E20 Health Coaching

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[00:00:06] Munir Adam: Hi guys. Welcome back. It's Munir Adam here and today's episode is on health coaching. And I'd like to start by saying that having had that conversation with Caroline, who is an experienced health coach and leader, I learned loads, and not least that health coaching helps plug what we often experience as being an important gap in the provision of care that we provide to patients.

[00:00:28] And it relates to 'em not following through with the plan that we think we've agreed with them. But the other thing is, although I'd heard about health coaching, I didn't think that somebody who is a busy frontline clinician necessarily needed to know much about this at all. But now I honestly believe that every single one of us needs to know at least as much as is covered in this episode, because it really is relevant.

[00:00:51] Now, we've just completed a series on managing time in consultations. Well, we're moving on from that now, but this episode is certainly in part about conducting more effective consultations. So it's certainly worth a listen. And so made possible by support from Integrated Care Support services, link in show notes, let's continue season two of Primary Care UK. 

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[00:01:28] Munir Adam: Okay, thanks for joining. And actually what I wanna do is start by taking a bit of a risk, really in the sense that being somebody who knows very little about health coaching, I mean, I just remember somebody talking about a health and wellbeing coach, and they've been talked about for maybe just a few years, but I've never really got to know what it's all about.

[00:01:47] One of the things that I've noticed in primary care is that, you know, there's so many things that we say, and then we never do those things. And there's something about maybe the traditional health professions, and by that I suppose, I mean doctors and nurses. We feel that we know what's right for any given patient, at least some of the time. Yet we find that many a time they just don't carry that through. 

[00:02:09] And actually, you know what? If I see myself in the patient's role, I'd probably be just the same. You know, I've been to my GP a couple of times, thankfully for minor things, but have I always followed their advice to the word? 

[00:02:21] Therefore, every time I hear about a different role, it fills me with a bit of excitement. Here's somebody who's going to somehow address that. The risk is, I know so little about this. I dunno what I've just said is actually of any relevance to this episode or not, and we'll find out at the end. 

[00:02:36] But, but can I ask you to start by just introducing yourself, your role, your background, and then maybe saying something about why you got into this.

[00:02:46] Caroline: Brilliant. Thank you so much. So thanks for having me on to talk about health and wellbeing coaching and the impact it can have with patients. I'm really passionate about this role and I see it as a huge asset to primary care. So, my name's Caroline. I'm a health and wellbeing coach and supervisor at Leatherhead PCN in Surrey.

[00:03:04] I've only recently started there actually, and prior to that I was the health and wellbeing coach, network manager and mentor looking after all of the coaches in London. So the objective of that role was to create a real network of coaches in London .

[00:03:18] And prior to that, I was a health and wellbeing coach in East Merton PCN in southwest London. I haven't always been a coach though. My background prior to the NHS was in banking and finance, spent around 16 years in that industry, so totally different to what I do now. And it was brilliant. You know, I made lots of good friends, learned many valuable skills. But after 16 years, I always knew I wanted to do something a bit more fulfilling. And I've always been into nutrition and fitness and taking a holistic approach to health. And I always thought I wanted to be a nutritionist. But whilst I was in my last job in banking and finance, I had career coaching, and, now, if you've never experienced coaching, then I urge everyone to try it because it's truly transformational. It's such an , empowering experience, and I just totally fell in love with coaching and that's when I realized that I could combine coaching and my interest in health.

[00:04:18] Munir Adam: And you know, you wouldn't be the first person to say that you found coaching so amazing. And I've had quite a few senior and junior colleagues who have recommended it as well. But actually hearing that you have these roles, supervising overseeing and developing this role is gonna help me understand the next bit, which is where has it all come about from?

Why we need health coaching?

[00:04:36] Munir Adam: You know what? Let's start with basics. What is health coaching?

