The pressure on primary care has never been greater, with significant demand, declining GP numbers, struggles to recruit and retain staff and knock-on effects for patients. According to the BMA, as of October 2022 there were the equivalent of 1,896 fewer fully qualified full-time GPs compared to the September 2015.
Covered by the Additional Roles Reimbursement Scheme (ARRS), primary care has recognised that health coaching is a Supported Self-Management (SSM) intervention that guides and prompts people to change their thoughts and behaviour, so they can make healthcare choices based on what matters to them. This increases patient autonomy and control and ultimately this leads to reduced demand on primary care.
Health coaching services focus on delivering a structured and/or targeted health coaching service for specific groups of patients, supporting them to become more active in their health and care.
Delegate feedback included:
- Clear presentations and lots of valuable information.
- Great speakers and topics – super easy to access.
- Lots of facts, stats, from a variety of speakers to show the benefits of health coaching and its positive impact on patient’s wellbeing in a non-clinical way.
- Very practical, researched, usable information that linked very clearly to our current transformation project in training allied health professionals in health coaching skills in an acute NHS trust (York and Scarborough).
- I work for a health charity, have counselling qualification and great interest in nutrition, spirituality, psychosomatic and overall holistic health and wellbeing. I am interested in doing health coaching and was really motivated by the outcomes clinicians have observed from patients receiving health coaching.
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Richard Pell, Flippin’ Pain Campaign Director, Connect Health
Jag Mundra, Population Health Lead, National Association of Primary Care (NAPC)
Question 1: What are the best ways to embed and magnify the benefits of health coaching?
Answer: It’s not OK not to measure because there’s always something quick that you can include to find out whether what you’re doing is working and to ideally work out an ROI and then start to communicate to that to people in presentations and in corridors. Existing NHS funding for the ARRS roles isn’t a given, so we’ve got to do that work to prove to people that it’s important.
Health coaching is a one-to-one intervention but we want to explore one-to-many interventions. Not everyone is going to be applicable or we won’t have the resources to support the whole population in a one-to-one way.
I’ve got four tips:
- Of the people who would value a health coaching intervention, they are already coming to see GPs and Community Health Services. 95% of them will have a contact in the next two years so we can nudge people to better health. A study done by the University of Oxford found that by spending 30 seconds talking about weight without an actual referral found that their weight dropped by 2.4 kilos.
- For health coaches working with services to develop them, there are a key number of services in the local Health Community that really matter, befriending Services, Park Run/Park walk etc. so I would recommend working with the key services to build them up.
- My one-to-many service tip is working with digital, and not getting digital to do the whole health coaching job for you. Think of hybrid approaches to maximize or magnify the effect of health coaching so you’re doing something face to face but you’re complementing it with something that can support people digitally in their day-to-day lives. We’re currently thinking about video group role-playing sessions where you’re recording big sessions, giving advice and creating podcasts. We’ve got interventions like digital walking groups where we’ve got health coaching setting up Strava groups, this way we can see how many steps patients have done.
- Finally, peer and “buddy” support, pairing people up so they support each other and then working with families and working with communities to get people thinking about moving more and eating better.
Question 2: Which of the 4 (obesity, anxiety, frailty, respiratory) has the best uptake/impact?
Answer: I would put obesity + anxiety + frailty as 1st equal as they are very modifiable and then respiratory 4th although it’s really about finding patients who have risks in perhaps 2 or more areas, so for example good proactive work around obesity will likely generate a better cohort (with better uptake) if it includes those with weight management needs AND a mental health risk in their records. Then you can improve the target group even more by including patients with high clinical demand and low clinical complexity (e.g. those on <6 repeat medications).
Question 3: Do regular G.P. & frailty teams’ review visits to care-homes, help to reduce A&E events?
Answer: We’ve done a large scale evaluation of an aging well model for predominately moderately frail patients in Calderdale and found that there was a secondary care saving of £593 per patient per year and a return on investment of 4.2. Unfortunately, we don’t have a split for elective and non-elective though.
BWEL study – GPs had a 30 second conversation with patients about their weight and made a referral to local weight management services. They found that those referred and supported lost 4.7kg but fascinating to see that those spoken to and referred but didn’t take up support lost 2.4kg – this challenges us to really this about what micro health coaching interventions we could use to help larger groups of people (e.g. using Accurx) – https://www.phc.ox.ac.uk/research/research-themes/health-behaviours-theme/research/bwel-brief-intervention-on-weight-loss-trial
Dr Selena Stellman, GP Lead – MSK and Personalised Care, NHS North West London Personalised Care Team and GP at North End Medical Centre
Question 1: Obviously health coaches might have limited clinical training and that might make things challenging when looking after patients with chronic pain who often have complex medical needs – how have you addressed this?
