Lucy Jackson- Consultant in Public Health / CO LCC Jonathan Lace – Better Conversations Lead, Leeds

Overview of session Health Coaching/Better Conversations and Personalised Care Model The Leeds Journey Across the ICS-West Yorkshire and Harrogate Questions and Answers

Health Coaching and Personalised Care Jo Johnson Senior Manager Personalised Care Group NHS England Hello my name is Jo Johnson. I’m a nurse and I work as a senior manager in the Personalised Care Group in NHS England. I’m going to talk for 10 minutes about how health coaching supports the delivery of personalised care and increases choice and control for the people and communities we serve.

What is personalised care? People having choice and control over decisions that affect their own health and wellbeing within a system that harnesses the expertise, capacity and potential of people, families and communities in delivering better outcomes and reducing health inequalities. This incorporates: . a proactive and universal offer of support to people with long term physical and mental health conditions to build knowledge, skills and confidence through supported self-management and community-centred approaches whole population approaches to supporting people of all ages, and their carers, to manage their physical and mental health and wellbeing and make informed choices and decisions when their health changes Intensive approaches to empowering people with more complex needs to have greater choice and control over the care they receive Personalised care means people have choice and control over the way their care is planned and delivered, based on ‘what matters’ to them and their individual strengths, needs and preferences. This happens within a system that supports people to stay well for longer and makes the most of the expertise, capacity and potential of people, families and communities in delivering better health and wellbeing outcomes and experiences. This shift represents a new relationship between people, professionals and the health and care system. It provides a positive change in power and decision making that enables people to feel informed, have a voice, be heard and be connected to each other and their communities.

Comprehensive Model for Personalised Care All age, whole population approach to Personalised Care TARGET POPULATIONS INTERVENTIONS OUTCOMES People with long term physical and mental health conditions 30% Specialist Integrated Personal Commissioning, including proactive case finding, and personalised care and support planning through multidisciplinary teams, personal health budgets and integrated personal budgets. Empowering people, integrating care and reducing unplanned service use. People with complex needs 5% Plus Universal and Targeted interventions Targeted Proactive case finding and personalised care and support planning through General Practice. Support to self manage by increasing patient activation through access to health coaching, peer support and self management education. Supporting people to build knowledge, skills and confidence and to live well with their health conditions. INCREASING COMPLEXITY PEOPLE MOVE AS THEIR HEALTH AND WELLBEING CHANGES Plus Universal interventions Chapter one of the NHS Long Term Plan1 makes personalised care business as usual across the health and care system. This document is the delivery plan for personalised care. It sets out how, working with people with lived experience and partners in local government and the voluntary and community sector, we will systematically implement the Comprehensive Model for Personalised Care to reach 2.5 million people by 2023/24 and then aiming to double that again within a decade (by 2028/29). Personalised care takes a whole-system approach, integrating services including health, social care, public health and wider services around the person. It provides an all-age approach from maternity and childhood, through living with frailty, older age and end of life, encompassing both mental and physical health and recognises the role and voice of carers. It recognises the contribution of communities and the voluntary and community sector to support people and help build resilience. Universal Shared Decision Making. Enabling choice (e.g. in maternity, elective and end of life care). Social prescribing and link worker roles. Community-based support. Supporting people to stay well and building community resilience, enabling people to make informed decisions and choices when their health changes. Whole population 100%

Specific Personalised Care commitments in LTP Accelerate roll out of Personal Health Budgets… Up to 200,000 people will benefit from a PHB by 2023/24 (para 1.41) Over 1,000 trained social prescribing link workers by 2020/21 and 900,000 people referred to social prescribing link workers by 2023/24 (para 1.40) Ramp up support for people to self-manage their own health (para 1.38) People have choice of options for quick elective care, including choice at point of referral and proactively for people waiting for six months (para 3.109) Support and help train staff to have personalised care conversations (para 1.37) Use decision-support tools (para 3.106) and ensure the least effective interventions are not routinely performed… potentially avoiding needless harm (para 6.17viii)) 30% 5% 100% This is one of the five major, practical, changes to the NHS service model in the NHS Long Term Plan. It recognises that personalised care is central to a new service model for the NHS, including working through primary care networks, in which people have more options, better support, and properly joined-up care at the right time in the optimal care setting.