[00:04:40] Caroline: So health and wellbeing coaching in the NHS has been around for about four years or so. So really in the grand scheme of things, we are right at the beginning of that journey. Of course, things are still evolving and embedding, and of course there's still many practices and PCNs that don't have health and wellbeing coaches.

[00:04:58] And there's also still places that have health and wellbeing coaches where the other clinicians and other staff still maybe don't understand what they do or how to utilize them in the most effective way. And, you know, this is all to be expected and this is why things like this podcast is, is so important , to help with the understanding of the role and knowing how you can utilize them and the best way to help your patients.

[00:05:22] But I guess kind of going back to the original question, so why does the role exist in the first place? Well, I'm gonna give you some surprising stats here. So, most patients, well over 50% don't understand the clinical information given to them in a consultation.

[00:05:37] Munir Adam: It's, it's worrying, isn't it, that it's so common, and yet we've done so little about that over the years.

[00:05:44] Caroline: I mean, we're starting to do things about it. I think this, this is where this role is born from really. The annual cost of NHS primary care medicine wastage is 300 million, and 70% of NHS spend goes are managing long-term conditions. So all of these factors really point towards the need for more behavior change focused conversations, and that's exactly what a health and wellbeing coach can help with, with behavior change.

[00:06:13] So, I'm sure as a GP over the years , you might have felt frustrated, perhaps, or annoyed because you can see someone's lifestyle is affecting their health. But in a seven to 10 minute clinical conversation, there's not much, you know, you can't really have those in-depth conversations that might help someone to unlock their motivation and understand what is really keeping them stuck in these behavior patterns.

[00:06:37] So, for example, you might see a patient who's putting on weight and you might see them yeah, over a number of years, and they keep on putting on weight. You might give them some information about weight loss or some resources on healthy eating, but when you see them the next time, you can see that they've struggled to lose weight.

[00:06:53] And this is a patient who might really benefit from seeing a coach. , I'm sure you can think of examples of patients where lifestyle has really played a part in their health challenges, but however much you encourage them to change, you can see that they're finding change difficult. 

[00:07:07] This is in no way like blaming people for this. You know, I'm very sure we can all name a number of changes we've all tried and failed to make, or perhaps you've been wanting to do more exercise or eat less sugar or drink less alcohol or go running each morning before work but for some reason you can't quite make yourself do it.

[00:07:26] Munir Adam: Absolutely. I mean, with me it's chocolate.

[00:07:29] Caroline: yeah.

[00:07:29] Munir Adam: I guess everybody has something that they just can't let go of.

[00:07:32] Caroline: Exactly. Yeah. And you know, maybe it's not such a priority in their life for them to make them do it. But sometimes your health gets so bad that you really do need to pay attention to these things. And you know, weight loss is a great example because we've all probably tried to lose weight or know someone who's tried to lose weight, sometimes successfully, sometimes not.

[00:07:51] You know, we've probably all made New Year's resolutions that we've not managed to stick to, even though, you know, we made them with the best intentions, , we all like living in this comfort zone and it's safe in our comfort zone, even if we know that it's not quite where we want to be.

[00:08:08] Munir Adam: Yeah, absolutely. In many respects, what you've just said actually reminds me of an episode we did on lifestyle medicine. Yeah. How, how would you define that? What would be the main differences between this and lifestyle medicine? Um.

[00:08:22] Caroline: Yeah, so there's similarities in that they're both quite holistic. Um, but my understanding is that lifestyle medicine is still prescribing a solution. So it's advice abeit holistic and more natural advice than let's say prescribing a drug. Um, Conversely, health coaching is not giving advice. It's non-directive, meaning the emphasis is on helping individuals to identify their own resources and find their own answers and solutions.

[00:08:50] So it works on the basis that the individual being coached knows their own life better than anyone else, and they are resourceful and capable, given the right support they can find the way forwards. So, you know, if you were having a conversation with a friend and describing a problem. You know, you might say, I've got this problem and this thing is happening, and I'm, you know, feeling bad about it.

