Health changing conversations: clinicians’ experience of health coaching in the East of England
ABSTRACT
The changing nature of healthcare and the challenge of long-term conditions require a paradigm shift in the mindset and behaviours of professionals. Central to this is the quality of clinician–patient communication, which determines how responsibility is shared. Health coaching training for clinicians provides them with new mindsets, communication skills and behaviour change techniques that transform the clinician–patient relationship and enables patients to become more active participants in their care. This training improves patient experience and health behaviours, provides self-management support and can reduce demand and costs. This article describes the East of England health coaching training programme and provides an overview of the evidence, required competencies and challenges clinicians experience when putting health coaching into practice. It illustrates that health coaching is a mechanism to deliver person-centred care. More must be done to provide clinicians with these much-needed skills especially in the management of long-term conditions.
Introduction
It is predicted that three-quarters of all deaths in England by 2020 will be from chronic disease; 60% are due to detrimental yet avoidable behaviours, and long-term conditions account for the majority of health and care spend.1,2 The rapidly changing nature of healthcare, challenged by the emergence of frailty, multimorbidity and the dominance of non-communicable diseases, requires a paradigm shift in the mindset and behaviours of professionals.3,4
Involving patients more in decisions about them, and giving them more control, is top priority for both patients and the NHS alike.5,6 Informed and empowered patients have the knowledge, skills and confidence to manage their own health and make healthier lifestyle choices, make personally relevant decisions, adhere to treatment regimens, and experience fewer adverse events.7 Activated patients (those who have the knowledge, skills and confidence to manage their own health and healthcare) save between 8% and 21% of costs.1
The quality of communication between clinician and patient is pivotal as it influences the degree of partnership and, hence, the balance of responsibility held.8 Coaching uses communication techniques, based on a trusting, empathetic relationship, to change a person’s relationship to a problem and maximise their performance.9,10 Although coaching is used predominantly in leadership, its use in healthcare and with patients is increasingly recognised, particularly in the USA.11
We provide a high-level overview of health coaching training across the East of England, demonstrating clinicians can do more to realise the potential of their patients to self-care. We cover what health coaching is, the programme of work, associated competencies and barriers and next steps in moving forward drawn from studies outlined in Table 1.
The case for change
The Royal College of General Practitioners (RCGP) states ‘The most important thing is that we enable healthcare professionals to have better conversations with patients’.17 Low levels of compliance with medication and lifestyle advice (50% and 10%, respectively) illustrate that patients can find it difficult to follow clinicians’ advice, change their behaviour, and feel motivated to improve their health.18 Alignment between clinician and patient expectations (goals, choices and shared decision making) is often poor;19 and clinician–patient communication can be a major source of dissatisfaction.20 Patients often feel insufficiently involved in decisions about them.21 Clinicians may not have adequate training in behaviour change or possess the complex interpersonal skills required.22
What is needed is a change in the paternalistic ‘expert’ clinician-patient relationship, which can create dependence;21 a psychologically minded workforce that operates from a psychosocial, rather than a purely medical model, to enable care and support planning;17 and new competencies such as health coaching.23
What is health coaching?
Health coaching is defined as ‘helping patients gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified health goals’.18
Studies describe health coaching as being patient centred and goal orientated, bridging the gap between clinician and patient, offering emotional support and adopting behaviour change techniques that tap into the intrinsic motivation of patients. The health coach provides self-management support, helps patients navigate the healthcare system and serves as a continuity figure.18 They use motivational interviewing, positive psychology, solution-focused and leadership coaching techniques, as well as problem solving with an ability to manage cognitive and emotional barriers.20,24,25 Key to health coaching is the patient setting self-directed goals.11 Health coaching is based on shared responsibility, patient centeredness and coaching the whole self.26,27 It is distinct from the medical model, health education, psychotherapy, executive coaching and life coaching.11
As an umbrella term, health coaching includes a wide range of applications. It can be a standalone intervention, integrated into clinical practice or part of a system of care; carried out by telephone, online, face to face or in groups and effectively delivered by all health professionals and peers.15 Health coaching is used as an adjunct to risk stratification, case management and telephonic navigation,28 and in conjunction with technologies such as apps and self-care platforms.
Health coaching is widely applicable to people with single and multiple long-term conditions, covering prevention, decision making, self-management and medication compliance. For example, it has been used effectively in smoking cessation,29,30 weight reduction,31 reduction in cardiovascular risk factors,32 diabetes control,33 asthma management,34 readmission,35 management of depression,36 and for medication adherence. 37
An analysis of 284 articles provided a consensus definition for health coaching (Box 1).
Box 2 describes the related concepts of shared decision making, care and support planning and person-centred care. A full exploration of their relationship with health coaching is outside the scope of this paper. However, these definitions share the same ethos of partnership between clinician and patient and who both bring different, but equally important, knowledge and expertise. The main focus of health coaching is in achieving patients’ self-determined goals to elicit motivation and behaviour change, and the coaching mindset and communication techniques can be applied to all three related concepts.
Health coaching in the East of England
In 2010 we pioneered health coaching training for clinicians to improve outcomes for people with long-term conditions. The goal was to provide clinicians with health coaching skills, techniques and mindsets to use in daily clinical practice to help them manage increasing demand, repeated patient visits and patient expectation, while simultaneously improving quality and patient outcomes.
