Health and care professionals committed to partnership working: right wall of the House of Care framework

WHERE ARE WE NOW? OUR BURNING PLATFORM

Prevention, intervention, and social improvement have resulted in people living longer with multiple long-term conditions (LTCs). The cost of such longevity and multimorbidity is increasing exponentially without people necessarily ‘getting better’ or achieving a greater sense of wellbeing. There is a universal anxiety about how we can continue to provide high-quality care for patients, balanced against financial constraints imposed by austerity. Terms such as ‘transformational change’, ‘enhanced productivity’, ‘system resilience’, and ‘integration of care’ are invented as we consider new ways to do the above while seeking to ‘balance the books’.

Both patient and professional experience are increasingly characterised by such complexity that hearing and delivering what is most important to a patient can frequently be overlooked. The drive to improve quality and reduce inequity means that we work in a standardised manner using guidelines and measure performance; a risk-averse culture has meant that we have moved away from meaningful risk-to-benefit conversations between doctors and patients, with systems of working now more likely to ‘prescribe’ actions to us as clinicians, in order to mitigate risk.

Traditional GP training embeds the art of the consultation as a core competence, promoting patient-centred and partnership-based decision making, and recognising the expertise of doctors and patients as having a role in the consultation and its outcome. With the complexity of modern-day general practice, the increasing prevalence of LTCs, sicker patients, and routine data capture competing for precious time within our consultations, this gold standard may be at risk of faltering. Professional anxiety, compounded by increased workload, conflicting demands, and weariness with continuing change, reduces our resilience and we may lose our way.

For many patients, we sense a low level of empowerment or efficacy to self-manage. This, when coupled with high expectations of cure, fosters dependence, and generates demand for formal health care. This is neither sustainable nor empowering.

The concept of health ‘literacy’ describes the motivation, knowledge, skills, and confidence a patient has to participate as equal in the understanding and management of their own care.¹ It cannot be presumed, but it can be promoted and enhanced, with one element being the way that professionals impart information and communicate.

As GPs we consider ourselves adept in handling a range of dualisms (medical versus biopsychosocial or clinician versus patient centred). However, there is now a growing and collaborative voice from patients and professionals that our traditional methods need a ‘refresh’ to bring a greater sense of empowerment to patients. A greater emphasis is needed on individual wellbeing not being an ‘absolute’ state of health, but instead more the ability to adapt and self-manage, while emphasising the role of the individual as a partner in achieving this. This requires a different conversational style, based around the motivational interview, with patients invited to participate as equals, and working towards personally identified goals.

Compelling evidence now exists in support of this approach, that of salutogenesis.² Improving a patient’s sense of wellbeing has a positive impact on health outcomes, which has a value that is ‘more than medicine’.

HOW DO WE EXTINGUISH THE FIRE?

We need to ‘re-form’ a community-oriented service (at the heart of which is the delivery of meaningful, person-centred, coordinated care), which promotes personal independence, and the language of ‘ability’. There is increasing evidence that empowering patients to take greater control of decision making improves outcomes and is better value.

The Coalition for Collaborative Care³ has championed the House of Care (HoC) framework of LTCs management, developed by the Year of Care Partnerships.⁴ It focuses on autonomy and self-care, to improve all aspects of wellbeing for patients and carers. To realise its full potential, all elements of the HoC need to be in place.

Care and support planning for those at risk should be seen as yet another dualism that professionals broker when considering the holistic needs of a patient; viewed from two ends of a spectrum we bring together the medical and social models⁶ and their different approaches into a way of doing things that delivers what people need (Table 1). Through purposeful, structured conversations it allows the setting of achievable goals focused on wellbeing and not the diagnosis-driven aims of ‘cure’. This is more likely to achieve positive change:

‘People are more likely to follow through on decisions they make in partnership, helping them to better manage their conditions and stay well and independent. This applies to people at all stages of life.’ ³

Table 1.

The dualism of person-centred coordinated care

Medical model	Function	Social model
• Grounded in pathogenesis seeking to identify the source or cause of illness or disease.	Theoretical framework	Grounded in salutogenesis2 as an approach to focus on enhancing factors that promote and maintain human health and wellbeing.
• Coordinating complex care delivery so that different elements of care work together effectively.	Tools and strategies	Improve outcomes by encouraging learning through support and coaching strategies with patients.
• Identify disabilities in individuals and put in place interventions to reduce impact of these.	System reaction	Create ability among individuals to enhance factors supporting improvements in health.
• Focus on formal and statutory care entitlements	Care planning	Focus on autonomy and self-care to improve physical, social, and emotional wellbeing involving patients, service users, and their carers.
• Reducing use and cost of acute services through better care planning and coordination.	Potential impact on services	Improve outcomes and reduce costs through enabling self-management of acute exacerbations and prevention of complications.
• Power imbalance has the potential to disempower patients and make them dependent on the system.	Potential impact on patients	The equalising nature of this approach has the potential to empower patients and encourage greater involvement in decision making and self-management.

THE MEANING FOR PROFESSIONALS

We should all consider how this could bring improvements to the care we give our patients. Patients should be better prepared and able to work in partnership, and more likely to achieve improved outcomes through taking small achievable steps, developing confidence, knowledge, and skills to better self-manage. Professional wellbeing is improved through participation in more meaningful conversations with patients.

Commitment to collaborative working can be enhanced through education. Programmes such as the Year of Care Partnerships⁴ or Coaching for Health⁵ develop professional skills in elements of collaborative care planning, motivational interviewing, solution-focused coaching, goal setting, and action planning. They not only focus on the inherent philosophy, attitudes, and behaviours required, but also teach communication tips and system organisation. Cycles of education need to be repeated to ensure coverage and provide updates and refreshers.

For patients, communication from different professionals must be consistent, using the same person-centred approach. Ultimately, this is embedded through teaching staff together via collaborative multidisciplinary professional education (for example, driven from formal Community Education Provider Networks) or working together. Making this really work is the added value of true co-production, with patients or ‘experts by experience’, trained to support peer-to-peer learning, professional education, and service redesign.

A commitment to collaboration must include working with other professionals: relationships, parity of esteem, and trust will need to be nurtured. The cultural divide between health and social care is an example recently cited,⁶ with social workers and GPs failing to understand each other’s unique role, responsibilities, and perspectives, and, therefore, having a detrimental impact on the delivery of person-centred care. Greater collaboration brings opportunities to support people at home, energising the offer through community-development social work. New roles such as navigators are emerging, helping people connect to services that are ‘more than medicine’, which, hitherto, have been difficult to map or access.

Finally, returning to the concept of salutogenesis² (the origin of health), this lies in the ability of an individual to maintain a sense of coherence in the face of stress. Coherence is formulated from three elements: comprehensibility, manageability, and meaningfulness. The last element is the most important; without sense of meaning there will be no motivation to comprehend or manage. The sense of coherence is a predictor of positive health outcomes. The HoC, through its focus on delivering meaningful, person-centred, coordinated care, drives us to understand what is most meaningful to individuals, and, through collaboratively developing knowledge, skills, and confidence, yields a sense of coherence, improving health outcomes and enriching working practice.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

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