Patients encouraged to be seen as partners

Podiatry care in Swansea Bay has moved up a step up by placing patients firmly at the centre of their treatment.

It moves away from the traditional paternalistic approach, instead treating patients as equal partners in their care. 

Led by the health board’s podiatry clinical lead, David Hughes MBE (above), it no longer relies on a ‘one size fits all’ approach and encourages self-management where that suits the patient.

The new model of care has been so successful that it is now being rolled out across Wales.

Key to its success is identifying highly activated patients, who have the knowledge and problem-solving skills to manage their conditions, freeing up more time for additional support to those who need it.

Mr Hughes said: “As clinicians we shouldn’t focus on telling somebody what to do and what not to do, and that’s it, we’ve done our bit. That’s not real life.

“Everything you do and say to a patient must be in a way and at a level that matches their current problem solving ability; their importance and their confidence. Otherwise they could be set back.”

Initially Mr Hughes and his team devised a pre-consultation questionnaire to determine what mattered most to the patient, if they would like coaching to manage their condition, and how confident they would be about seeing it through. 

He said: “When a patient walks through the door and hands over the piece of paper, we can immediately reflect back the exact words that the patient has written. For the first time they feel that somebody is actually listening to them.

“You have patients opening up and trusting this stranger in a way they have never have done before. 

“Some of the conversations around healthy behaviours are quite personal. If we talk about smoking, for example, it’s all very well to think that we need to continually remind people that smoking is bad for you – we put photographs out there to show people – and we put out services which support giving up. Does it make a difference to the majority? No it doesn’t. 

“What we need to consider is their importance and confidence. 

“Some people are smoking and it’s highly important to them that they don’t smoke. They smoke with absolute guilt. So why are they still smoking? 

“They haven’t got the confidence because in the past they have tried to give up and gone cold turkey and they’ve failed and have gone into a panic.
 

“What we need to do is empathise with those people. 

“And this is the crux of the model – if somebody is low on confidence you stop giving them information. You have got to give someone with low confidence a molehill to go over and not a mountain.

“It’s not about living their lives for them – if you’re living with a chronic condition, you’re living with that for nearly 8,800 hours a year. If you’re seeing a podiatrist for two hours that year then you’re on your own for the vast majority of that time. 

“The NHS has been delivered through the ideal of ‘if a patient has this, they are high risk and must have that’. But we believe each patient needs to be treated as an individual.

“This is not only good for the patient, but we can then concentrate resources on those who need us most.” 

The work carried out in Swansea Bay was ratified by all the heads of service across Wales enabling the team to receive funding to boost its research.

Mr Hughes said: “We were able to secure funding, around £50,000, to be able to purchase an insignia patient activation licence for 20,000 people across Wales, which gives a validated score of a patient’s problem-solving ability - everything we do with them from then on is based upon their score. 

“If they are already a level 3 or 4, there are 4 levels, then we know that those people are going to be able to listen and put it into practice. 

“If a patient is a level 1 or 2 we know that we need to slow them down and show them the molehill and not the mountain – make baby steps change agreements with them.

“By them succeeding in those baby steps they are building a confidence to learn more and more. Eventually we are hoping to raise their level to a 3 or a 4 so they can climb the mountain.”

To date 1,800 patients have been tested, revealing that around half of our local population are low activated.

Mr Hughes said: “You may say it’s because of high levels of deprivation, it’s in relation to education, or you may say we have been a very paternalistic health service provider in the past and there is an expectation that we will continue to treat patients and do for them, and to them, and allow them to continue to be passive recipients of care. 

“At the end of the day, whatever it is, half our patients do not have problem-solving ability or activation to do what they need to do to live well. 

“High-activated patients have better clinical outcomes, escape crisis and prevent ill health. Low-activated patients have poor clinical outcome, demand more of services, need more services and can do very little if anything.”

The distinction allows health care professionals to target those who are most in need.

Mr Hughes said: “With our low-activated patients we release capacity – care for those with the greatest need first. 

“This score now allows us to say, Joe Bloggs there, who was previously regarded as high-risk under the previous model of care, can see the banana skins in his room. He is level 4 activated, he knows where we are, and we have direct open access to allow him to get to us at any moment in time at the point of symptom, but we know he can manage himself.

“That isn’t to let us have more cups of tea and sit down, it’s to release us to give Jane Bloggs, who scored a level 1, more of our time to be able to coach them to be able to develop small baby step change and become a level 2 activated and then a level 3 or level 4.

“That’s where we are now – bang in the middle of our patient activate measure project.

“Currently our health board, Cardiff and Vale, and Cwm Taf Morgannwg are using the validated score. The other health boards in Wales are working towards joining us.”

The feedback from patients has been extremely positive.
 

One said: “I wanted to highlight a really positive consultation I had with a podiatrist. 

“I’ve had the unfortunate need to see quite a few of the NHS teams over the last couple of years linked to my own health issues and those of a family member and the experience has not always been this positive. 

“However, today was very different. The podiatrist didn’t seem rushed in her consultation and took the time to understand all my history and what may have led me to come to the service as a self-referral. 

“She explained everything to me in layman’s terms in a way that explored what I wanted to achieve going forwards and gave me practical and proportional advice and guidance that created ownership in me and was very motivational in her approach.”

While another said: “I want to provide my sincere thanks for the health advice and education that the podiatrist has supported me with through my time in podiatry and orthotics. 

“Thank you is not enough. The difference that it has made in my ability to self-care in living with my diabetes has been enormous. 

“Prior to being seen I had never appreciated the potential impact that my lifestyle changes could make in my condition and the consequences of not making those changes sooner. If I had been seen sooner I would have made the changes sooner.”