Answer: It’s very difficult with chronic pain patients because they’ve got lots of medical needs, social needs, psychological needs which can be quite overwhelming for a health coach who has lots of experience but not necessarily clinically. Talking to our health coaches, they can often felt a bit overwhelmed about how to answer patient’s questions around if they need more blood tests and their diagnosis. Have some sort of structure that the health coaches can get advice and support if they need it. Empower health coaches to understand their role and become confident in their abilities so we’re not placing them outside their competency levels. Allow them to understand that they can direct issues to a GP or take action, focus on patient goals and moving things forward. It is important for all healthcare professionals to have a good understanding of each other’s roles and what the different members of the team can contribute to a patient’s care and work together in an MDT to do that.
Question 2: Lots of interventions can have a great short term effect (which may often be placebo) but follow-up at 12 months can show little change or even worse (Obesity, a great example). Intuitively you would expect better long term outcomes with Health Coaching but is there any evidence for this or does this work need to be done?
Answer: There’s probably more work to be done, to be honest. If we’re equipping people with skills to self-manage one would hope and expect that they are going to be able to continue to do that but I think often the evidence is that that doesn’t necessarily become sustained. Perhaps, as we have more of a culture shift and it becomes the norm for people to self-manage, that might mean that we do start to see those changes sustained. I think also it’s about other healthcare professionals promoting this and encouraging patients and saying let’s do it which maybe wasn’t done so much in the past and actually now is becoming more the case. More data is needed really to be able to show benefits.
Jag: This is inevitably something we’ll get better and better information on and at a population level there is a rebound effect – a certain amount of time after an intervention had ended but generally the short to medium term impact is over a placebo or underlying trend (and we factor this out using good multiple control cohorts and time based cohorts).
When you look at a health coaching intervention compared to a typical NHS intervention like the Vanguard programme, you look at the ROI of health coaching. The value of health coaching far exceeds a typical intervention that’s more acute in nature.
Question 3: What governance do you have around the health coaching completed? Do you review the advice that is provided?
Answer: In terms of health coaches themselves, each health coach should have a named clinical supervisor, and a formal structure, someone who normally would be a clinician or GP. It’s also useful to have a more informal peer support and networks so that they can bounce ideas off each other because often there’s not a right or wrong way of doing things. Different coaches can have different styles and unique patients are going to respond to different things so it’s often about coaches just building out this experience and confidence, and having the clinical support there should they need it.
In our pilot project we have been running reflective sessions for healthcare professionals including health coaches which has focused on giving them an informal setting to share challenges and learn from peers, in addition to more formal governance structures.
Question 4: For those on constipating opioid patches Rx for chronic pains, could concomitant long-term oral laxative use adversely aggravate the risk of iatrogenic dementia developing – and what Ix should be used for monitoring to averts complications (+ shouldn’t the underlying painful aetiology be elucidated, than patch up elderly Sx)?
Answer: Where possible, in many cases opioid use should be limited for long term chronic pain – these drugs have shown to have significant side effects and are not always effective in treating peoples’ pain. Additionally, even the drugs used to treat the side effects of opioids such as laxatives can also have side effects themselves. Using non-pharmacological treatments to support patients with long term chronic pain, for example psychological support, pacing, and social prescribing and health coaching can often be more beneficial.
Regarding aetiology, certainly in all cases of patients with chronic pain any underlying pathological cause must be identified and treated. Some patients may have multiple causes for their pain, some structural (e.g disc problems, arthritis), some systemic (e.g. diabetes), and some non-structural such as fibromyalgia. Symptoms may be further confounded by social isolation and psychological distress. All of these causes are relevant and important, and teams may need to take different approaches to address each one, whilst ensuring treatable conditions contributing to patients’ pain are not missed.
Dr Chloe Stewart, Health Psychologist, National Specialist Clinical Advisor in Personalised Care/MSK, NHS England
Question 1: Where can I access training in health coaching approaches?
Answer: You can access training online via the Personalised Care Institute (PCI) that NHS England has commissioned to provide accredited training for Health and Care Professionals to build their knowledge skills and confidence. This ensures that they’re involving people in decisions about their care and treatment. On the PCI you can access training in terms of course skills, shared decision making, personalised care and support planning. There is specific training for junior doctors and also people working in maternity services and, for our commissioners watching this webinar, you’ll also see a list of accredited training providers on PCI as well. There are a number of other resources too. You can sign up and see these here: https://www.personalisedcareinstitute.org.uk
Question 2: What is the recommended training for health coaches?
