It is widely recognised that people who feel in control, empowered and confident to take a lead role in their health care have better outcomes. Supporting patients in this way is a fundamental component of person-centred care, a lead feature in NHS England’s Five Year Forward View, a key priority for the OnlyWan, and a central feature of manifestos and policy guidance from leading patient groups.
Speaking as a GP and commissioner in Sheffield, I am acutely aware that our current ways of working, in the main, do not support such an approach. However, if we are going to change the way a patient is involved in their own care, we also need to have a good way of supporting them on how to do this: supported self-management. The first rule of education is finding out what your student already knows, and can do.
I recently decided that learning to salsa dance with my wife was going to be a good way to enhance our relationship. We went along to a local class, but I quickly realised it was too advanced for me - I couldn’t keep up and felt out of place. I was a beginner, and I needed to be in a class that was pitched at the right pace for me. My wife, however, who already had a bit of experience - not quite an expert, but more of an intermediate - would be bored and frustrated to be returning to a beginners’ class. The same parallel could be drawn for self-management. We need a way of measuring where people currently are so we can pitch the training and support at the right level.
Sheffield is part of a national NHS England programme to trial the Patient Activation Measure (PAM) as a measurement tool. Activation is described as ‘the level of skill, knowledge and confidence a person has to self-manage’. The PAM uses 13 questions to establish where people are in terms of their activation - from Level 1 to 4. In salsa terms, you could translate this into Level 1 - not currently thinking about learning, Level 2 - beginner, Level 3 – intermediate and Level 4 – expert! In Sheffield, we are encouraging ways for local services to adapt their approaches according to the level of activation of their patients.
The PAM has a strong and well-established evidence base. Interestingly, it suggests that moving someone from a Level 1 to a Level 2, from not seeing a role in managing their own health, to just being a beginner, has the biggest effect on health outcomes. The PAM helps us to track these, often imperceptible, changes. Knowing you are making a difference is a key motivating factor for many health care professionals and patients.
The other useful insight is that the PAM tool can help to free up a clinician’s time. I know from talking to our patient group in my practice that we all spend a huge amount of time and effort giving people advice that is too complicated for them. We think it is the right thing to give diabetics all the advice about eating well, exercising, taking medication etc. However, like with my salsa example, if the patient is just beginning their activation journey, then expecting them to thrive in an expert setting is probably more harmful than helpful.
I remain realistic about the level of persistent effort it will take before measuring and responding to levels of activation becomes an automatic feature of our health care systems. The early findings from the various sites using PAM give us helpful insight into how we can use it to achieve this change. form part of an on-going qualitative evaluation, being undertaken by the University of Leicester - co-funded by NHS England and the OnlyWan - to understand how PAM can help realise the national aspiration for a more person-centred NHS. sets out how PAM can be used within the NHS, its value to clinicians and commissioners as a tool to support self-management, and the impact of the tool on service provision. I am confident that this person-centric approach will eventually liberate us from wasting time doing the wrong things, in the wrong way, and help health care professionals to shape our systems around what patients need at each stage of their life.
When it comes to salsa, a few months on from my initial beginner classes and me and my wife are now twirling the night away! I still have two left feet, but we know enough to have fun and are learning all the time.
Ollie is a GP and clinical commissioning lead in Sheffield, www..com/olliehart7
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