Personalised Care ambitions by 2023/24: Shared decision making Shared decision making embedded in 30 high-value clinical situations in primary care, secondary care and at the primary/secondary interface where it will have the greatest impact on experience, outcomes and cost Personalised care and support planning 750,000 people, including people with long-term conditions, people at the end of life and pregnant women Enabling choice, including legal rights to choice Legal rights to choice are maintained throughout wider system transformation, with 100% of elective referrals exercising choice through e-RS and 100% of CCGs compliant with the minimum standards in the CCG Choice Planning and Improvement Guide Social prescribing and community-based support 1,000 trained link workers recruited by 2020/21 and 900,000 people referred to social prescribing link workers by 2023/24 Supported self-management Continue to increase the opportunities for people to benefit from supported self-management approaches Personal health budgets and Integrated personal budgets 200,000 people benefitting from PHBs or IPBs Personalised acre

Health coaching Health coaching is a form of coaching that aims to help people to set goals and take actions to improve their health or lifestyle. Health coaching can be done on a one-to-one basis, in pairs or in small groups and can be delivered in person or – for individual coaching at least – by telephone or online. A health coaching role can take many different forms, i.e. built into the roles of existing healthcare professionals, i.e. trained to use these techniques and tools within routine consultations, or delivered in a community setting. Health coaching has some synergies with other SSM approaches. A key distinction, however, between health coaching and some other forms of support, such as SME , is that the health coach is not there to teach, advise or counsel but, rather, to support people to find the answers themselves and plan to achieve their goals.

Whilst the NHS is undoubtedly a towering achievement, the foundations on which the health and care system were built and evolved contain a number of divides running through them: between health and social care;9 between physical and mental health;10 between children’s and adults’ services;11 and between community-based care and hospital-based services.12 More fundamentally, there has also been a cultural divide between the professional and the person. This reflects a medical model of health over one that also gives proper consideration to wider determinants of health.13 People are often unable to make appropriate decisions about their own health and health care, or exercise control over decisions about their health and that of their communities.” Meeting this challenge, personalised care represents a new relationship between people, professionals and the health and care system. It enables people to stay well for longer and provides a positive shift in power and decision making that enables people to have a voice, to be heard, and to be connected to each other and their communities. It means people have the opportunity to choose how best to live their lives with the support to do so.

Action 10: Continue to support the development of programmes and initiatives that seek to increase the knowledge, skills and confidence of people to better self-manage their long-term conditions • Continue to promote the systematic application of self-management education, health coaching and peer support. • Support commitments in the Long Term Plan that seek to increase capacity for supported self-management, such as offering new models of providing rehabilitation and self-management support, including digital tools, to those with mild COPD. To meet the challenge and practically deliver personalised care by 2023/24 and beyond, we have set out 21 clear actions that will enable the Comprehensive Model to be delivered: Health coaching is part of action no 10 in the 21 commitments. Continue to support the development of programmes and initiatives that seek to increase the knowledge, skills and confidence of people to better self-manage their long-term conditions.

1. Steps of SSM Peer support in health and care encompasses a range of approaches through which people with similar long-term conditions or health experiences support each other in order to better understand the condition and aid recovery or self-management. It can be delivered on a one-to-one basis, which may be in person or through telephone support, or through a peer support group Self-management education includes any form of formal education or training for people with long term conditions that focuses on helping them to develop the knowledge skills and confidence they need to manage their own health care effectively (RtV 2016). One-to-one support approaches include peer listening, to enable someone to talk through current concerns and offer support.

40% of people with LTCs have low / no confidence to manage their health and wellbeing 25% of population 15% of population 7% of the population are at level 1 ‘activation’- they tend to have a worse quality of life and have worse outcomes than people at level 4 ‘activation’ More activated people are more likely to: attend screenings, diagnostic tests etc have healthy behaviours have ‘normal’ clinical indicators

An independent evaluation found that people who had the highest knowledge, skills and confidence had 19% fewer GP appointments and 38% fewer A&E attendances than those with the lowest levels of activation122 • This finding was corroborated by a Health Foundation study which tracked 9,000 people across a health and care system123

So why aren’t we doing it? “We’re doing it already” “We don’t have the right tools” “Patients don’t want it” “How can we measure it?” “We have too many other demands and priorities” Lack of implementation strategy

The Comprehensive Model for Personalised Care Sets out more detail on the six, evidence-based components of the Comprehensive Model. This includes a summary of the standard, replicable delivery model for each component that must be in place for that component to meet the key features of personalised care. Through these standard models we seek to create the balance between specifying a national, consistent standard and enabling flexibility for local adaptation and implementation. We also seek to align with or build on existing personalised approaches that have been adopted by both social care and health in many areas.

