Nick Lewis-Barned from Year of Care Partnerships reflects on Year of Care training.
This was prompted by Ross Grieve, Lead Training Consultant for the Thistle Foundation, own reflections after attending Day 1 of Year of Care training.
It’s probably worth saying, at the start, the House of Care approach isn’t really intended as a new system of consultation skills in the sense that Motivational Interviewing or solution focussed approaches might be. Of course the HoC can be taken at different levels, but it comes out of a biopsychosocial approach to working in partnership with (as opposed to ‘for’ or ‘at’) people with health needs. As we began to work out what was needed for this to become part of normal care, making use of all sorts of synergistic consultation models and drawing on experience of ‘what works’ (so also pretty pragmatic as regards local health systems in primary care), we identified two key dimensions:
- The first was a process, which ‘made sense’ and in the context of which the core and more advanced communication skills could be most effective. So ‘information gathering and sharing … agenda setting … exploration and discussion … goal setting / action planning …review’ as a way of structuring a person centred approach which allows a focus to develop progressively. The skill set for this is derived from a range of theoretical and evidence based sources. This aspect is not attempting to supplant existing well founded skills or be ‘new,’ just to create an orderly approach in which they can be used effectively. In a sense this is the inside of the house;
- The second is a recognition that effective self management means a person will be able and, where needed, supported to live well along the ‘wavy line’ -the ups and downs of everyday life. For this some specific things need to be in place within the system, not only to make the conversation between people and professionals as useful as possible, but also to help people to find their way to the resources they want and need between contacts. This is in a sense the walls, roof, foundation of the house itself.
This approach allows a way of thinking about all of the components and skills that might be needed, to identify what is already in place and what needs to be developed and also recognises where and how existing work fits together – such as the work by the Thistle Foundation. This is one of its great attractions as it means that rather than a potential competition between good programmes and projects, there is an opportunity to see how they might dovetail / enhance / complement and learn from each other.
In all of this, and absolutely critical to it, is the implicit, and at times explicit, challenge to people’s current learned attitudes (our current failing culture of healthcare). In many ways this is where much of the ‘ripple’ will happen. Once people start to think about our current paternalistic approach, and start to experience a different way of working, it makes it harder to take the more ‘traditional’ approach in other areas of clinical care, and they become more challenging of it. The “traditional” approach becomes uncomfortable and a lot less fun / effective.
Regarding follow on training, I guess this is where an effective steering group becomes really important to help a locality to identify its development and training needs and how these can be met. I’m really not sure there is a ‘one size fits all’ for this anymore than for individual patients in terms of meeting needs. It will depend on where the locality and teams start, what their capabilities, resources and skills are, what the perceived priorities are, and critically on leadership – most especially amongst clinicians (i.e. practitioner peers). Our experience is that this happens differently in different places.
In this sense the Year of Care training is indeed a starting place. Of course it would be naïve to imagine that training for 1 ½ days will automatically change everything straight away. What it can do however is help people to shift people’s perspective, identify their needs and set their individual and collective agenda for change. The YoC team is developing experience and where needed resources that people can tap into to help move things forward.
We don’t do heaps of trying out skills on day 1. I suppose this is a bit about how much material there is to cover to get people started, and a bit of a recognition that people need time to internalise things that might be quite new before ‘giving it a go’ in front of their colleagues. We actually thought lots about this when we were developing the programme in the pilot stages and found trying to get people to be too sophisticated too early didn’t work very well. So as you’ll see on day 2 there is some thinking about what has already happened in the intervening time, and then a chance to try stuff out. Some sort of reflective follow on process on skills development seems to be quite a common perceived need.
What issues do practitioners seem to grapple with? Chatting with some of our really experienced trainers, and backed up by my own experience, there are things we hear about that pose challenges to getting colleagues on side within practices; practical struggles with systems and IT; trying to work in one way with diabetes (or some other single condition) and then finding their system pushes them back to working in old ways with other long term conditions; skills for challenging situations such as people who seem disengaged or seem to want the professional to own the results or make the decisions for them; the assumption that we can only work this way with intelligent people like us and most people are incapable (not my sentiments you understand). We deal with this a bit in day 2 including thinking about what to think about with low confidence and importance ratings.