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The personalised consultation for long-term conditions: part two

Key learning points

 - The routine consultation for long term conditions is, ideally, a precious encounter, which values the time, expertise and contribution of all parties

- A personalised approach to the consultation considers preparation for the consultation and its environment

- Person-centred consultation skills include active listening, acknowledging feelings, goal setting and action planning

This is the second of thre articles looking at personalised care for people with long-term conditions, including practical and straightforward ways that it can be implemented in everyday practice. 
 
The first article1 looked at the background, process and what's involved in implementing personalised care planning. The final article, in the next issue, will cover engaging and activating people in their healthcare. The present article gives you further insight into the personalised consultation. It includes practical ways and ideas to make your routine encounters with people with long term conditions even more person-centred, to mutual benefit.
 
People with long-term conditions are invited, if not expected, to attend regular review appointments. These are typically held at their general practice with the GP, practice nurse, dietitian or other health professional. They may involve investigations or tests before or during the consultation and frequently feature a discussion of the results of such tests, whether or not the person has prior knowledge of these. There is evidence that people with long-term conditions often approach the consultation with trepidation, including concern about being judged and receiving 'bad news'2 and health professionals are concerned about their skills and the availability of time to meet both clinical and the personal agendas.3 A personalised care planning system1,4 and a person-centred approach to the consultation both go a long way to alleviating both these issues. We will now focus on what the latter means in practice.
 
 
 
How does the consultation start?
 
How does your usual consultation begin? You might start with 'hello, how can I help you?' or 'come in, have a seat, where shall we start?' Of course, all of these are excellent 'opening lines', but a person-centred approach would suggest that the consultation actually begins before these words are spoken, with the preparation for the consultation and consideration of the environment and 'journey' the person has taken before even entering the consultation room and meeting with you.
 
Preparation
 
Preparation for the consultation is important for both the health professional and the person themselves. It can remind the health professional of the last meeting (if there was one) and what was decided, or to gather some basic information about the person, and to plan what questions to ask or issues to follow up, so that time is not wasted in constructing the agenda from 'scratch'. For the person with a long-term condition, preparation can include deciding what are their main concerns, what questions they wish to ask, what help they feel they need, looking at their test or investigation results (if these are sent in advance) and deciding what their goals are for the future. In a personalised care planning system, they would be explicitly invited to do this, and perhaps provided with an preparation tool such as those discussed previously1 or a 'diabetes concerns assessment form'. Such tools have been shown to enable focus in the consultation and make the best use of everyone's time.5,6
 
Environment
 
The environment through which the person travels to the consultation and in which it takes place is rarely addressed from a person-centred point of view.7 It is not always possible to choose the environment in which you work, but it is possible to assess it from the point of view of the person attending. During workshops, I often invite health professionals to 'go and see yourself' in order to gain insight into what messages the environment is sending to people attending and highlighting issues which could be addressed. For example, the cleanliness, clutter and noise occurring in the waiting area, the way in which people are called through or invited for routine tests and the arrangement of equipment and furniture. All of these can be so familiar to people who work there everyday, that it is possible to overlook their impact on those who are rarely there.
 
In relation to the consultation itself, how the person is called in, invited to be seated and the arrangement of seating and equipment - particularly the computer - are all of concern in a person-centred approach. These may seem trivial, but can make all the difference to the way a person feels about trusting you with their thoughts, feelings and concerns, and shows as well as tells about your commitment to being person-centred.
 
A person-centred consultation model
 
Once you have arrived at what we might call 'the consultation proper', a person-centred approach would first focus on the views and main concerns of the person attending. This is in contrast to the traditional approach, which tends to prioritise the agenda of the clinician. As we've previously discussed, this is suitable in acute situations, but for long-term conditions, which are largely self-managed, it makes sense for discussions to first centre around the person. If they have been able to prepare their agenda in advance, addressing this first can be very efficient and extremely time-effective. Many people already have ideas and options about their issues that they wish to discuss, and focusing on these, rather than simply medical solutions or professionals' suggestions, can create an action plan quite quickly and satisfyingly.
 