Answer: You will find some good information in the workforce development framework for health and wellbeing coaches: https://www.england.nhs.uk/publication/workforce-development-framework-health-and-wellbeing-coaches/. Hopefully, people will find this guidance really useful as it sets out really clear, consistent standards for health and wellbeing coaches and demonstrates the benefits that health and wellbeing coaches can have in the NHS. It provides information on training, support, supervision and how you can continue to develop your practice as a health and wellbeing coach as well. It touches on how we might start to make sure that we’ve got quality and consistency across our health and wellbeing workforce in the NHS so that we can reduce any variation and make sure that we have quality standards in place.
Dr Ollie Hart, GP, Director, Peak Health Coaching
Question 1: Can you say a little more about supervision, what sort of supervision does a newly qualified health coach need?
Answer: What we’re seeing is that you can train people in the basic skills of health coaching and there’s a new workforce framework out for those roles that Chloe talked about, in particular, health coaching where it details that you really need to support people as they’re starting to build this in the system. Having some clinical supervision probably once a month, but also support from an experienced coach that can help to build their skillset. Interestingly, we think there’s a real value for peer support as well, people who are working in groups of four or five health coaches in a PCN, supporting each other and building each other’s skills. This is developing a really functional, new way of working that’s highly valuable for the NHS.
Question 2: What is the general training background / training needs of the health coaches in these sorts of services?
Answer: We’re often seeing health coaches coming from specialties where they’ve been used to lifestyle interventions, so personal trainers or dietitians or nutritionists. It’s worth trying to generate the role that people take, if you hold that mindset it’s not a huge skillset you need to build on top in terms of specific knowledge. If they’re then put into a system that allows that to happen and gives that priority, you can quite quickly see some big changes.
Question 3: Is health coaching only for people who are motivated?
Answer: As healthcare professionals we’re very drawn to people that want to do stuff. Ironically, activation data shows us that about a third of our population are totally disengaged with healthcare, it’s not a priority, and ironically they make up the bulk of the people that use the NHS services so actually we should be getting really good at trying to work with people who are not very well motivated. Health coaches have a skillset that enables them to work with people who are motivated, but also to do the right things for people who are not motivated yet, to help them to grow their skills and motivation. What’s really interesting is that it’s not often a lack of knowledge that people have, it’s not just that they haven’t heard what they should do, it’s around building their confidence and their personal belief and their agency to be able to come to the table.
Richard Couch, Service Transition Manager, Connect Health
Question 1: Regarding Time pressures, what would your advice be to someone who is concerned with a lack of time, say they only had a 10 minute appointment with a patient?
Answer: I might not give them advice, I might turn it around and have a coaching conversation with them. I would question “what is the most important thing to do in the consultation?” maybe it’s not just to perform prescribing action. Perhaps the best use of the time is to gain trust and rapport. Another thing is to be aware of is unwanted consequences. Such as needing to do an enforced wean which may cause people to seek medication from other sources. So, time spent having a coaching conversation and looking at alternatives to opioids will probably save time and effort in the future.
Question 2: As a First Contact Physio working in GP practice I often find that patients don’t want medication if they are offered options for their pain.
Answer: One of the solutions that we’re trying to encourage is to give other options at the beginning, rather than just opioids, then we’re not creating a problem further down the line.
Summary question for speakers
What is it that Health Coaching can do to alleviate primary care pressures and what should commissioners do about it?
Jag: In the short term, measure more and then the longer term, nudge more for larger populations.
Selena: Empowering patients to self-manage and for the Commissioners it’s about recognising the benefits of non-medical treatments that can be offered for people with long-term conditions and chronic pain even if they are more difficult to measure.
Chloe: Health coaching is about recognising that we don’t necessarily have the answers for people. It’s about supporting people rather than assuming we have the answer for them and understanding what can commissioners do. Commissioners can think about that house of care model, it’s not just about training your Workforce, it’s about having supportive systems and processes, it’s about having a prepared and informed public. It’s about commissioning services that people want and need rather than what we think they should have.
Ollie: I’d like to refer back to a story of someone who was treated in a different way where we might have gone down the medication line and actually supported them for self-management and really took them out of the system and helped them to manage really well. The exceptional thing about that story is that it’s not exceptional, it’s really doable with the framework that the NHS is pushing at the moment.
Richard: A new skilled workforce that could help turn the tap off with revolving door patients hopefully.
Watch the webinar again, which includes further insight from the speakers including a full Q&A session, and read more about the speakers here: