Tuesday, 24 July 2012

Consultations – A Meeting of Minds or an Appointment with Fear?




This week, the spotlight has well and truly shone on consultations, in the form of several reports released by the Health Foundation, including one entitled ‘When doctors and patients talk: Making sense of the consultation’ (Health Foundation, 2012).

This is welcome news to us, as consultations and how they are conducted, and helping health professionals develop more person centred skills, has long been a central theme of our work. This is because we know that people with diabetes have mixed and often unpredictable experiences with their health professionals, and frequently spend days and even weeks before their meetings feeling anxious and concerned about what might happen, particularly about whether they might hear bad news about their health. Not least of their worries is being judged for not achieving better control of their blood glucose, without the chance to explain the complexity of managing diabetes day by day in the face of other pressures and demands. As one person memorably put it ‘consultations for me are about attending to receive my ritual telling off’ (although in reality the words ‘telling off’ were said in rather more colourful language!). Another lady put it like this – with tears in her eyes -  ‘I feel like I’ve failed an exam every time I go to the clinic’. 

The Health Foundation review, which is based on extensive interviews and workshops with a range of doctors and patients, not only completely validates this aspect and discusses fear of patients as a key influencer of their participation in a consultation, but also suggests that the fear of doctors is a factor too. Their fear centres on making the wrong diagnosis or on potentially being regarded as less professional if they alter the way they work. With the power in healthcare still largely residing with the health professional, the consultation is often structured to allay the fears of the doctor rather than the patient, giving rise to the experience of many of being talked at rather than with and being unable to fully express their thoughts, feelings and wishes.

It’s not all bad news for consultations of course - many go very well, and the bond between health professionals and the people they see is often close and productive. Diabetes UK’s magazine ‘Balance’ runs a regular column ‘I couldn’t do without…’ in which people describe where their best support comes from. This very often features a nurse, doctor or other health worker. What we need is more of these obviously successful encounters and less of the ones that are, frankly, a waste of time and effort, not to mention money, for all concerned.

But the good news is, a knight in shining armour may be coming to the rescue. A new way of working is hovering on the edge of diabetes care, looking for ways into the mainstream. This is personalised care planning, which features shared decision making at its core and has been shown to be successful in transforming the routine, health professional-based consultation to one that is truly collaborative, to the satisfaction, and in many cases delight, of both health professionals and people with diabetes.

With personalised care planning, people with diabetes are able to have a much greater say, literally, in the consultation, and no longer have to wait in trepidation for their own test results (blood, eyes, feet and so on) to be given - or often partially supplied - to them by their health professional. Personalised care planning means they receive a comprehensive set of results and have time to reflect on them well before their consultation. They can then make decisions in the comfort of their own home before meeting up with the health professional to talk about what aspects of their diabetes, if anything, they wish to work on as a priority. Quite often, they attend having already made a decision about changing something, and have got started on it, so saving a lot of time which can then be used to discuss other aspects of their health or make for a shorter consultation.

Health professionals are naturally sceptical and need convincing about new practices, an aspect highlighted by another of the recent Health Foundation reviews on the evidence for shared decision making in consultations (de Silva, 2012). This review describes principles that are known to promote shared decision making, which happily including many that feature in personalised care planning, such as: goal setting and review; making care plans in partnership together; emphasising options; problem solving; and preparation for the consultation in advance. However, even though this evidence is available, health professionals are also as vulnerable to the difficulties of changing their practice and behaviour as anyone else, and for these reasons, personalised care planning has not yet been widely implemented. 

Fortunately, the body of evidence for personalised care planning is increasing all the time, and we are proud to be contributors to this in a number of ways:
·      Our website resources, including workshops (Successful Diabetes, 2012)
·      2 recently published papers (Walker et al, 2012; Walker and Rodgers, 2012)
·      Our book explaining the nuts and bolts of how to set up personalised care planning (Walker and Rodgers, 2011).

Now, with the Health Foundation’s timely reviews, we sincerely hope that services will be able to stop saying ‘why should we?’ and see that ‘how can we?' is the only question they need to ask!

Does anything in this blog ring true for you? Do you have experiences of consultations or personalised care planning... or the opposite? Post your thoughts and comments and share them with us here…

References

de Silva, D. (2012). Helping people share decision making: a review of the evidence considering whether shared decision making is worthwhile. Health Foundation. http://www.health.org.uk/publications/helping-people-share-decision-making/

Fischer, M., Ereaut, G. (2012). When doctors and patients talk: making sense of the consultation. Health Foundation. http://www.health.org.uk/publications/when-doctors-and-patients-talk-making-sense-of-the-consultation/

Successful Diabetes Workshops http://www.successfuldiabetes.com/workshops

Walker, R., Rodgers, J. (2011). Implementing Personalised Care Planning in Long Term Conditions. SD Publications. www.successfuldiabetes.com/books

Walker, R. et al (2012). Introducing personalised care planning to Newham: outcomes of a pilot project. Diabetic Medicine, 29, 8, 1074-1078. Abstract can be viewed at

Walker, R., Rodgers, J. (2012). Personalised care planning for long-term conditions. Diabetes and Primary Care, 14, 3, 177- 181. Online at







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