Supported self-management: Increasing the knowledge, skills and confidence (patient activation) a person has in managing their own health and care through systematically putting in place interventions such as health coaching, self-management education and peer support. Design principles: 1. Understand a person’s level of knowledge, skills and confidence, using tools such as the Patient Activation Measure (PAM) or equivalent 2. Health and care professionals tailor their approaches to individual assets, needs and preferences, supporting people to increase their knowledge, skill and confidence 3. Interventions are systematically in place: health coaching, self-management education, peer support and social prescribing focussed on, though not limited to, those with low activation to build knowledge, skills and confidence, and take account of any inequalities and accessibility barriers

SSM Standard model • Proactive identification of people’s knowledge, skills and confidence, paying particular attention to those who may have low levels, within the population through: Routine review of hospital discharge Risk stratification and segmentation Review of priority groups of people Review of local data and demographics and the wider determinants of health Tacit knowledge of primary care team • Measure people’s knowledge, skills and confidence via an appropriate tool, such as the Patient Activation Measure (PAM), long-term condition patient-reported impact measure (PRIM) or self-efficacy scales, for all people with long-term conditions • Staff are trained in administering PAM or other specific approaches through e-learning, webinars and group training • A person’s support needs are identified through shared decision making or personalised care and support planning. These are carried out by relevant staff – healthcare assistants, link workers, health trainers, general practice nurses, district nurses, specialist nurses or GPs, depending on the person’s level of activation and complexity • The impact of an intervention on people’s levels of knowledge, skills and confidence is measured within six months, for at least 75% of people still in the local area. People can be referred to the following support, tailored to their levels of knowledge, skills and confidence: • Quality assured, evidence-based health coaching or structured group coaching course • Quality assured, evidence-based self-management education approaches (face-to-face and virtual), which include disease-specific, generic and online self-management courses • Peer support through a link worker (see above)

If supported self-management is delivered according to this standard model, our indicative expectation is: Increase in knowledge, skills and confidence of people with long-term conditions for at least 75% of people with measured patient activation levels of one or two by 15 points. There is a positive impact on GP consultations, hospital readmissions, and A&E attendances for those with activation levels one or two, achieving: 9% fewer GP appointments 19% fewer A&E attendances

4. National Support SSM Summary Guide – March 2019 Health Coaching Quality Standard – May 2019 Health coaching training - ongoing PAM regional webinars - quarterly Incentives/ levers to embed SSM in PCNs – ongoing Support for developing business cases and implementation

Health coaching quality standard: NHS England in the process of commissioning a health coaching service provider to work in collaboration with the system including with other health coaching service providers, clinicians, people with lived experience to: Create a health coaching standard that outlines what a high quality, safe, evidenced based personalised health coaching service needs to look like. This will provide a consistent baseline from which to support the commissioning and developing of high quality health coaching services. The work has started and will be published on NHS England PCG web pages in May 2019.

Pairs Introduce yourself and discuss when was the last time you had a great conversation and why was it great? What gets in the way of better conversations in your role/life? What are the benefits of a better conversation in your role/life?

But they all require a skilled workforce !! 6 Components But they all require a skilled workforce !! 1. Shared decision making 2. Personalised care and support planning 3. Enabling choice, including legal rights to choice 4. Social prescribing and community-based support 5. Supported self-management 6. Personal health budgets and integrated personal budgets.

Better Conversation – our journey Golden thread- Beeston/Armley/Chapeltown 2017 ‚Better Conversations- - working with people NHSE funding 2016 Commonalities – added value Hilton - 2015 Building the Houses of Leeds- 2013 Post Health Coaching Year of care ‘Motivational interviewing

-Leeds H&WB strategy a key driver for a working ‘with’ approach - Everything starts with people and what matters to them 5 outcomes, outcome 4 – People will be actively involved on their health and care 12 priority areas – priority 11- a valued, well trained and supported workforce

Our agreed actions and principles Our bold ambition: Leeds will be the best city for health and wellbeing Our clear vision: Leeds will be a healthy and caring city for all ages, where people who are the poorest improve their health the fastest Principles of our approach We put people first: We work with people, instead of doing things to them or for them, maximising the assets, strengths and skills of Leeds citizens and our workforce.  We deliver: We prioritise actions over words to further enhance Leeds' track record of delivering positive innovation in local public services. Every action focuses on what difference we will make to improving outcomes and quality and making best use of the Leeds £.   We are team Leeds: We work as if we are one organisation, taking collective responsibility for and never undermining what is agreed. Difficult issues are put on the table, with a high support, high challenge attitude to personal and organisational relationships. I guess building on that ambition and where we align with the Leeds plan is where we put people first: We work with people, instead of going things to them or for them, maximising the assets, strengths and Leeds of Leeds citizens and our workforce. There are lots of experience in the room today around working in this way, I am really looking forward to hearing more about it as we work together through the day. 6