[00:09:14] And you might say, oh, well I heard that this is good for it. Why don't you try it? Or, my neighbor tried this and it really worked for her. Or if it were me, I'd do this. And the problem with this approach is that you are just giving more information. You know, there's a wealth of information out there.

[00:09:31] We're living in the age of information overload. So the tips of our fingers, it's carried around in our pockets and our smart phones, and a lack of information is probably not the problem. Being able to implement the information is usually the problem. Sometimes why we can't implement the information is because of some sort of kind of underlying emotional reason.

[00:09:54] For example, I've seen many patients who are trying to lose weight, but in the past they found themselves overeating when they're not hungry. Now the problem isn't the food. The problem is that they're using food to change their emotional states. You know, it's natural not to want to feel painful and emotions, and an easy and quick way can be to change how we feel temporarily by eating or drinking.

[00:10:18] Now, This isn't necessarily a problem if it happens occasionally, and we're not trying to lose weight, but if we are feeling tough feelings frequently and our default coping mechanism is to eat, then this does become a problem. So you can see in these instances that the weight is just a symptom of something else going on, and in this case it's emotional pain.

[00:10:36] So with patients such as this, a healthy eating plan or more information, giving them a diet is gonna be hard to stick to. What they need to do is understand why they are emotionally eating and what is that emotion? Let's unpick that. And alongside that, think of some new coping strategies that don't involve food and working on self-care and self-esteem.

[00:11:00] Munir Adam: Okay, so that's really helpful way to distinguish between lifestyle medicine, which I, if I understand correctly, is a very holistic approach to the patient, which again, is something that we don't or are not necessarily able to do in our 10 minute consultation, versus actually digging right into the depth of why a patient may or may not be able to do something that they should be doing, or they feel that they should be

[00:11:23] Caroline: Yeah, exactly that.

[00:11:25] Munir Adam: And actually, the other thing that I'm hearing from you, even if we just look at obesity and nothing else that still justifies the role, but overall, what is the scale of the problem that we're trying to address by health coaching?

[00:11:40] Caroline: I mean, health inequalities is a big conversation at the moment, isn't it? So just as a bit of background, and I'm sure you'll know all of this, but in England there's this relationship between deprivation and life expectancy. So if you live in a deprived area, your life expectancy is shorter. For men, I think this difference is around nine years and this, this is getting bigger, this gap, so, One of the other measures looked at in healthy inequalities is healthy life expectancy, which estimates the time spent in good health. And the gap in healthy life expectancy is huge. So for example, people living in the least deprived areas could expect to live almost two decades longer in good health than those in the most deprived areas.

[00:12:24] And people's behavior is a major determinant of how healthy they are. So smoking, poor diet, physical inactivity, harmful alcohol consumptions are all leading risk factors that drive preventable ill health and behavioral risk factors are more common in deprived populations. 

[00:12:42] So this is a huge problem and incredibly complex and obviously needs a multiplex strategy to start to reduce these rates. But health and wellbeing coach can be a part of this work though. As you know, we work with patients who are living with conditions such as obesity, type two diabetes, cardiovascular disease, depression, anxiety, which we know are higher in deprived populations. So it's, you know, a tiny bit of the puzzle.

[00:13:08] Munir Adam: But a very important component nonetheless, because what I sometimes hear people say is, yes, I know I should be having healthier food, but chicken and chips is just so much cheaper and so more accessible to me given my other priorities, which are far more important and I can't afford this, and so on.

[00:13:26] Finally, we have somebody who's actually gonna go into that and say, if I understand this correctly, yeah, we're actually, we're gonna have a conversation taking that into consideration.

[00:13:35] Caroline: Yeah, absolutely.

What a Health Coach does and why it works? 

[00:13:36] Munir Adam: So the next thing I want to ask is, what is a health coach? How, how do you get to that point? What is, what kind of a background would you have?

