by Cindy Mann
Senior Research Associate
Centre for Academic Primary Care
@Jcindymann
Person-centred healthcare is accepted as desirable on moral grounds and because it potentially leads to better health outcomes, greater efficiency and less waste. It means both involvement of individuals in their healthcare and individualisation of care.
The NHS has been chasing the goal of person-centred care planning for several years and there are many good examples of innovation. The ‘House of Care’ describes what it might mean in practice for people with long-term conditions. At its heart is personalised care planning, taking account of patients’ expressed needs and priorities. The national new models of care programme, involving 50 vanguard sites, is also pursuing this goal and recently reported on lessons learnt. Many of the vanguards have invested in health coaching and communication skills training for clinicians.
I recently worked on a large research project, The 3D Study, which aimed to make the care of people with multiple long-term conditions more person-centred, using a combination of strategies. One of these was to create health action plans in a collaborative way, including actions for both the GP and the patient. While GPs and nurses found it easy to get patients to talk about their most important current health concerns, they found it difficult to develop a plan with them in a truly collaborative way. They found it particularly difficult to avoid taking the lead.
Barriers to collaborative action planning
Interventions to achieve greater involvement of patients in their healthcare face many challenges. Behavioural change is required from both health professionals and patients, with patients’ health literacy level potentially a huge barrier that needs to be overcome by education.
The burden of improving health literacy lies mainly with health professionals who must be willing to explain and answer questions, often within severe time constraints. Patients also have a responsibility to ask and seek clarification, which they are more likely to do if they feel they might gain something from it, such as a satisfactory reason for their symptoms, a good rationale for their treatment, which they can understand, and a genuine part to play in decisions. Also important is achieving a health outcome which matters to them as an individual with preferences, priorities and unique concerns related to life roles, identity and quality of life.
Arguably, the most significant barrier to genuinely collaborative action planning is that health professionals hold both the power and the responsibility. This leads to a power imbalance, in which both health professionals and patients collude, but which is often unsatisfactory to both.
Training is the key
There is no question that patients need support in managing long-term conditions. But exhortations to modify their life-style, while important, are often ineffective. A truly patient-centred approach would involve a change in the power balance, with health professionals establishing a relationship with the patient on equal terms that permits genuine negotiation, informed by the knowledge of both patient and health professional.
This has a better chance of leading to a mutually agreed care plan that addresses the patients’ own important goals, but first healthcare professionals require training in communication, negotiating and contracting skills, and knowledge of their patient. Of these, negotiating and contracting skills are the least well understood and least likely to have been included in training, despite the strong focus on practising in a patient-centred way.
Meeting the need for training
Researchers at the Centre for Academic Primary Care at the University of Bristol are aiming to develop a novel training intervention based on real-life examples of productive negotiations between patients and health professionals, drawn from previous research. They hope that this training in collaborative action planning will help to achieve genuine sharing of responsibility and plans between patients and their health care professionals.
The research team will work with patients, GPs, nurses and health commissioners to develop the most relevant and effective training. The project is known as Collaborative Action Planning for Long-term Conditions (CAPLoC).
If you would like to know more, or are interested in helping to develop the intervention, please contact Cindy Mann: cindy.mann@bristol.ac.uk.
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What is the 3D approach for managing multiple long-term conditions? by Dr Mei-See Man