Strength based social care The ways we are embedding a whole city approach to ‘working with’ people Strength based social care   Health Coaching Better Conversations   ABCD community development  Shared decision making  Restorative Practice   Co-production  Collaborative care and support planning  In Leeds we believe wellbeing starts with people: The connections, conversations and relationships between services and citizens and between people in their families and communities have a huge impact on us all. Quality conversations make a difference, especially when used positively by services to work ‘with’ people to find solutions rather than things being done ‘to’ people or ‘for’ them.   Our commitment to working with people is about bringing these beliefs to life, by developing the skills and mind-set across Leeds’ health and care workforce to use solutions that work with people wherever it is safe, appropriate and the right thing to do.

Better conversations: A whole city approach to working with people Focus on ‘what’s strong’ rather than ‘what’s wrong’   Focus on ‘what’s strong’ rather than ‘what’s wrong’   Put people at the centre of all decisions   Put people at the centre of all decisions   Working ‘with’ means… Working ‘with’ means…     Build on the assets in ourselves, our families & our communities   Build on the assets in ourselves, our families & our communities   Actively listen to what matters most to people   Actively listen to what matters most to people   Be ‘restorative’. Offer high support and high challenge   Be ‘restorative’. Offer high support and high challenge   Start with people’s lived experience   Start with people’s lived experience   Emerging work has brought together all the similar working ‘with approaches to create a Better Conversations team Better Conversations the glue at the centre of Leeds approaches that include restorative practice, care and collaborative support planning, health coaching and making every contact count Work as partners to achieve individual goals   Work as partners to achieve individual goals   In Leeds we believe wellbeing starts with people: The connections, conversations and relationships between services and citizens and between people in their families and communities have a huge impact on us all. In Leeds we believe wellbeing starts with people: The connections, conversations and relationships between services and citizens and between people in their families and communities have a huge impact on us all. Quality conversations make a difference, especially when used positively by services to work ‘with’ people to find solutions rather than things being done ‘to’ people or ‘for’ them.   Quality conversations make a difference, especially when used positively by services to work ‘with’ people to find solutions rather than things being done ‘to’ people or ‘for’ them.   Our commitment to working with people is about bringing these beliefs to life, by developing the skills and mind-set across Leeds’ health and care workforce to use solutions that work with people wherever it is safe, appropriate and the right thing to do. Our commitment to working with people is about bringing these beliefs to life, by developing the skills and mind-set across Leeds’ health and care workforce to use solutions that work with people wherever it is safe, appropriate and the right thing to do.

ENGAGED INFORMED PEOPLE ENABLING SYSTEMS PROCESSES Digital systems/ records – Person, workforce, carer Workforce systems – Menu of training options available to embed an approach to ‘better conversations’ LCP/ Neighbourhood asset based approaches – Better together. NNs ENGAGED INFORMED PEOPLE Improved/flexible structured education programme for people with LTC’s 10 Integrated Breathe Easy groups across Leeds by 2018 Leeds directory Social Prescribing Development of digital solutions- e.g. mycopd Peer support HCP COMMITTED TO PARTNERSHIP WORKING THROUGH ‘BETTER CONVERSATIONS’ Health Coaching Collaborative Care and Support Planning Strength based social care MECC Patient Activation Measure Shared decision making COMMISSIONING/ INVOLVEMENT Social prescribing review Structured Education review Peer Support plan Health and care portal review Co-production

“working with” Putting people at the centre of all decisions. Actively listening to what matters most to people. Working as partners to achieve goals. Focusing on people’s strengths and assets. So, as XX mentioned, Better Conversations a citywide movement to support a consistent approach to health and care conversations. One where all staff work with people- putting them at the centre of all decisions, actively listening to what matters most to them, working as partners to achieve goals and focusing on their strengths and assets.   Better Conversations work with you, the health and care workforce across Leeds to support you to get the most from your conversations, so that people achieve the best outcomes. 8

Better Conversations Working Working across Leeds With Teams Adult Social Care Listen Primary Care Explore Leeds & York Partnership Foundation Trust Working With Teams Working across Leeds Leeds Teaching Hospitals Trust Develop 3rd Sector / Community organisations Better Conversations works with staff across the whole of the city- whichever trust or organisation you work for. We operate across systems to support an integrated approach. Our model is quite simple. We listen to what’s important to you and your team, how this affects your communication and the conversations you have. We explore ways in which you can refresh your skills, develop and embed the “working with” principles, hopefully sustaining them into your daily practice and supporting others to do so as well. Leeds Community Healthcare Sustain

