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.

Table 1.

Studies related to health coach training created in the East of England and methodology.

Work	Method
Evaluation of health coaching delivered in the East of England	Study of 290 health coaching appointments delivered by 13 practice nurses from seven practices using pre- and post-coaching patient self-efficacy questionnaires.12 Qualitative report of health coaching based on participant surveys to 779 clinicians post-training and at 6 months.13 Qualitative evaluation using interviews and focus groups in five pilot sites including a clinical commissioning group and in primary, mental health, social and acute care settings.14
Evaluation of international evidence	Rapid review of 275 health coaching studies, primarily from USA.15
Competency framework	A thematic analysis of qualitative feedback from 83 participant and 29 trainer surveys compared to European Mentoring and Coaching Council executive coaching competencies.16
Assessment of barriers to health coaching	A thematic qualitative analysis of survey and focus group feedback from 20 health coaching trainers about perceived barriers to clinicians using a health coaching approach.

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 1.

Definition of health coaching established from systematic review.

A patient-centred approach wherein patients at least partially determine their goals, use self-discovery and active learning processes together with content education to work towards their goals, and self-monitor behaviours to increase accountability all within the context of an interpersonal relationship with a coach. The coach is a healthcare professional trained in behaviour change theory, motivational strategies, and communication techniques, which are used to assist patients to develop intrinsic motivation and obtain skills to create sustainable change for improved health and wellbeing.11

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.

Box 2.

Related concepts to health coaching.

Shared decision making is a process in which clinicians and patients work together to make decisions about care and treatment based on both clinical evidence and the patient’s informed preferences.38

Care and support planning is a process to enable people with long-term conditions and their carers to work in partnership with health and social care professionals, to design their care shaped by their own assets, goals and priorities. It encompasses five steps: preparation, conversation, recording, making it happen and review.17

In person-centred care, people who use services work in partnership with their health and social care professionals. They are treated with dignity, compassion and respect. They are supported to develop the knowledge, skills and confidence they need to make informed decisions about and to better manage their own health and care. Their care is coordinated and tailored to their individual needs.39

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.

Table 2.

Health coaching competencies.

The application of a patient-centred approach	Improving patients’ health and wellbeing through establishing a trusting and empathetic relationship with the patient, facilitating behavioural change and providing self-care support.
Goal setting and action planning	Facilitating patient-determined goals that align clinician and patient priorities, delivered through a shared plan and joint responsibility.
Managing the process and relationship	Overseeing the health coaching process, holding patients’ and clinicians’ agendas simultaneously and effectively applying specific behaviour change, communication, and motivational skills.
Using core coaching and consultation skills	Raising awareness, increasing responsibility and shifting patients’ mindsets to enable behaviour change through great listening, effective use of questions, and supportive challenge.
Managing self	Holding and demonstrating a belief in the potential of patients to self-manage and developing a higher level of awareness of consultation style, use of language and impact on patients.
Building on clinical expertise	Integrating both clinical skills/knowledge and interpersonal skills in behaviour change to encourage accountability for behaviours, preferably through a continuing relationship between an experienced clinician and patient.
Reflecting and the wider system	Managing expectations and reflecting on effectiveness of the coaching approach, and considering the impact on the wider system and resources.

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

Table 3.

Perceived barriers to clinicians using health coaching as reported by health coach trainers.

	Barrier
Clinician	Strong identification with expert role Perception of already delivering person-centred care Concerns about increasing length of consultation, decreased control and managing clinical risk More emotional investment required
Patient	‘Expect to be fixed’ and devalue own resources and potential for change More psychological effort required in recognising reality Threat to potential secondary gains associated with being unwell
System	Structure – working in silos, more demand than capacity Competing priorities – increasing workloads, fire-fighting, short-term thinking, change fatigue System instability – reorganisation and recommissioning Primacy – person-centred care skills not prioritised, not measured routinely and poorly resourced

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.