“What is the goal you are working towards?”
“So, what will you do this week?”
“How important is it to you?”
“So how much…will you do?”
“When will you do it?”
“How often will you do it this week?”
“If you visualise yourself doing this over the week, how
confident do you feel that you can achieve this?”
29
S – Specific – “So what will you do this week?”
M – Measurable – How much, how often: “So how
much….....will you do this week?”
A – Achievable – ““If you visualise yourself doing this
over the week, how confident do you feel that you can
achieve this?”
R – Realistic – “How confident are you?”
0
7
10
T – Time-based – “When will you do it?”
30

Consider where you are, right now, on the journey of
supporting patient self-management:
◦ Write down what you have stared doing that
contributes to your success
◦ Write down other skills, techniques and phrases you’d
like to add to your practice

In groups of 4, share your thoughts about what you have
accomplished and where you would next like to go in
your journey.
31
Thank you for joining us today.
We hope you have given you a taste of what we have
been doing with clinicians and patients to improve the lives
of people with long-term conditions.
If you are interested in finding out more, please contact the
Self Care Team on 01803 210476 or e-mail
selfcare.tct@nhs.net
32