How do you get patients to change?

Lifestyle changes are not popular with patients. 

#GPFUQ 5 What’s the T to T ratio? A high ratio of  a patients tattoos to teeth may indicate the limited benefits of health education.

#GPFUQ 6 How do GPs change patients behaviour? Slowly and with difficulty. You can’t make someone change, you can only change yourself and how you react to them, that might make them think about change. The first step is to help change the patients awareness of himself.The more patients can change themselves, the more effective doctor I seem. 

#GPFUQ 7 How do you help patients change? Nudging them through each of the smaller steps that lead onto bigger changes. 

The transtheoretical theory of change brought together diverse theories of change and psychotherapy and recognised that people go through stages of change (i.e. precontemplation, contemplation, preparation, action, maintenance and termination) and use different change process at different stages of change ( e.g consciousness raising, social liberation, emotional arousal, self revelation, commitment, reward, countering, environmental control and helping relationships). Understanding and using the stages and different processes helps the teaching and learning process. An overview is available at http://www.uri.edu/research/cprc/TTM/detailedoverview.htm
From the GP point of view it makes like easier because you don't have to succeed in helping with a major change quickly, you just have to help patients with the through the  different stages over a longer period of time. 

#GPFUQ 8 How do you reconcile a long term relationship with giving unwelcome advise? Think hard GP v soft GP  tactics. GPs usually have a relationship with their patients over many years. Now GPs have to advise stricter control in chronic diseases like diabetes. There is a conflict between having a long term relationship, that is empathic, and getting patients to make major changes in their way of life. 

Giving additional training of practice nurses and general practitioners in patient centred care on the lifestyle and psychological and physiological status of patients with newly diagnosed type 2 diabetes demonstrated better communication with the doctors, greater treatment satisfaction and well-being. However body mass index was higher, triglyceride concentrations were higher and knowledge scores lower. There was no significant difference in lifestyle and glycaemic control. The trained practitioners seemed to give greater attention to the consultation process rather than to preventative care (reference 1). In contrast there are stories that when doctors who have no continuity with the patient (eg locums, GPs in other parts of the country, or hospital doctors) give the patient feedback on their lifestyle, the patients remember the feedback and say it made a difference.

For example.....Dr Caresalot counselled one of her patients (Mr Heartsink) weekly for many years without ever making much progress. Dr Caresalot takes a much needed and well earned six month sabbatical to study how to improve her counselling skills so that she can give a better service within the 10-20 minutes appointments that she can actually provide for patients in her practice. Upon her return to her practice she is surprised that Mr Heartsink no longer comes to see her. A year passes and finally Mr Heartsink comes to the doctor. They exchange greetings, Mr Heartsink is well except for a physical problem, shingles. They talk and eventually Dr Caresalot asks why happened that made Mr Heartsink not seek medical attention weekly. Mr Heartsink explains that the when Dr Caresalot was away he came to see the locum Dr Getalife, and the locum had listened to Mr Heartsinks usual list of worries and complaints and told him 'Stop it'  and 'Pull yourself together', and so he had, and only wished someone had said this years ago. So perhaps we now need two sorts of doctors the caring and empathic that helps patients through change, and a more honest and blunt doctor that holds up a mirror and gives the patients the truth about their self destructive behaviour and prompts the patient into changing their way of life. An example of an intervention could be that we target the poorly controlled diabetes patients, from our current knowledge decide what is the most important lifestyle intervention (diet, better tablet adherence, more exercise, switch to insulin) and send the patient an invitation to see our specialist in the management of poorly controlled diabetes Dr Hammerfest. Dr Hammerfest who is not in a long term relationship with the patient gives the patient the truth about the risks to health and very clear instructions about what the patient must do to reduce the risks to their health. The usual GP & team then provide ongoing support for the lifestyle change. The good news is that this is a relatively easy intervention, one consultation per patient, and can be applied to many practices. This style of intervention is already happening with practice nurses running chronic disease management programmes that check a patients treatment against a guideline.

Reference 1: Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. Kinmonth AL, Woodcock A, Griffin S, Spiegal, Campbell MJ. BMJ 1998;317: 1202-8.

#GPFUQ 9 Can GPs make a difference to problems like obesity?  Yes by holding up an honest mirror to the patient (to increase self awareness and choice), and by generally influencing the community so that lifestyle problems like simple obesity are as unacceptable as spitting and smoking. 

#GPFUQ 10 What stops people changing their behaviour? Three elements must converge at the same moment for a behavior to occur: Motivation, Ability, and Trigger. When a behavior does not occur, at least one of those three elements is missing.   More details on the Fogg Behavior model at http://www.behaviormodel.org/

Whats quality in GP?

#GPFUQ 4 Whats quality in GP?  You need all of the the following: great access, best treatments, customers satisfied, depth of caring, efficient & effective, fair to all.

The Quality Cube

Lewis Carroll’s Humpty Dumpty understood the words he used.  “When I use a word, it means just what I choose it to mean—neither more nor less.”  Quality has always had a specific vagueness so its not clear what quality means for most people. General Practice only discovered the word Quality in the 1990s and like lots of concepts it was used with no real understanding. Overtime it lost meaning (e.g. the Quality Outcome Framework) but was a worthy endeavour for a dwindling band of enthusiasts (e.g.  the 3% of practices that completed the RCGP Quality Practice Award). 

The Cheshire Cat said “If you don’t know where you are going, any road will get you there.” Quality is not a destination: it’s a journey of aspiration and achievement rather than completion. It will always mean different things to different people at different times.

