A Train the Trainers Programme for NHS South of England

1. Shared decision making, self management support and care planning.Changing relationships in public services A Train the Trainers Programme for NHS South of England Supported by

2. Session 1Welcome, introductions, group working

3. Welcome • Workshop facilitator introductions • Practicalities • Fire alarms • Toilets • Food and drink • Anything we forgot?

4. Why are we here? • Purpose: aims and learning objectives • Knowledge, skills and confidence in teaching others the principles and practice of shared decision making • Knowledge, skills and confidence in facilitation and coaching skills • Principles • Adult learning • All teach, all learn • Connected, evolving conversations preferable to • Disconnected, dissolving conversations • Parking lot for questions/challenges that could halt progress

5. Introductions • Your name • Your organisation and your role • What expertise/experience/qualities you bring to this workshop

6. Reflective exercise (next slide). Firstly, ground-rules for working in groups • Brief introductions • Elect facilitator • The aim is to learn from each other • One person speak at a time. Propose boundary (‘no more than a minute’) • Offer a point of view rather than impose a point of view • Reflect (‘what I think you are saying is..’). • Thenuse link and learn to move the conversation onwards (‘and I’d like to add that….’) • Don’t be afraid to challenge. Consider prefacing challenges with ‘I have an alternative view’ or ‘I have a challenge’. Use reflections and link and learn (‘however’ is preferable to ‘but’)

7. Why are we here? • Do we need to change relationships in public services? • Why? • Feedback

8. Our time together Day one morning • Session 1. Welcome, introductions, timetable, introduction to group work and practice. 11.00-11.30 • Session 2. Shared decision making overview and case for change. 11.30-12.00 • Session 3. Long term conditions- the challenge and the case for change. 12.00- 12.30 • Session 4. Shared decisions about treatments- the challenge and the case for change. 12.30- 13.00 • 13.00-14.00 lunch

9. Our time together Day one afternoon • Session 5. Conversations about the case for change. 14.00- 14.30 • Session 6. Self management support and care planning overview. 14.30-15.00 • Session 7. Reflect, contextualise. 15.00-15.30 • 15.30-16.00 Tea • Session 8. Workforce and systems. 16.00-17.00 • Session 9. Care planning and self management support skills rehearsal Part 1. 17.00-18.30

10. Our time together Day 2 all day • Agreeing our agenda for the day 09.00-10.00 • Care planning, self care support skills • Care planning, self care support skills and coaching rehearsal • Shared decision making skills • Shared decision making skills and coaching rehearsal • Facilitating large groups • Managing conflict • Your action plan

11. Team and practice level training

12. Step 1. Getting on the agenda • Stakeholder map • Elevator pitch to give you a foot in the door. Do not forget that you are supported by NHS South and the national and regional LTC and Right Care QIPP teams • Who could you train? • Community matrons, re-ablement teams • Specialist nurses in LTCs • Interface services • Primary care teams • Secondary care teams

13. Step 2. Presenting a case for change • A half hour presentation and exercise for a team, a practice or a board at level 1 or 2 activation. • Aim of the session is that the training programme becomes more important for them. • Session 2 is a good overview of SDM, care planning and self management support • Session 3 focuses on LTCs • Session 4 focuses on shared decisions about treatments

14. Step 3. Delivering the programme • Community matrons, re-ablement teams, LTC nurses (care planning and SMS) • 2 sessions of 2 hours minimum • 3 sessions of 2 hours preferable • Use section 6 for first hour (could consider using section 3 instead) • Use section 7 for next hour • Then sections 8, 9 and 10 • Ensure team nominates a lead to implement system changes • Ensure team develops a leader and action plan to sustain changes in long term

15. Step 3. Delivering the programme • Primary care teams (care planning, SMS and brief introduction to SDM and treatments) • 6 hours best. 9 hours doable but needs small team (ie extra training for LTC nurses) • Sessions as above • Ensure team nominates a lead to make system changes • Ensure team nominates a lead and an action plan to sustain change in the long term

16. Step 3. Delivering the programme • Interface services, secondary care teams (SDM re treatments) • 3 hours single session • Session 4 then session 11 • Ensure team nominates a lead to make system changes • Ensure team nominates a lead and an action plan to sustain change in the long term

17. Session 2Shared decision makingAn overview and the case for change A 10 minute presentation, a 15 minute group exercise then a further 5 minute presentation

18. ‘No decision about me, without me’

19. A definition.(Shared Decision Making. Coulter, Collins. Kings Fund, July 2011) Shared decision making is a process in which clinicians and patients work together to clarify treatment, management or self management support goals, sharing information about options and preferred outcomes with the aim of reaching mutual agreement on the best course of action.