Interactive Skills Day Open to all staff across Health and Care. Reflect on your communication skills, recognise what you do well, and identify areas for development. Practice your communication and consider your interpersonal skills. Share learning with colleagues across Leeds. How can you embed these skills into your day-to-day roles/practice, in the face of things that get in the way? Our One Day, interactive Skills session, supports with this. The Skills Day is available to all staff that work in health and care across Leeds, in any role, at any level. The skills covered are universal and of equal importance to us all- the challenge is how do we relate the material to our specific roles, and apply it to the types of conversations we have on a day to day basis, to get the most out of the experience? Having a mixed group of people from services across Leeds has been really powerful, as people from different backgrounds, with different levels of experience can come together and share learning in a supportive and positive environment. This time out from the day to day grind, meeting new faces, having different conversations, and reflecting, is sometimes all people need to reconnect, and can provide a fresh perspective on things. One participant reported they found the skills day “thought provoking” and said it “encouraged a great deal of self awareness”. better.conversations@nhs.net

This slide outlines our approach when working with teams in embedding areas, following the Listen, Explore, Develop, Sustain method. We initially make contact with team leads, to outline our offer and ask whether they might be interested in working with us. We want to know what issues affect the team. What do their conversations look like? What would they like to focus on? What’s getting in the way? One example in my workstream for instance is focusing in on discharge conversations, as these are important to the team- but this will look different to different teams, and individuals, which is why some of these circles have been left blank for us to populate together. We hope that our workstreams will attend our Skills Day to start to think about some of these issues in more depth, before receiving follow up visits from the Better Conversations Team. We want to know what people took away from the day, and how they plan to bring it to their practice. How will they keep better conversations on the agenda?

‘Working with’ teams to support embedding Bespoke workshops Peer support sessions Team meetings Shadowing with collaborative feedback Group work 1:1’s/home visits Telephone calls Our work to support the embedding of skills is flexible, based upon what individuals feel would be most useful. Things that have personally worked well for me, have included attending team meetings to explore as a group how things are progressing, and supporting people 1:1 through exploratory conversations, observing practice with the opportunity for collaborative feedback and discussion afterwards.

33 Better Conversations Skills days have taken place 33 Better Conversations Skills days have taken place. Another 20 are to take place by the end of March As of 15th February 371 people across Health & Care system and 3rd sector have attended Better Conversations Skills days From first evaluation 93% of respondents were either likely or extremely likely to recommend the skills day to a colleague Feedback from the skills days: “Great to share experiences with colleagues outside the NHS, it was refreshing and broadened my perspective.” “ I thought I was having a good conversation in my role, but after attending the skills day today it was shown I was  not.” “I thoroughly enjoyed the session and learnt so much.”

Supported Self-Management & Health Coaching What is happening in Places and how you can find out more Bradford Calderdale Harrogate Kirklees Leeds Wakefield The Self Care and Prevention Programme is delivered in partnership with NHS, LA and VCS Cardiac rehabilitation - Self management The Better Living Team -Motivation to Move programme and to support people who have survived a stroke to improve their mobility. Baby cafe DAFNE and DESMOND programmes. Range of services available. Daphne for existing Diabetes. Diabetes Prevention Program for those at high risk. Program for back pain. Breath Easy Programs. Range of services commissioned to support self management including My Health Tools (an online platform to support people by providing a goal based list of resources tailored to individual need) Integrated Wellness Model will be in place during 2019. Better conversations health coaching training. Structured education -Diabetes, COPD/Pulmonary Rehab and Cardiac Rehab Increasing referrals. increase referrals into Structured Education, via tailored interventions with GP practices. Self Management education and 1 to 1 support is in place through the Live Well Wakefield and local SWYFT recovery collages district wide. Health coaching workforce development is underway. A range of specialised programmes are tailed to individual need. Bridget Jones Bridget.Jones@bradford.nhs.uk Sarah Antemes Sarah.Antemes@calderdaleccg.nhs.uk Paula Middlebook paula.middlebrook@nhs.net Rachel Millson Rachel.Millson@northkirkleesccg.nhs.uk Jonathan lace (j.lace@nhs.net)- Lucy Jackson Lucy.Jackson@leeds.gov.uk Structured Education: Helen Lewis(helen.lewis5@nhs.net) Pam Sheppard pam.sheppard@wakefieldccg.nhs.uk

Questions What can we do together across WY&H? What can we do individually? How do we embed personalised care in our work?

Thank you!