The Health Foundation’s Co-Creating Health Initiative

1. The Health Foundation’s Co-Creating Health Initiative Travelling on the journey of change with people with long-term conditions

2. Why Co-Creating Health? 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.

3. What is Self-Management? • 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.

4. Why focus on Long-Term conditions? • 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

5. Why focus on Long-Term conditions? • 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

6. 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

7. The three strands of Co-Creating Health • 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

8. Why do we train health professionals and patients? • 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

9. Traditional vs. Collaborative Interactions

10. Activation is developmental Source: University of Oregon

11. Insights • 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

12. Tailoring support to activation levels Source: University of Oregon

14. The Challenges • 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

15. Core Co-Creating Skills • 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

16. Exploration • Inviting patients to contribute their beliefs, knowledge and values that are critical to co-creating an approach to their health and well-being

17. Planning • Clinicians and patients collaborating on the goals of treatment and action steps that each will pursue to address health and well-being

18. Follow-up • Patient and clinician supporting self-management by arranging to learn from the results of an action plan

19. Problem-solving • Clinician and patient examine challenges to self-management and collaboratively identify possible solutions to try out

20. Co-Creating SkillsPractice 1Agenda Setting:Skills for Exploring the Patient’s Perspective

21. Explore Skills for learning the patient’s perspective • The power of the patient’s perspective • A strong relationship • Key skills • Open-ended questions • Reflection • Empathy

22. Explore Open-ended questions • Begin with: “How?” “Where?” “What? “Who?” “When?” “Tell me..” • Avoid: “Why?” - can be risky • Questions that invite many possible answers, not yes/no answers or a number

23. Skill: Reflective Listening Words to start reflection: • “So, you are saying…” • “It sounds like…” • “You are wondering if…” • “ I hear you saying…”

24. Skill: Empathy • Reflection: “You seem [frustrated, worried, sad]…” • Validation: “Anyone would feel…” • Partnership: “I’d like to help…” • Respect: “I’m impressed by how you…”

25. Agenda Setting using Co-Creating Skills 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

26. Co-Creating SkillsPractice 2Goal Setting: Skills for planning goals and action plans patients

27. Co-Creating Goals The patient’s perspective • Agenda, priorities • Level of activation • Importance and confidence

28. Co-Creating Goals The clinician’s perspective • Patient health status • Take a long-term view • Supporting autonomy and choice

29. Action Plan:The bridge between intention and results • “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?”

30. Action Plan:The bridge between intention and results 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?”

31. Action Planning using Co-Creating Skills • 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.

32. Summary and Personal Action Plan 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