The problem with the quality journey is that, although we may know what route we think we need to take, we don’t know where we are going, or when we are going to get there. Guides like the English NHS quality and outcome framework (QOF) are like satellite navigation: authoritative and useful but prone to major errors at critical junctions.

We are not there yet, but over the past 20 years our journey has advanced considerably with more aspirations for outcomes and real achievements in the structure and processes for quality in primary care.  Imperfect as QOF is, it is an example of the vertical advance. Examples of other more horizontal advances include the RCGP Quality Practice Award, NHS appraisals, and the RCGP core curriculum. Rapid advance in any direction is usually  fuelled by financial incentives.

A simple approach to quality as we continue on our journey is to run through an A to F checklist on our dashboard gauges to make sure we are still roadworthy. Always check: A, we provide good access to our service, B, the best treatments are available, C, the customers are satisfied with the service, D, we provide a depth of care, E, the service is efficient and effective, and F, we treat everyone fairly. The reality is that we can rarely keep  all the six gauges of quality optimal. We should recognise both effort and achievement. Practices have very different problems and it not fair or useful to use the same gauge readings or scorecards to mark the achievements of different practices.

Lewis Carroll’s advice: “Begin at the beginning and go on till you come to the end; then stop.”

Will GMC revalidation of GPs assure their quality?

#GPFUQ 3 Will GMC revalidation of GPs assure their quality? No - we only need a few failures to destroy the credibility of revalidation. 

We have started the first cycle of revalidation of UK Doctors in 2013. Now all doctors working in the UK must have passed 'revalidation' by the GMC to continue to be licensed as doctors. The plan is for revalidation every 5 years. The standard needed to achieve revalidation is fairly low and can't assure quality.

So what might be better? There are a couple of options that might drive improvement and greater confidence in quality assurance of doctors. 

1. Annual Maintenance of Competence schemes or 

2. Medical indemnity or GMC fees linked to perceived riskiness. 

Annual Maintenance of Competence

Do we need annual maintenance of GP competence? The US boards of medical specialities have years of experience recertifying doctors competence, and they are shifting from the episodic recertifying examination of doctors competence every 5 -10 years to a continuous maintenance of competence? (MOC) cycle that assures a doctors professional standing, lifelong learning and self-assessment, cognitive expertise and performance in practice throughout the term of the maintenance of competence. The specialist or craft societies (like the RCGP) are not involved in the recertification process and just help members pass the exams. If the GMC revalidation process does not assure quality then this may be our future.

MOC usually has four components:

1. Professional standing is a check that doctors licence to practice is not compromised, and may need references and feedback from colleagues or evidence of institutional appointments.

2. Life long learning and self assessment. Most schemes require continuing medical education hours ranging from 10-50 hours each year. Self assessment is by examinations, tests and educational modules.

3. Performance in practice. This is a challenging assessment of doctors performance. Doctors are assessed for how closely their practice compares with accepted standards of care. This includes assessing confidential patient satisfaction measures, use of evidence based or best guidelines, review of operative records or logs of procedures, office record reviews or audits, practice performance improvement modules, specific board feedback, case based oral examinations, linkage to practice data or outcomes though guideline measures and national benchmarks. The goal is to use the tools and techniques that are credible, valid, reliable, practical and feasible and improve doctors performances.

4. Cognitive Expertise. This required passing an examination within the course of the MOC cycle.

Does all this sound familiar? Most of the MOC components already exist in UK general practice, and only await the full assembly by a competent authority.

Professional standing is tested by DBS (Disclosure and Barring Service) checks, and the annual NHS appraisal. Life long learning and self assessment is included in the annual appraisal process and resultant personal learning plans. 

Performance in practice is very similar to the GP contract markers like Quality outcome frameworks points scheme.

Cognitive expertise is the only component missing and eventually may be a feature in the recertification process. The only debate is what sort of examination will this be? Should we all get ready to take the knowledge test MRCGP examination every 5 years? Is this the future of GP education?

Medical indemnity or GMC fees linked to personal risk 

GMC investigations and hearings are expensive, insurance claims for medical negligence are expensive. We currently have flat fees for GMC registration and fairly flat and similar fees from the providers of medical indemnity. More expensive annual fees for practitioners who can't demonstrate maintenance of competence, or for whatever reason appear to be at higher risk may provide a continuous incentive for improvements inbetween the 5 year cycles of revalidation. 

What's GPFUQ - General Practice Frequently Unasked or Unanswered Questions with some answers

This is collection of Frequently Unasked or Unanswered Questions in General Practice or GPFUQs. 

A few years ago I had a sabbatical to try to discover how to find the best practice faster and spread it faster. My conclusion was to get yourself a better network. This may not be the better network but its a different network.

Whats GPFUQ - General Practice Frequently Unasked or Unanswered Questions with suggested answers. Labelled as #GPFUQ 1, 2 etc. Your Questions, Answers and comments are welcome. I'm hoping that I will find the best questions, the best answers and comments about General Practice aka Family Medicine via this Blog and Twitter. I hope it will gradually grow both in the quantity and quality of questions and answers relevant to improving the care of patients. 

#GPFUQ How do you contribute? Send me your own or new Questions or Answers for FUQ in GP  

#GPFUQ 1 How do you find and spread best practice faster? Find yourself a better network eg via Blogs and Twitter?

#GPFUQ 2 How will we know if the new NHS (post April 2013) is a success? It should be something to do with better access, higher quality and lower cost but we'll never know because there are no winning criteria to achieve. The new NHS will be judged by any perceived lack of success. This makes failure and more reorganisation seem inevitable. What are reasonable ways to measure success ie success criteria for the new NHS?