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Doing things differently

25 November 2013

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Change can be a challenge within any organisation, but involving your practice in new initiatives and projects can benefit everyone

We are all well aware of the problems facing the health service – an increasing elderly population with fewer people of working age around to provide the care these people are likely to need, ever-rising levels of patient expectation, the impact of health inequalities and lifestyle choices on patients’ health, and the ongoing financial squeeze. We know from daily experience how busy life in general practice is with the quality and outcomes framework (QOF), enhanced services, commissioning, integration, over-capacity list sizes, and a myriad of other factors that could be added to this list. By Friday everyone is on their knees – pity our poor colleagues who have a Saturday morning surgery to face, or a weekend shift at the out-of-hours centre. 

So what can we do to improve our lot? It is a definite no-brainer that things have to change. We – and that is both the patient and the primary health care team (PHCT) – need to find ways of doing things differently. The good news is that there are already lots of new initiatives and projects around looking to do exactly that. 

Patient empowerment

For many people, the fundamental answer to this dilemma is empowering the patient to take greater responsibility for looking after themselves. Fortunately, there are a variety of ways in which to engage patients in this process. While lots of patients are already motivated enough to go away and research their condition, the sources can be dubious and the information inaccurate. It is in our best interests to point these patients towards robust, reliable health-related information, and to encourage other patients to do likewise. Third sector organisations, especially charities supporting specific disease areas, provide useful sources of such information, as indeed can pharmaceutical companies – but the latter will depend on your practice’s viewpoint on using information that contains explicit pharma branding and advertising.

Signposting, particularly by reception staff, is an activity that is receiving lots of attention at the moment. Our front-line staff have always been able to tell patients which buses go to the general hospital or where the local carers group meets, and on which day. However, this could be taken a step further, possibly allocating a member of staff to produce a folder of information or a themed noticeboard for the waiting room, or else developing skills in order to become adept at using the bespoke health search engines that are around. (At this point, you are not only empowering patients, but staff too, as this could be an alternative development opportunity for the member of the team who is too squeamish to consider phlebotomy!) These search engines are designed to provide robust information on a huge range of topics, and self-help tips and to signpost patients to relevant, and local, support groups. It may even be worth considering having a terminal in the practice just for this purpose. 

Practices are also experimenting with link workers, members of the team whose role it is to work holistically with service users, pointing towards appropriate – not necessarily medical – services or support groups and providing relevant information. These staff are often seen as less formal than the more traditional health professional roles, able to establish a different type of relationship, providing a flexible service that can be adapted to suit the needs of patients, carers, families, etc, and at the same time reducing some of the demand currently placed on GPs and practice nurses. Definitely worth a thought.

Perhaps you could consider providing patient education for defined groups, such as diabetes awareness sessions, helping to increase understanding thereby improving the patient’s ability to live with a long-term condition. Other healthcare professionals are likely to be keen to help with such sessions – for example, dietitians and pharmacists participating in diabetes sessions. Many primary care outpatient departments are making excellent use of ‘expert patients’ to help others newly-diagnosed with the same condition to come to terms with this, to understand what this means for them and to see how people cope with the condition on a daily basis. This is often done in conjunction with a condition-specific manual that the expert patient supports the new patient to work through, improving the uptake of this resource and optimising outcomes for the patient. Could your practice find out which outpatient departments are offering this service – and which ones are using self-help patient manuals – in order to make links and build on this service? There may even be opportunities for your PHCT to learn from these patients too, for example, at a practice learning event. 

Another increasingly important member of the primary care team is the patient involvement worker. This staff group is expert at representing patients’ views and setting up focus groups. They would be delighted to help practices to establish such groups, given the importance of patient focus and public involvement (PFPI), putting the patient at the centre of what we do and thereby encouraging greater participation in their own healthcare. 

Telehealth and supported self-management (SSM) provide patients, predominantly those with long-term conditions, with the ability to monitor symptoms and gives the knowledge and confidence required to better control their condition(s). The ever-growing range of telecare technologies offers patients the opportunity to remain safely at home while still being closely monitored by health staff. The self-management plan allows patients to record key information about themselves, important reminders about staying well, and what to do if the condition worsens. Copies of plans can be easily sourced from local clinical networks and, of course, the internet. Many areas have successfully introduced telecare and SSM plans and have found that these not only help to maintain a quality of life for patients, but also reduce the number of admissions into secondary care. 

Not surprisingly, colleagues in the acute sector are also actively encouraging the use of SSM plans, primarily by completing a plan either when discharging patients back in to the community or during routine OPD appointments. SSM plans are routinely recorded in patients’ anticipatory care plans (ACP) and/or key information summaries (KIS). These technologies and plans are positive examples of how we are improving joint working between secondary and primary care, and simultaneously providing person-centred services. 

Culture shift

Of course, all the above means that the practice team will have to change its ways of working – and, most significantly, the mindset of the team and each individual member of that team. Healthcare professionals, in particular, will need encouragement and large helpings of peer support to adopt the empathetic approach required during consultations to empower patients to better self-manage. Happily, there is lots of help available to assist with this culture shift, for example training sessions that promote more holistic ways of consulting, techniques to check the patient’s understanding of information given during a consultation, thought-provoking DVDs developed to make staff consider their usual style, e-learning modules and widely reported academic research evidencing the success of these approaches in general practice. 

Making (and managing) changes will not be easy. Many people will be reluctant to stop doing what they currently do – after all, they will have invested years in building up the manner in which they interact and consult with patients. Changing style will be easy for some, requiring little or no effort but, inevitably, will be quite alien and difficult for others. No doubt you can already hazard a guess as to which camp certain members of your team would belong.

There is also the financial implication of doing something differently as it often means running with the status quo while trialling the new. This automatically increases rather than decreases cost, at least in the short-term. Hiring the link worker mentioned earlier provides opportunities to develop staff and to offer patients an alternative resource but does not come without additional expense. The challenge for the practice manager is getting the partners to see the value of having such a post and securing their agreement to fund another member of staff – never an easy feat at the best of times but even more difficult in the present climate. Hopefully, he/she can refer to the evidence from other, successful projects; provide real life examples of these models, techniques and roles working well in other practices and source appropriate training. 

Implementing this will require the practice manager to have nerves of steel, continually promoting the positive benefits, ensuring everyone stays on board, dealing with practical issues and HR challenges along the way. However, as I stated right at the start, the bottom line is that something has to give, as going on doing what we are doing is not a long-term option. I hope I have given you some ideas to consider. You don’t have to do all of it – in fact, start small, especially if this keeps everyone on board – and build up.

But please, just don’t do nothing.