A 4-day training course was piloted with 17 practice nurses from eight GP practices and used in 290 dedicated appointments. The skills, behaviours and techniques learnt were taken from health psychology, performance coaching and clinical training. These early tools were then developed into 2-day programmes for integrated care teams from four clinical commissioning groups (CCGs) and tested in other parts of the country.
Between April 2013 and December 2015 Health Education East of England (HEEoE) commissioned 43 2-day programmes for 779 clinicians, including nurses, doctors and allied health professionals from 45 organisations across community, primary care, mental health and acute settings. Twenty local trainers received a 10-day Train the Trainer programme.12–15 Five other regions later adopted the training.
Does health coaching work?
Despite limitations in the research methodology, and lack of definition, evaluations of health coaching, as developed in the East of England and internationally, show growing evidence that health coaching training can enable clinicians to deliver more personalised care to patients.
In the East of England, a patient survey before and after health coaching by practice nurses showed significantly increased self-efficacy and satisfaction.12
In the evaluation of five pilot sites from across the East of England, a wide range of clinicians reported an increased patient confidence, motivation and satisfaction, change in health-related behaviours, reduction in dependency and improvements in medication compliance. Clinicians found the tools useful in structuring difficult conversations, their work was more fulfilling and their resilience increased. Further, the evaluation reported that the training was a catalyst for organisational change. Observed benefits to the NHS included improved patient compliance, earlier discharge from caseload, fewer episodes of care, acute admissions and appointments, shorter waiting times and reduced costs from unnecessary tests and medication.14
Evidence from use of East of England training on a rehabilitation ward in Wessex resulted in an increase in the patient’s independence (Barthel ADL scores) and self-efficacy, and reduced the need for residential care placements at discharge.40
Rapid review of evidence from 275 studies, mainly from the USA, indicated that health coaching works best for people in most need, increases patients’ motivation to self-manage and adopt healthy behaviours, is widely applicable, and can be adopted by all professionals.15
However, not all studies show benefit, there is insufficient evidence of cost-effectiveness and more research is needed.15,41,42
Health coaching competencies and barriers to their use
Health and wellness coaching competencies will soon emerge as a basis for a national certification in the USA (Margaret Moore, CEO, Wellcoaches Corporation co-director, Institute of Coaching, McLean Hospital, personal communication,18 March 2014). In the UK, while there are defined standards, competencies and levels of training in leadership coaching to enable quality assurance,43 this is a gap in health coaching.
As a result, a competency framework or defined set of skills for health coaches was created through qualitative research with doctors, nurses, physiotherapists, dieticians, occupational therapists, psychologists, podiatrists and coaches (Tables 1 and 2). This further illustrates how health coaching skills build on and are integrated with clinical practice and how they help deliver person-centred care.
Our next line of inquiry was to ask clinicians who are now training others in health coaching about barriers to application relating to clinician, patient and system factors. Clinicians reported that practitioners may not be psychologically minded. In general, the workforce is not trained or skilled in person-centred care and the system is designed around a biomedical model, as reported in other studies (Table 3).11 The impact from health coaching at the organisation level was not just about the quality of the training provided.14
Discussion and learning points
This paper outlines key elements of a health coaching approach based on 5 years of accumulated experience and a review of international evidence. The four East of England evaluations are qualitative and based on the experience of training from a single provider. As a result, the description in this paper is exploratory rather than definitive.
Primarily we have attempted to describe health coaching, including health coaching competencies. This illustrates that health coaching is synonymous with person-centred care, and the training for clinicians is a mechanism to deliver it. More clarity is needed on how health coaching relates to care planning, wellness coaching, shared decision making and the house of care, or national delivery system for people with long-term conditions, if these different approaches to engaging patients in their care are to be prioritised and adopted.43
As health coaching is an innovation in the UK, more evidence is needed on value and impact in the NHS. However, together these early evaluations and international evidence point to health coaching as a potentially important tool to add to a clinician’s toolbox. At the very least, training in health coaching for clinicians improves patient–clinician communication and quality of care and, at best, reduces demand and costs. Clinicians report a ‘triple benefit’ as the mindset is used with all patients to deliver person-centred care; the communication skills support behaviour change, and a coaching approach is also helpful with colleagues in appraisals and leadership. While many interventions focus on creating expert patients, health coaching helps ‘activate clinicians’ and service providers within the mainstream of care provision in order to create a culture that is receptive to informed, empowered patients.
Health coaching is used increasingly throughout the USA where it is delivered by a range of providers to private individuals and as part of healthcare systems.27 These trends are likely to be indicative of future developments in the UK given the global challenge of chronic disease, as evidenced by its recent adoption into national programmes to deliver NHS England’s Five Year Forward View.
A coordinated approach to introducing health coaching is now needed, led primarily by Health Education England. This should include exploring the synergies between health coaching and other approaches with overlapping skill sets, mechanisms to share resources, further development of training competencies and standards written for commissioners for quality assurance. More must be done to provide clinicians with these much-needed skills at undergradate and postgraduate level, for example, to deliver the new standards of community nursing. Critically robust data on cost effectiveness of health coaching is now required. Overcoming the cultural and systemic barriers encountered by clinicians will require sustained effort by organisations to optimise return on investment.
In this way, with other measures, health coaching is well placed to become a significant lever in achieving the paradigm shift required and enable patients to become more active participants in their care, improve health-related behaviour, outcomes and quality of life.
- © Royal College of Physicians 2016. All rights reserved.
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