Shared decision making and self-management support are evidence based practices that are integral to making services more person-centred. They need to be understood as part of a broader commissioning intention to embed person-centred care across all the services within a local health economy.
Therefore, commissioning shared decision making and self-management support is not like commissioning hip replacements or stroke care, because what you are commissioning is not only an intervention. It is a culture change – a change in the relationship between the health professional and their patient; a change in the conversation between the health professional and their patient, and a change in the way services work to support that shift.
There are, however, some elements that can be commissioned to support this more person-centred approach:
Shared Decision Making
Health professionals need to use particular approaches, skills and techniques to ensure people are active in decisions about their own care. Training in shared decision making helps individual practitioners to develop their clinical practice and it helps teams and organisations to develop and embed a culture of shared decision making. Read more about workforce development.
Patients often go into a consultation expecting that their clinician will make the decision about what treatment they should have, and they do not feel confident or empowered to be involved. Creating the confidence and expectation of playing an active role can be done at a number of levels – from across healthcare organisations such as Trusts or Health Boards, across healthcare settings such as hospitals and community services, and by individual clinical teams or within GP practices. Read more about building patient awareness.
Support to refine systems and processes
Health services need to work in ways that encourage people to play an active role in decisions about their treatment and care. Web-based tools and approaches are also becoming increasingly common and may provide ‘off-the-shelf’ approaches or need to be developed locally. However, health teams often need support to identify and make the changes that are needed. It may therefore be appropriate to commission some support to help services refine their systems and processes. Read more about refining systems and processes.
Clinicians often feel they are already helping their patients to self-manage, but there a range of specific skills and techniques that healthcare professionals can use in consultations that can really help patients to self-manage effectively. These are relevant across the full range of health professionals and settings.
There a range of courses and programmes to help clinicians develop the relevant skills to support lifestyle behaviour change, including the Health Foundation’s Practitioner Development Programme and much learning about how best to target training to maximise its impact. Read more about workforce development.
Services that specifically aim to develop people’s knowledge, skills and confidence to self-manage
The objective of self-management training programmes is to enable people to better manage their own health by becoming activated patients who feel in control of their health choices. Effective training programmes: increase people’s self-confidence in their ability to manage their own health; increase their knowledge about their condition; build their self-management skills including skills in personal goal setting, action planning and problem solving; and support people to make positive changes in health related behaviour.
Training programmes range from generic programmes that are open to people with a variety conditions (such as the Expert Patient Programme or the Health Foundation’s Patient Skills Programme) to programmes that are condition-specific and open only to patients with that condition (such as DESMOND or Pulmonary Rehabilitation). They may be stand-alone programmes that focus only on building the knowledge, skills and confidence for self-management, or they may be broader programmes that include self-management elements. Read more about training for patients.
Services that provide on-going support to enable people to maintain their health
The support that health services provide to help people manage their long term condition is only part of the self-management picture. There are many other services, sectors and groups that people might tap into to help them manage their health – from the person with diabetes who joins a local walking group to help them manage their weight, to the person with chronic pain who joins a local social group that helps them get out of the house. The use of technological tools and approaches, such as web-based support and telehealth, are also increasingly being developed and used by people with long term conditions to provide on-going support. Many of these are already freely available and, for example, enable people to connect and get support from others nationally and internationally. In other cases, it may be relevant and helpful to develop local tools and approaches. Commissioning self-management support therefore needs to include commissioning a menu of related services. Read more about on-going support to patients.
You need to work in partnership with people with long term conditions to identify the kinds of support they need – in effect macro-commissioning so the individual patient can micro-commission.
Thanks for the Petunias was developed as part of Year of Care and provides a guide to developing and commissioning non-traditional providers to support the self-management of people with long term conditions.
No matter how extensive the services you commission, it will never be possible to commission every form of support that every person with a long term condition might want. You need to commission to ensure that services work in ways that enable people to find and tap into the support that they want. This might include commissioning some specific enablers, for example a directory of relevant support groups, but must also be more than simply information – information on its own is often not enabling. For example, Islington CCG has commissioned health navigators based in primary care.
Support to refine systems and processes
Health services need to work in ways that support people to self-manage. However, health teams often need support to identify and make the changes that are needed. Examples of ways that services can support self-management through the systems and processes they use include:
- Send out of results prior to consultations.
- Ensure people have access (including electronic access) to their records.
- Have a way of recording people’s preferences, agreed goals and follow up.
- Have access to tools to enable people to track progress, set and track goals.
- Provide telephone and web based support.
- Have options to interact with clinical teams via text, email etc.
- Establish online support groups and forums.