1. Practitioner Development Programme Skills Workshop 1

2. Welcome and Introductions Tutors All in group Name and area of work House keeping; -Manage self - All teach all learn -Toilets -Fire alarm & exits -Refreshments -Mobile phones

3. Successes & Challenges Share your experiences of signposting people with long term conditions to the SMP Share your experience of the Self Management Questionnaire Share update action plan activating intervention

4. Aims Skills Workshop 1 During this workshop you will have the opportunity to explore the skills which contribute to successful collaborative agenda setting including; Building the relationship & rapport Establishing an empathic relationship Co-producing the agenda Eliciting the patient’s priority and expectation Clarifying & negotiating boundaries for the consultation You will also have the opportunity to consider how your team and services work and how these processes impact your ability to successfully support patients to self manage and identify ideas you have to overcome barriers

5. Programme aim – review 5 Achieving improvement by changing relationships between people & health services The nature of the interaction created by the structures, processes and behaviours that exist within the system Patients, clients groups, service users, carers, families and communities Both the people who work in and deliver care services and the wider system Safe, effective, timely, person centred, equitable and efficient

6. Co-creating Health. What are we trying to achieve? Our aim is to support people with long term conditions to develop the knowledge, skills and confidence to manage their own health and healthcare (to become activated). Co-creating Health supports 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 live a higher quality of life, have better clinical outcomes and make more informed decisions about accessing medical services. 6

7. Levels of activation 7

8. The CCH Integrated Model 8 ©The Health Foundation

9. Health behaviour modelling 9 Biological Social / Behavioural Emotions / Thoughts

10. Learning agenda Share something that is working well for you in supporting people who live with LTC’s to self manage Share something that you find challenging/frustrating Record on flip chart Review list end of skills workshop 3 Consider how the skills we cover can support you to find solutions to your challenges

11. 11 Agenda setting – Identifying issues and problems – Preparing in advance – Agreeing a joint agenda Goal setting – Small and achievable goals – Builds confidence and momentum Goal follow-up – Proactive – instigated by the system – Soon – within 14 days – Encouragement and reinforcement – Most challenging to achieve – Key for maintenance & progress Becoming an active partner Making change Maintaining change Three key Enablers for clinicians, patients & systems

12. 12 The CCH Integrated Skills Model E ©The Health Foundation Agenda setting Goal setting & Action Planning Goal follow - up Exploration Planning Problem solving

13. Traditional v collaborative Information & skills are taught based on clinician agenda There is a belief that knowledge creates behaviour change The patient believes it is the clinicians role to improve health Goals are set by the clinician and success is measured by them Decisions are made by the clinician Patient & clinician share their agendas and collaboratively decide what information and skills are taught There is a belief that one’s confidence in the ability to change, together with skills and knowledge creates behaviour change The patient believes that they have an active role to play in changing their own behaviours and improve their own health The patient is supported by the clinician in defining their own goals & success is measured by their ability to attain those goals Decisions are made as a patient-clinician partnership

14. Successful Co-Creation requires: Exploration Inviting patients to contribute their beliefs, knowledge and values that are critical to co-creating a partnership approach to their health and well-being Supporting patients to explore their ambivalence and explore decisional balance Using exploratory skills to find out what is important to the patient rather than considering what is important for the patient

15. Successful Co-Creation requires: Planning Clinicians and patients collaborating on goals of treatment and the action steps that each will pursue to build health, well-being and confidence Exploring levels of importance and confidence Supporting autonomy and choice Exploring what will support this process and what challenges and barriers might get in the way Agreeing how and when to follow up

16. Successful Co-Creation requires: Follow-up Patient and clinician supporting self-management by arranging to learn from the results of the action plan within a meaningful, proactive timeframe and agree next actions. Phase 1 experience has shown that timely follow up (preferably within two weeks) is essential if patients are to continue to translate intention into action, implement action plans, achieve goals and become more successful confident self managers. Current systems and economics require us to find creative and sustainable solutions to these challenges.

17. Successful co-production requires: Problem solving Clinician and patient explore the challenges to self- management and collaboratively identify possible solutions. Clinician coaches patient to develop problem solving skills and confidence for self-management. Patients identify the support and services they need to achieve their goals. Organisations and systems develop/amend processes to support successful SM and SMS.

