This case study, written by NHS Innovation Accelerator Alumni, Dr Penny Newman, describes how creating a social movement around workforce innovation, Health Coaching, supported spread across England’s NHS to empower patients to self-manage and make clinicians’ work easier.
The problem with our conversation
The fundamental building block of good health and care is effective communication between a clinician and patient, and their family or carer. Excluding therapeutic conversations for treatment of mental health conditions, health and care conversations have two main forms:
1. Transactional conversations include polite exchange of information, e.g. eliciting information in history taking and about appointment times, referral, prescribing
2. Transformational conversations are empathetic, help raise patient’s awareness and responsibility, and change thinking, e.g. about their condition or situation, and allow people more control to take action towards better health
This case study explores a social movement around transformational or ‘health coaching’ conversations that support people to self-manage. These types of conversation are vital where health is not easily ‘fixed’, where there are multiple treatment options and/or a need for behaviour change.
What is health coaching?
Health coaching is a person-centred, partnership model of communication based on health behaviour change theories where a coach or clinician and patient collaborate to identify goals and action plans that optimise personal well-being and overall health.
The use of solution-focused techniques, e.g. motivational interviewing, goal-setting, reflective enquiry and joint problem-solving all help increase patient empowerment toward autonomy. People are encouraged to draw on their own experiences to identify realistic actions that fit in with daily life and become internally activated and motivated to change by aligning health-related goals with their personal values.
While used throughout the USA, health coaching remains an innovation in the NHS. Health coach training was first developed by Drs Newman and McDowell in 2010 and it was one of 17 innovations to be selected for the NHS Innovation Accelerator Programme (NIA) during its first year. The training has now reached over 6,000 health and care professionals across the country working in hundreds of organisations, with 105 clinicians trained as local trainers. The training is delivered by TPC Health aided by the social movement, Better Conversation.
Better Conversation as a social movement
One key challenge with scaling is that a product or innovation developed in one area, isn’t always taken up beyond its original sites – in this case, the East of England. As health coaching is a complex innovation targeting cultural change, it was decided to use a social movement to aid spread, capitalising on the passion of health and care professionals for the training.
Qualities of a social movement
A social movement is a voluntary collective of individuals committed to promoting or resisting change through co-ordinated activity. Social movements produce a lasting and self-generating effect, and create, as they do this, a sense of shared identity*.
The below table is sourced from the NHS Institute, 2008: How does a movement view of change differ from our current view?
Current prevailing beliefs about change
Change starts at the top
It takes a crisis to provoke change
Only a strong leader can change a large institution
To lead change you need a clear agenda
Most people are against change
Change management is a disciplined process
A movement perspective of change
Change builds from bottom-up action
Change can be driven by passion to improve
Change comes from collective action of individuals
You need to have a clear cause but can be uncertain how you will achieve it
People have an inner desire to make things better
Change is opportunistic and spontaneous
The key elements that helped spread Better Conversation include:
Piloting: Two day (core skills), four day (EMCC accredited) and ten day (train the trainer) training materials were created and piloted with a Regional Innovation Fund. These spread across the East of England with support from Health Education England (HEE), reaching over 800 staff from all professions. Workshops were held to bring participating organisations together.
Co-production: The drive for the social movement was a collective desire to enable people to: “thrive by feeling more motivated, confident and in control of managing their own health and care.” With support from the Innovation Unit, NIA and HEE, new materials and a website were developed with key stakeholders at a series of co-design workshops to create a shared sense of identity.
Communities of interest and practice: Large groups of people were brought together on a regular basis to learn from and connect with each other. The new materials were launched at two conferences supported by AHSNs in Cambridge and Liverpool, and a community of practice created with the NHS Leadership Academy. These communities are supported by an online platform for sharing resources. As the work is constantly evolving, communication is vital through regular articles, events and publications.
Local adaptation: The programme uses coaching at all levels, including to determine how sites can best target the training to meet the needs of local people. Flexibility in training delivery allows for site adaptation.
- Horsham and Mid Sussex CCG adopted telephonic health coaching, targeted at people risk stratified by using the patient activation measure (PAM)
- Bedfordshire has trained all their social prescribing link workers in health coaching
- Symphony Vanguard in the south west has used the training in multidisciplinary teams within primary care, increasing activation especially with the most vulnerable people
- In Manchester the training is part of an asset-based approach for community staff from all sectors
Developing local trainers and leaders: 105 local trainers have received ten days training, and their organisations used the training and Better Conversation materials under licence to create a more sustainable local resource. These trainers have since developed as local leaders, spreading health coaching and a personalisation approach, and changing the culture within their own organisations and systems.
- East of England local trainers have trained nearly 1,000 additional clinicians and continue to train four years on
- Two physiotherapists at West Suffolk Hospital are now training across the whole of Suffolk with an £800,000 STP investment
- Leeds has employed Better Conversation advocates and trainers across the city with nearly £1m investment, which includes not just health coaching but other conversations
Evaluation: The training has been continually evaluated and coaches encouraged to elicit feedback to maintain effectiveness and enthusiasm. Three evaluations were originally funded by HEE, the Vanguards have recorded a consistent improvement in patient activation measure (PAM), and a feasibility study and review is currently underway.
All evaluations show a positive impact on patient activation, lifestyle behaviour and demand for services, and help clinicians structure difficult conversations, making their work easier. Evidence of cost savings is accumulating, and one study indicated a £3.6M saving with staff training on a rehabilitation ward. International evaluation indicates positive impact of physical and psychological health outcomes. Ongoing evaluation in this new field is vital.
The NHS is complex, and the spread of innovation is a recognised challenge. In an environment where communication skills are often undervalued, the degree of spread of Better Conversation and health coaching training feels like a big success.
While some aspects of the spread were planned, such as the website and free resources, much of the movement has happened more organically. This is down to the core application and effectiveness of the skills and passion of local clinicians, their commitment to sharing and learning, support from NHS partners, and the gap in current training.
As the heroic Better Conversation trainers will testify, a social movement isn’t an easy option. It’s a journey we are all compelled to take, to ensure that people are treated as partners in their health and care, and given the urgent need for better conversations.
For more information visit www.betterconversation.co.uk or follow the movement on Twitter @betterconvo #betterconversation
*Bibby J, Bevan H, Carter E, Bate P, Glenn R, The power of one, the power of many: Bringing social movement thinking to health and healthcare improvement (2009) Institute of Innovation and Improvement