None of the above means that the professionals' issues and concerns don't have a part to play - it's more the order of discussions than the content that is important in a person-centred consultation. People often want and need your expertise and experience to answer questions and deliberate over options. A person-centred approach is about valuing the person's expertise and experience in their own condition and life as well. The principle of collaboration is key to being person-centred.7
 
Key skills
 
Person-centred skills for consulting are mainly around active listening; asking open questions (and, don't forget, waiting enough time for the answer before asking another!); paraphrasing, summarising; and having attentive non-verbal behaviour, such as nodding, eye contact and an open sitting position. All of these play a big part in enabling someone to 'hear themselves think' and come to insights and decisions. Contrary to popular belief, with good advance preparation and well-honed skills, the time taken in such consultations is no more than in medical-orientated ones. The difference is in the usefulness and 'activation'8 of the person who is, after all, the main agent in what happens next.
 
Goal setting and action planning are two vital skills necessary for the person-centred consultation.9 Being prepared to invite and agree the person's own goal for their health and condition is essential, even though it may contrast with your own perception or expectations. If what you wish for is not important enough to the person themselves, it will not be acted upon. Trying to persuade, cajole or even force someone to do something that you think is 'best for them' and dealing with their resulting resistance, is one of the most effective ways of wasting time in a consultation. Action plans are the steps along the way to achieving the goal and these can be both for yourself, for example in relation to referrals, arranging further tests, providing support and contact point for questions, and for the person, which could mean taking agreed medication, self-monitoring, making lifestyle changes or getting information or support.
 
An action plan that you have both contributed to and is SMART (specific, measurable, achievable action, realistic and timescaled) is much more likely to be undertaken successfully. A further aspect of action planning is considering what might be a barrier to its success and how such barriers might be overcome. A high confidence level in achieving the action plan (say on a scale of 0-10 where 10 is high) means that commitment to the plan is likely to be high, even in the face of difficulties.10
 
 
Conclusion
 
This article has given an insight into the person-centred consultation, including its preparation and environment, along with the principles of focusing on the person's agenda before that of the clinician's and collaborating on the resulting action plan. Key 
skills are active listening, goal setting and action planning. A consultation conducted in this way for routine reviews with people with long term conditions is likely to be more effective in actions being undertaken, more time effective, and much more satisfying for all concerned. 
 
 
 
References
 
1. Walker R. Care Planning for Long Term Conditions: part one. Nursing in Practice 2014;78:86-90.
 
2. Aloha AJ, Groop P-H. Barriers to self-management of diabetes. Diabet Med 2013;30:413-20.
 
3. Grant P. wWhat do patients want from their diabetologist? Diabetes Update Winter 2013;34-35.
 
4. Walker R, Rodgers J. Implementing Personalised Care Planning for Long Term conditions. 2011. SD publications. 
 
5. Royal College of General Practitioners. Care Planning. Improving the lives of people with long term conditions. London: Clinical Innovation and Research Centre; 2011.
 
6. Hong YY, Lim YY, Audrey Lim SY, O'Donnell MT, Dinneen S. Providing diabetes patients with personalised written information in the diabetes outpatient clinic: a pilot study. Diabetic Medicine 2010;27:685-690.
 
7. Walker R. Person centred Practice: a concise guide to success (ebook) 2013. Available at: www.successfuldiabetes.com/books.
 
8. Hibbard J, Gilburt H. Supporting people to manage their health: an introduction to patient activation. London: The Kings Fund; 2014.
 
9. Walker R. In the consultation room: goal setting and action planning. Diabetes
and Primary Care 2014;16:44-45. Bandura A. Self Efficacy theory: towards a unifying theory of behaviour change. Psychological Review 1977;84:191-215.
 
10. Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA August 23/30 2000;284:8:1021.
 
11. Anderson RM, Funnell MM. Diabetes Concerns Assessment Form. Diabetes Research and Training Center, University of Michigan.
 
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