[00:13:44] Caroline: So a health coach facilitates a reflective learning process that aims to grow an individual's awareness of their condition and responsibility for their health, and the choices in the changes that they make. So a health and wellbeing coach can help patients to change their behavior, to reach a health goal based on what matters to them, can help them to increase activation, become empowered to take control of their own health and improve their health and feel better by making diet and lifestyle changes. 

[00:14:16] And the aim with seeing any patient is to help them to become self-supporting so that by the end of their sessions they have the knowledge, skills and confidence to become active participants in their own care.

[00:14:28] So, as I said earlier, they're not there to give advice. So health coaches aren't dieticians, for example. And the reason why I mentioned that in particular is because a lot of the time using the obesity example again, that is how it's sold to the patient. So, you know, go and go and see Caroline. She'll give you advice on what to eat.

[00:14:47] However, You know, a lack of information is isn't usually the problem. You know, if you think about all of the millions of diets out there and the wealth of information that we have, if someone wanted to find a diet plan, they could very easily find it. A lot of the time doing these detrimental health behaviors is not because people don't know what's good for them and what's not good for them, it's because of some other underlying reason.

[00:15:10] So, You know, for example, I'm sure you know about the correlation between childhood experiences and adult obesity. You know, that's a really good example of how this underlying stress can cause obesity in later life. 

[00:15:24] Patients living with obesity often feel judgment because of their weight. And I've had many patients say that they felt really patronized because people have told them to like eat less and exercise more, which is very reductive and, and, and not really helpful. And this is where our health and wellbeing coach can help because. This person doesn't need another person telling them what to do or implying that they're lazy.

[00:15:45] They need someone who's gonna listen to them, understand what's really going on, and walk beside them and support, challenge them to find solutions.

[00:15:54] Munir Adam: Mm, so I'm not gonna tell you what to do cuz you probably have already heard it a thousand times. I'm gonna help you to do it.

[00:16:01] Caroline: Yeah, exactly.

[00:16:04] Munir Adam: Such an important gap being filled there.

[00:16:06] Caroline: Yeah. And. Another problem is that patients come with low motivation to make a change. And health and wellbeing coach can really help people to kind of unlock their motivation. So sometimes people will come to their first appointment and I might ask them why they want to lose weight. And many people will say, well, because the doctor told me I needed to.

[00:16:26] And you know, this extrinsic motivation is never gonna keep someone going when things are hard. And you know, we know it's hard to make changes. And what a coach can do is help people to understand why they want to make a change. What's their intrinsic motivation? So the first answer might be, I'm here because the doctor told me to be.

[00:16:43] But actually, if you keep kind of unpeeling the layers of the onion and asking why, what's important to you about making this change? Then they will always get to the root of the motivation and usually it's to do with, you know, connection or relationships or love. 

[00:16:58] And, you know, a a nice example of that is I had a patient who wanted to lose weight, and when I asked her why, you know, she told me that she doesn't wanna be fat anymore. And I, and I kept asking and we went through a number of iterations and, you know, she kept on saying things like, I don't like my tummy. I don't wanna be the fat one anymore. And then it kind of moved on to things like, you know, I want to be able to move around more easily. I don't wanna feel all these aches and pains. And, and then the last reason was we kept on at this, the last reason was, I want to be able to look after my grandson and I wanna be able to play football with him in the garden. And this is intrinsic motivation that really matters to people. And helping someone to understand that can be really powerful.

[00:17:40] So rather than using shame to motivate themselves, so, you know, I, I hate being fat. This sort of motivation is kind of counterproductive and it damages self-esteem and it contributes to poor mental health and poorer outcomes. So really unlocking that intrinsic motivation that's really important to people is, is key as well.

[00:17:59] Munir Adam: Oh, so I see what you mean now by peeling the layers of the onion then, and you're getting right to the core of it. 

[00:18:06] So why does health coaching work? I.

[00:18:09] Caroline: So it works because we can challenge patients to have new insights about their current situation, so we can help them to challenge beliefs that they might have held for many years that are holding them back. 

