Health Coaching for patient centred care and behaviour change Dr Penny Newman Clinical Lead, Health Coaching Programme, Associate, Health Education East of England Dr Andrew McDowell, DirectorThe Performance Coach

Our aspiration NHS Constitution National Voices Renewable Energy – sustainability Cost savings

Our long term condition challenge Lifestyle causation Multiple comorbidity Age and poverty related Unaffordable

The impact is overwhelming

Our current approach isn’t working Low levels of patient understanding, adherence and behaviour change Clinicians are not trained in behaviour change Alignment between what patients want and what is provided is poor - goals, treatment choices, shared decision making and patient and carer involvement Poor communication – introductions and interruptions 104% rise in GMC complaints Paternalism breeds dependency… and increasingly affects patient satisfaction Bennett H, Coleman E, Parry C, Bodenheimer, 2010 GMC Annual report 2013, Rhoades DR, Fam Med 2001. Wolever R, 2013 Coulter A, 2011 KPMG Creating value with patients, carers and communities 2014

Self care and self care support

Our response 2010 Regional Innovation Fund Health Coaching Pilot 2011 4 CCGs with national LTC Programme 2013/14 HEEoE roll out to 800 clinicians and develop 18 internal trainers

Aim: Equip clinicians with new skills, knowledge and behaviours A tailored consultation Listen with compassion Diagnose and fix Guide and advise Review and encourage Support self care Promote self-care, motivation and responsibility in patients Improve patient satisfaction Provide a tailored approach to different patient's needs Supplement core clinical skills

Expanding the tool box 2 day core programme Developing internal trainers Co-delivery to gain experience On-going roll out of health coaching skills

Uptake in a time of reform nurses (44%) allied health professionals (28%) doctors (9%)

Health coaching to support self management In the clinical context “performance”= self-management Health coaching aims to raise awareness and increase responsibility for health Health coaching is about supporting someone to change their relationship to a problem or challenge

Health coaching transforms the clinician/patient relationship Role of patient Role of clinician The coach is a healthcare professional trained in behaviour change theory, motivational strategies, and communication techniques, which are used to assist patients to develop intrinsic motivation and obtain skills to create sustainable change for improved health and wellbeing. Wolever 2013 A patient centred approach wherein patients at least partially determine their goals, use self-discovery and active learning processes together with content education to work towards their goals, and self-monitor behaviours to increase accountability all within the context of an interpersonal relationship with a coach.

Psychology, Coaching, Clinical Skills Behaviour Change theory Social Cognition theory Patient Activation Stages of Change Motivational Interviewing Positive Psychology Mindful awareness Cognitive Behaviour Therapy Principles and models from Health Psychology & Behavioural Medicine Health knowledge Health recommendations Diagnostic skills Consultation skills Questioning skills Listening skills Problem solving skills Patient – clinician relationship Knowledge and skills of Health Practitioners Skills & techniques from Performance & Development Coaching Goal setting Coaching models Coaching competencies Range of approaches Awareness & Responsibility Potential & emergence Using Challenge & Rapport Scaling 13

Integrating skills 14 Clinical Skills Behaviour Change Assistance relationship Coaching Self determined goals and activation 14

Key ingredients Foundations of coaching Patient self determined goals Directive and non-directive approaches Structuring health coaching conversations Listening, trust, rapport and supportive challenge Positive psychology approaches Readiness to change Managing interferences Health coaching behaviour change techniques Highly experiential using a coaching style Fast paced and challenging Time to allow mind-set shift Application to real issues Opportunities to practice skills and receive feedback

New mind-sets, skills, and techniques Techniques Specific coaching techniques and frameworks for conversations Useful for specific behaviour change conversations E.g., TGROW, ABC model, Managing interferences Skills General coaching skills and concepts Useful in many clinical interactions to increase awareness and responsibility E.g., Using supportive challenge, listening, empathy Mindset Developing a coaching mindset Useful in most clinical interactions and as a leadership skill E.g., people are more resourceful than they think they are

Widespread application Long term conditions Respiratory, DM, CHD, neurological, pain, cancer Mental health Depression, anxiety, stress Prescribing Compliance Rehabilitation Frail elderly Functional and skill development Palliative care End of life Pain management Widespread application Improved communication, lifestyle, shared decision making, integrated care

Reported benefits Patients ↑ motivation to change ↑ satisfaction Improved health/outcome Clinicians ↑ effective consultations ↑ resilience & job satisfaction Use with colleagues and others Organisation ↑ quality of care ↓ complaints Meet strategic priorities Improve multidisciplinary working Impact on utilisation, costs and outcomes

And indirectly …leadership

What clinicians find difficult Need to recognise need for change & value patient empowerment Learned behaviour hard to change Can require complex interpersonal skills Challenging patients is uncomfortable When to apply and with whom Time - managing all responsibilities and maintaining skills Using a coaching approach when colleagues are not Contra cultural – very different from biomedical model Clinician activation = Patient activation

Evidence Centre Rapid Review 275 studies, 109 RCTs In research on health coaching services (vs as part of usual care) Vulnerable groups benefit Can support patients motivation to self manage Can support adoption of healthy behaviours Applicable to population and of use by all professionals Insufficient evidence about the most cost effective training Mixed evidence on outcomes Insufficient evidence on costs Include as part of a wider LTC programme UK research needed

Summary No brainer Skills in empathetic communication that supports patient's motivation to look after themselves, including the most disadvantaged, improves patient and clinician satisfaction and looks like it may improve outcome and save money