18. The three roles Teacher - information & education Manager - acute & emergency Coach – collaboration, partnership, confidence We need a full‘tool kit’ of skills All roles have a place and a value We need to be confident to move in and out of the roles We need to consider the these roles in the context of our professional responsibility, job satisfaction and self esteem

19. Skills list Reflection/Empathy Explore agenda/priority Explore agenda: clarify boundaries Explore beliefs about self- management Explore importance 0-10 Explore confidence 0-10 Support autonomy & choice Double-sided reflection Explore ambivalence Invite goals Ask before advise Problem solving Action planning Effective Follow-up

20. Learning & understanding the patient perspective Exploring the patient’s perspective is very powerful It helps build a strong relationship and rapport It enables us to gather excellent information It allows us to make efficient use of the time Key skills that support us to do this are; - Open-ended questions - Affirmation, normalisation -Reflection -Empathy

21. Open-ended questions Questions that cannot ne answered with a ‘yes or no’ They invite a broader response They create a more equal conversation -How…?-Where…? -What…?-Who…? -When…?-Tell me…? Avoid Why…? Can be risky, it can make the individual feel defensive and that they have to justify their answer

22. Affirmations, normalisation Affirmations: Look out for ‘change talk’ in patient story and affirm (‘you told me you tried to change before- that shows great determination’) Normalisation: Helps patients feel validated, that they are not alone, and that the practitioner has experience of working with people like them ‘Many people tell me a similar story’ ‘Its natural to feel the way you do’ 22

23. Reflective listening Using words to let the person know that you have heard what the they have said or to check facts; So, you are saying… It sounds like… You were wondering if… I hear you saying… Non verbal body language is not enough

24. Empathy Using words to let the person know that you understand or are trying to understand how it feels for them emotionally Reflection … You seem [frustrated, worried, sad] Validation…Anyone would feel Partnership…I’d like to help Respect…I’m impressed by how you

25. Listening to change exercise Think of a change you are considering Groups of 3 Interviewer, Observer, Interviewee Explore using (only) OEQ’s, reflection & empathy Switch roles Group debrief

26. Treat with care Never underestimate the value of empathy & reflection It’s the what we lose when we are busy, stressed or distracted It delivers a value to the patient and clinician and their relationship over and above the basic exchange of information As we start in our working lives we often have a more human gaze – as our knowledge and experience increase we adopt a more medical gaze – as we realise the complexities of life and illness and the difficulties people face with regard to health behaviour change we seek to redress that balance

27. Co-producing the agenda Use open ended questions, reflection and empathy to explore everything that the patient wishes to cover in the consultation, find out their priority and what they are hoping will happen (allow time for their response) What would you like to talk about today? [avoid temptation to use ‘how can I help you?, what can I do for you?’] So you have been feeling more tired and you have been coughing more... Is there something/anything else? Give the patient the opportunity to share all their issues ? Use summary reflection to pull together ‘Out of those things which do you feel is your priority?’ ‘What were you hoping would happen/we would achieve today?’

28. Co-producing the agenda Gather this overview before funnelling down to detailed information gathering Avoid the temptation to explore the chief presenting complaint before eliciting all the agenda Do not fear ‘the list’ The process is efficient and can be successfully utilised within the time frames for a primary care consultation Helps minimise the late addition to the agenda ‘Oh by the way’, ‘whilst I’m here’ Can be applied to all clinician:patient interactions

29. Co-producing the agenda Once you know patient agenda, priority, expectation Recognise & share clinician agenda, priority, expectation, inviting patients to acknowledge clinicians responsibility From my perspective the things we need to cover today are.....is that OK? Other things I think it would be helpful for us to discuss are....is that OK? I have some information regarding your test results that I would like to share......is that OK?

30. Negotiating & clarifying boundaries When both agendas are known it is possible to negotiate and agree what is to be covered in the consultation and to give just attention to other agenda items at a later time or in a different way If medical agenda truly supercedes patient priority due to clinical risk, use collaborative language to explain and negotiate Share your perspective and rationale Find common ground before proceeding Use language of focus, patient’s self interest

31. Empathic Bridge A useful tool for refocusing if the consultation goes off track You need to know agenda, priority, expectation Use the patient’s language Link with And..... Underpin with empathy Back on track..... Try to avoid using ‘But’ in this or any other situation ‘But’ negates all that has gone before Consider your own response to statements that contain ‘but’

32. Example I’m really sorry to hear you have had such a stressful time it sounds as if it has been really tough for you....... And..... I know you wanted us to cover your leg pain, your sleepless nights and your increasing breathlessness.... And......That your breathlessness is your main concern and you wanted to know if your heart is coping....... So.... Is it OK if we focus on examining your chest...... 32

33. Beware?! All the skills; whose agenda? Collaborative agenda setting is the foundation for successful goal setting Why might goal setting fail? What is important to the patient as well as what is important for the patient

34. Examples of Activating interventions Results in advance Agenda setting sheets Patient held record Access to information Information sharing Patients attending SMP skills training What do we need to change in the way we work that will support collaborative agenda setting and how might we do this?

35. Experiential practice Consider the skills we have covered and decide what you would like to try Most useful to select an area for which you attach high importance and have low confidence Safe environment to try things in a different way and seeing what happens

36. Action plan & next steps The skill I am going to work on; (e.g. from the skills descriptor list) The patient focused activity I am going to work on; (e.g. finding out about patient education & support groups, testing support tools such as the confidence ruler) The process I am going to work on; (e.g. trialling agenda setting sheets, sending out test results in advance )