[00:18:21] For example, I had a weight loss patient who had tried many, many restrictive diets over the years. And she told me she was always on diets and she would lose weight and then she'd put it back on again. And the underlying message I could hear from her was frustration that she felt like she tried everything. And she also kept on mentioning that she found diets difficult because she was greedy.

[00:18:43] And we started to explore that topic of her saying that she was greedy. And I, I encouraged her to start questioning this because the thing with beliefs is that we believe them to be true and as humans, we like being right, so if our belief is that we are greedy, it's very difficult to act in opposition to this, and we'll only notice when our actions supports this belief. So every time she ate more than she thought she wanted to, she would be adding this to this bank of evidence in her mind, which supported her belief. 

[00:19:17] And actually once she recognized this as a belief and started to question if this was true, she could see many times when she acted in a way that was not greedy. So, for example, sticking to all of the many restrictive diets, you know, that's not greedy. In fact. That is exercising huge amounts of control over food that many of us, myself included, could never do. And in actual fact, she realized that the restrictive diet cycle was actually creating this belief in herself that she was greedy because they were so restrictive that it was difficult to stick to long term.

[00:19:50] So, for her starting to question this belief and this thinking pattern gave her the insights that this pattern of behavior was destructive, not just to her physical health and to her weight, but it was also damaging her mental health because it was making her feel like a failure and that she was greedy and that therefore could never succeed at this.

[00:20:09] Once she, she'd had these insights, she decided to change her approach to weight loss. Previously she had wanted to lose weight quickly and she'd do anything to get there, you know, but then, After that, she changed her goal so that it wasn't focused on losing weight in a certain time period, but rather to eat nutritious and healthy food and find some stability.

[00:20:30] And if that resulted in slow and stable weight loss, then that was a kind of side benefit. And she also focused on that self-compassion and being kind to herself, which in turn benefited her mental health. So, a lot of the times these beliefs are at the core of why we struggled to change. It's kind of this underlying narrative that is, you know, underlying when people are telling you a story, you can kind of pick out these reasons why their finding it difficult. 

[00:20:57] Another example. Is I had a diabetic patient who was referred to me and, uh, cuz her HbA1c levels were really high and rising and she had had diabetes for many, many years. And on the first sessions she said something to me that was really illuminating. She said, well, I'm never gonna be a good diabetic. Whatever had happened on her diabetic journey had contributed to her believing that she couldn't achieve this good diabetic status, whatever that means.

[00:21:25] What she had was this belief that she couldn't do it and. Obviously changing beliefs, especially beliefs that have been there for many years you know, it's not an instant fix. So me saying, yes, you can be a good diabetic, you know, that's, that's not gonna change someone's belief.

[00:21:40] There was this just underlying narrative that had been going on for ages of, you know, I'm not a good diabetic cuz I have a family history. I've not managed it before, my blood sugars are going up. And so what we did was work on building up a counter bank of evidence to support her that she could do this, that she could be a successful diabetic, and also that she could define what a good diabetic was.

[00:22:02] So, each session I asked her to define some small changes that she could make that were achievable, you know, given all of her other responsibilities. And what this did was stop building up an evidence bank that she supported her belief that she could do it. And. What a coach does is hold that belief for the patient that they can do it, that they are resourceful, they can find their own solutions, and it gives people this confidence in their own abilities.

[00:22:27] And very slowly, she got to a place where her HbA1c was, was coming down and she was at this place where she was happy with how she was eating and feeling, and she was happy and confident in the way forwards. 

[00:22:40] It's important to note that in alignment with personalized care, a coach will never tell the patient what changes to make. You know, they obviously know their lives much better than anyone else, so it would be way more likely that it would end up in failure if I did tell someone what to do. Someone coming up with their own action steps builds up the person's confidence in their own ability to self-manage. So you know, this patient, once she was connected to that and she realized that she was in control of defining the root forwards and what her version of a good diabetic was, she made progress really easily, having been stuck with her HbA1c rising for however long prior to that, and she turned it around pretty swiftly. So it was just a case of having the right conversations to support her.

