The problem is that while the patient usually answers “Yes”, they often don’t make the behavioural changes they should and inevitably, their health suffers. This, explains Lewis, is why the NHS is increasingly focusing on improving self-care, especially for patients with long-term conditions. “The NHS can’t possibly do everything for the 17.5 million people currently living with long-term conditions.”
North and Eastern Birmingham Primary Care Trusts have decided that the best way to improve self-care is by nurses coaching patients over the telephone. The trusts have commissioned Pfizer Health Solutions, in partnership with NHS Direct, to develop the Birmingham OwnHealth programme, which began in April.
“To make a behavioural change – such as losing weight, taking the right medicines at the right time, or stopping smoking – you need to be motivated. Coaching enables healthcare professionals to understand what is likely to be the motivational spark and what kinds of behaviours they may be able to start off with changing,” explains Lewis.
She adds that coaching is far more holistic than the traditional healthcare model. “Coaching is about the whole person. So rather than only focusing on the clinical issues, we look at whether they’re employed and, if they are, what kind of work they do. Other things we might look at are their stress levels or how many people they live with.”
She adds that coaching works because it is client- (in this case, patient-) centred. “There is no set amount of coaching within our programme. If someone is diabetic and just starting insulin therapy, they might need daily calls to check their confidence and answer questions. But if someone is trying to lose weight to help them manage a condition, they might only need a call once a fortnight for encouragement and support.” The length of the call and of the coaching relationship is equally variable, although Lewis says calls start off being long, then tend to average around 15 minutes each, and the whole programme averages 9–12 months for each person. “It’s a rolling programme, so as some people move off it, others come on board.”
Pfizer Health Solutions has 11 years’ experience of delivering disease management coaching in the US, as well as having done a pilot scheme in the UK. It’s learnt that the success of coaching is ultimately reliant on the skills of the nurses – or care managers – who work with the patients. After all, they are the ones who provide the individuals with the support, motivation, skills and knowledge to self-care on a daily basis.
“We have therefore placed a lot of emphasis on recruiting nurses with the right level of both clinical and interpersonal skills, as well as investing heavily in training,” says Lewis.
As Andy Jordan, one of the care managers, points out, “For nurses, coaching is a huge cultural shift. The idea of almost removing yourself from the position of ‘expert’ and working in a more collaborative, patient-led way, was quite different to what we were used to. So I really welcomed the solid four weeks’ training, which is almost unheard of in the NHS.”
It was particularly helpful to have people such as psychologists going through the ideas behind motivational interviewing techniques, he adds.
Own Health supports individuals with selected chronic diseases such as type 1 and 2 diabetes mellitus, coronary heart disease, cardiovascular disease and respiratory disorders.
One of the challenges for many of the trusts’ 12 care managers – who typically work with 150-200 patients each – was the idea of working with people with such serious conditions on the phone. “It’s not a usual way of providing care for patients,” says Jordan. “But each person has a single, named care manager and many of us have found that telephone coaching actually works better than face-to-face coaching. People are often more forthcoming.”
One of the biggest benefits of OwnHealth, says Lewis, is that it’s about small steps. “A doctor might say, ‘You need to lose three stone.’ But a care manager would say, ‘Tell me what you eat in a typical day,’ and ‘What are your favourite foods?’ Then they’ll suggest small substitutes such as replacing morning biscuits with an apple. Crucially, they’ll find out what kind of changes are acceptable and which fit in with the patient’s lifestyle.”
If the care manager meets resistance (eg, to giving up smoking), they’ll leave that idea and work on something else. “Then, over time, once they’ve identified the individual’s motivational spark, they’ll come back to it. By that time, the individual will hopefully feel more con. dent about at least thinking about cutting down.”
The coaching relationship, she explains, is about stages of change. It works in five fundamental steps: assessment, recommendation, follow up, ongoing monitoring and evaluation, and then starting the care process again. Within this model are eight priorities ranging from, ‘Know how and when to call for help’, to ‘Take medicines correctly’, and ‘Make lifestyle changes and reduce risks’.
There have been some early successes in people making changes to diet and reducing alcohol consumption. “We’ve also made a real difference in getting people who were very poor at turning up for clinical appointments to go to them and in getting patients to understand the importance of monitoring themselves medically.”
Lewis believes the key lessons from OwnHealth are recognising the value of in-depth training for coaches, the importance of the role of motivation in behaviour change and that changes need to happen in stages.
Learning points
- The success of coaching depends on having the right level of interpersonal skills and in-depth training Coaching can play a vital role in motivating people to make behavioural changes
- behavioural changes need to happen in stage