20. supportive system • Working in partnership • Sharing decisions • Planning care Activated, engaged patients Prepared, proactive, trained teams Optimal functional and clinical outcomes

21. When is it relevant? • Shared decision-making is appropriate in any situation when there is more than one reasonable course of action • In this case, the decision is said to be ‘preference sensitive’ • Most (nearly all) health and healthcare decisions are ‘preference sensitive’

22. What does it represent? A significant shift in the relationship between clinicians and patients, citizens and public services

23. Commissioning for patient need A system that captures the wishes of individual patients can be aggregated up and used to inform a new commissioning strategy based on patient need A commissioning strategy to deliver care that people want- rather than care that clinicians feel they should have The care, treatment or support people need and no less The care, support or treatment people want and no more

24. What does it mean for clinicians? A clinician who values the patients role in managing their own health and healthcare..... An attitude .....and who is willing and able to work in partnership with them to support them to make wise decisions..... Knowledge, skills and confidence ...about how to manage their health and healthcare

25. Clinical teams need motivational tools and skills Clinical teams need decision support tools and skills

26. Reflective exerciseYour attitude to shared decision making

27. Each table is assigned a statement (see next slide) • On a scale of 0-10, to what extent do you as an individual agree with the statement? • Arrange yourselves on an imaginary line across the back of the room • 0/10 agreement on left of room • 10/10 agreement on right of room • Other numbers on a spectrum between • Then go back to your tables to discuss • Then feedback Workbook page 9

28. Statements Table 1 Shared clinical decision making between patients and healthcare professionals is a meeting of equals and experts. Table 2 Healthcare professionals are responsible for supporting patients to make decisions that patients feel are best for them, even if the professional disagrees Table 3 Healthcare professionals should routinely encourage patients to access independent information, and come prepared with their own questions and ideas Table 4 The healthcare professional should routinely tailor information to individual patient needs and allow them sufficient time to consider their options

29. Feedback

30. The challenge we face

31. When asked in polls………. • 85% of clinicians believe they share decisions about treatment with patients • 50% of patients believe this is the case Blakeman T BJGP 2004

32. And….. Proportion of inpatients who wanted more involvement in treatment decisions (Care Quality Commission 2010)

33. And diabetes……. discussed ideas about the best way to manage their diabetes agreed a plan to manage their condition over the next 12 months discussed their goals in caring for their diabetes had at least one check up in the last 12 months From ‘Managing Diabetes’ Healthcare Commission: 2007

34. Challenging the gap…………………… from healthcare professionals My patients don’t want it I don’t have the time! We do it already! What if they don’t do what I think they should do? Will it work?

35. So what is the problem? Is it: Why should we do this? (importance) or How can we do this? (confidence)

36. Why should we do this? • Ethical imperative (patients want to be involved more than they are) • Legal imperative (medicolegal requirement to discuss options, risks, consequences prior to any intervention) • Evidence base supports (see resource pack) • Appropriate allocation of resources (patients get ‘the care they need and no less, the care they want and no more’)

37. ‘The active involvement of patients is key to all of the priorities.’ Candace Imison June 2011

38. Pause, breathe, reflect

39. Session 3Long Term Conditions: An overview, the challenge and the case for change A powerful case for change- 10 minute presentation Then a 20 minute exercise; barriers to change

40. The Challenge – Long term Conditions (LTCs) • 15.4 million people in UK live with at least one LTC • 69% NHS budget • 50% General Practitioner consultations, 65% of out-patient appointments and 70% of inpatient bed days • Aging population and rising numbers • At current rate of growth, expenditure on LTCs would increase by 94% by 2022 (with minimal real potential increase in NHS budget) • Our healthcare system is not currently configured to cope with the increased demand No change is not an option

41. Meeting the challenge: implement the chronic care model CCGs need to work with Acute Care Trusts to develop integrated approaches. A key issue is the sharing of incentives to promote high quality care. Strategic partnerships between local authorities, community and voluntary organisations Software to support care planning, risk stratification, and monitoring quality The Expert Patient Programme Telehealth, telecare Multidisciplinary team in primary care co-ordinating care Risk stratification Evidence based guidelines incorporated in IT systems Service user facing decision support at every ‘decision point’ in clearly delineated care pathways

42. supportive system • Working in partnership • Sharing decisions • Planning care Activated, engaged patients Prepared, proactive, trained teams Optimal functional and clinical outcomes

43. The overall marker of success • Activated patients • Working in partnership with prepared and trained clinical teams in scheduled appointments in a supportive system • To proactively manage health and to anticipate and plan for times of need (care planning and anticipatory care planning)

44. Activation (measured by using the ‘Patient Activation Measure’ – the PAM) Knowledge, skills and confidence to manage one’s own health and healthcare See Hibbard J, Collins A Health Expectations 2011 and resource pack

45. Levels of activation ACTIVATION PREDICTS OUTCOMES

46. Support for activation: care planning and self care support. • Our aim should be to support people with long term conditions to develop the knowledge, skills and confidence to manage their own health and healthcare (to become activated). • In other words, to support people with long term conditions on their journey of activation • Compared with people at low levels of activation, people at high levels of activation tend to enjoy a higher quality of life, have better clinical outcomes and make more informed decisions about accessing medical services.

47. LTC QIPP workstream Outcome Proxy outcome Primary drivers

48. Reflective exercise Workbook page 11

49. How important is it to you that we support people to manage their own health and healthcare? 0-not at all important 10-extremely important

50. What led you to say the number you said?