Tag: House of Care

Control: What is in a name?

The British Medical Journal has sporadic articles under the theme ‘what your patient is thinking. In November 2018, the article was about control, and it was written by a woman called Judith Hendley, who has diabetes.

The article shows us how language in the consulting room can reduce patients to being their condition, a diabetic, a sufferer from diabetes, an unhealthy person, whose job in life is to control the only thing of interest to the clinician, their HBA1C.

She says ‘any kind of open question that allows me to feel understood and supported and not judged for the choices I make about how I manage my condition is more helpful. For example, “How are you feeling about your diabetes at the moment?”, “What is most important to you right now?”, or “What ideas have you thought about for how you could handle that?” ‘

This is where I think we are heading when we move to ‘House of Care‘ – shifting our focus to a style of working where the patient teaches us about their condition, and we help them deal with the important issues and problems that they bring to us.

In a small community, this is probably a bit easier, as we know our patients well as individuals, but the years of QOF have made us slaves to the check-list, the need to get in our questions about control early. Time to break that mould and bring in the new.

The article includes this wise guidance:

  • Listen to the language patients use and try to reflect it back to them in your observations or questions
  • Take the time to find out what matters to your patients—the things that they are worrying about might not be obvious to you
  • Think about the language you use when you are referring to or writing about people with diabetes or other long term conditions—would they find the language you have used empowering or disempowering?

You can read the article here: https://doi.org/10.1136/bmj.k3119

Preparing for the Benbecula House of Care

We are preparing for a new way of working in our practice. The idea is that we take what we do, and we supercharge it. Some of it sounds quite obvious.

Take the review of chronic diseases. At the moment, patients get called in for a pre-appointment check, then come back to see the nurse practitioner for a review of their condition.

The change is quite simple and also completely revolutionary. After the pre-appointment check, the patient is sent an update on their health, including any important areas to discuss, and space for them to consider what the key issues are for them. When they come to meet the nurse practitioner, the patient gets to choose which aspect of their health is most important for review, and for choosing which goals to set for the year ahead.

One of the key steps is how we reframe the review appointments. I personally believe that this is crucial: if we as a practice don’t understand and embrace this step, then all of the other changes are not going to be fully effective. This is the goal, the inspiring change.

I was very pleased to come across an article in the British Journal of General Practice: Setting goals with patients living with multimorbidity. Even the title is great – the goals are set with the patients, and they are the ones who are living with multimorbidity. The full article is in depth, and qualitative. The authors analyised 10 hours of VC to determine how goal setting is done. They describe ‘bearing witness’ to the patients goals. They conclude that this process requires a lot of time and energy from both parties, and it worked best when both GP and patient were prepared in advance.

I’m keeping that summary in mind, both for when we attend our training in Harris, and for when I prepare the staff-room QI noticeboard.

Patients and quality in health care – co-production at scale.

If you type patients, quality and care into google, the results suggest that this is something that we do for and to patients. Discussions about change agents take me to pages about how to engage clinicians within the healthcare system, but nothing directly about patients as systematic change agents.

I want to flip this on it’s head, and inspire patients to shape the health service, seeking provision that meets what matters to them. A 180 degree revolution. Clearly, there needs to be some strategy, some oversight from health care providers, so that those with greatest need don’t lose out to those with the strongest lobby. Both parties are required to create the service.

The current term for this process is co-production. On a personal level, working as a GP, this is our bread-and-butter. An effective consultation supports the patient with diagnosis, providing information, management choices, and opportunities to meet again to discuss progress.

While I was looking for articles about patients as change agents, I came across the concept of the Patient Activation Measure, a tool to assess how ready patients were to engage in these discussions. The tool is used on an individual, case-by-case level, where the doctor-patient relationship and the problem to be managed is the scope of the co-production. How could we lift this to a more strategic level? Could we use the Patient Activation Measure to see how successful systemic change is in increasing the number of patients able to use the tools of realistic medicine, able to develop that agenda with the clinicians they meet?

As a GP partner in Scotland, I am responsible for ensuring that our practice systematically provides safe appropriate patient-centred care. We provide opportunities for patients to feed back to us about their experience of healthcare, and give us suggestions about improvements. These tend to be about small things – how comfortable our seating is, whether we should have Radio 2 or another station in the waiting area.

Nationally, Care Opinion collects patient feedback, enables organisations to respond and reply, as well as being searchable. But this doesn’t of itself, change the relationship between clinicians and the public. Much of the positive feedback includes stories about care where the principles of Realistic Medicine has been at the heart of care. Within this movement, I feel I am getting closer to system-wide patient-led quality improvement.

The place where I feel this project really sits is as part of the House of Care. I seem to be trying to create an environment in which the left-hand wall is nurtured. Imagine a house which has, at it’s centre, conversations about care, support, realistic medicine. The foundation and floor is the social context, all of the sources of support in a community. The roof, sheltering this all, is the system and processes that bring the patient and clinician together. The conversation has on one side, individuals ready to engage in a therapeutic dialogue, and on the other, clinicians who are committed to partnership working with patients.

House of care

So far, most of the Realistic Medicine discussions that I have been involved in have focused on the clinicians, the ‘right-hand wall’, and on the roof. However, we could possibly be talking only to each other, unless we have individuals and carers that are speaking the same language, individuals and carers who can start these conversations spontaneously.

This model allows for work at local, regional and national scale. The British Heart Foundation has just published a report on a three-year project that used the House of Care Model in five health communities. The report describes how patients were involved in championing this approach, how important an enabling infrastructure is, how to flex the model to fit local need, and the importance of culture before paperwork.

I’m feeling inspired.

References (accessed on 11/10/2018):