The Health Coaching Consultation explained

[00:23:25] Munir Adam: Right. Well, I'm, I'm convinced. I've got a patient, well, many patients who could benefit from health coaching. How would I go about making a referral? Where, where would I find a health coach?

[00:23:37] Caroline: Health coaches work in primary care. Um, and there are many different ways of referring into a health coach if you have one in your pcn. And different PCNs will use different methods such as clinicians referring directly into the service when they see a patient who's eligible, or perhaps the diabetes nurse might be the main referrer depending on the cohort of patients that you are targeting. Patients can be targeted proactively as well using Emis searches and different filters or criteria and sending out text messages for people to opt in. Um, self-referral is also a route that can work really well. So, for example, have some information on your website explaining the service and having a form there that people can fill in if they'd like support.

[00:24:19] And this can be a really nice way to get great engagement with the process because people have decided proactively that they want to make a change already. Sometimes the reactive methods bringing people with lower activation, which isn't necessarily a problem, but when they come to a health coach, that means that the health coach has to work extra hard on increasing someone's intrinsic motivation for wanting to make a change. 

[00:24:41] Munir Adam: It must be better for those who are referring themselves in. Is that doable in primary care normally? Can we do that or does it have to be a referral based?

[00:24:49] Caroline: No, people can self refer easily. I mean, if you put the information on your website, obviously it may means a change to your website which in my experience hasn't been that difficult to do

[00:25:01] Munir Adam: One less form for me to fill in.

[00:25:02] Caroline: Yeah. 

[00:25:04] Munir Adam: Okay. Now you did say a little bit about the example you gave earlier about that particular patient, and peeling those layers of the onion was a really good one. It'd be nice to hear a little bit more about what's actually going on and what's gonna happen to my patient once they're referred in and see a health and wellbeing coach.

[00:25:19] Caroline: So health coaches usually see patients for a series of appointments, and the appointment length might be an average of 45 minutes or, or sometimes longer. Um, so it's much longer than an appointment that they would have with another clinician. It's really future focused. So we might start with exploring what is it that the patient would like to be different and creating a goal for them to work towards.

[00:25:43] So the patient is in charge of the goal, irrespective of what the referral reason is. So for example, they might have been referred for weight loss, but actually, they feel so stressed at the moment that they're not sleeping and their relationships are suffering and they can't focus at work. So they, what they actually want to do is focus on reducing stress levels and when they're feeling better mentally, they might feel ready to make a weight loss goal after that, but actually will make a goal based on stress.

[00:26:10] And we usually try to define a smart goal, which means creating a goal that's specific and stated in the positive. So I want this rather than, I don't want that. It's measurable so they can track their progress, actionable, realistic, and timely.

[00:26:26] And once we've defined the goal, the coach would guide them through a series of questions to find out what's really going on for them. What's the reality? What have they tried so far? What haven't they considered? What assumptions might they be making? What else might be going on; many times we might cover sleep, stress, exercise, mental health support structures, family and home life work. So we do really take that holistic view. Then we might ask them about all the various options available to them if they wanted to make some changes.

[00:26:59] And this part of the coaching session always surprises me because everyone's preferences or options are always so different. I had a patient once when we were talking about exercise and what he could do, and he suggested that he could walk up and down the garden. And in my head I was thinking, well, that sounds really boring. You know, I could never make myself do that. So I would find that, I would just find that so boring. I know I wouldn't do it, but that was the thing that he decided to do for various reasons. And because this was a solution that worked for him, he managed to do it every day and he started you know, feeling just a little bit better because of it.

[00:27:34] And then he decided that he could move on to walking around the block and, and then he started jogging around the park. And then he even started playing football with some friends. And this was someone who was so anxious previously that he'd barely left the house and he spent most of the day on the sofa.

[00:27:48] So if I'd said at the beginning, why didn't you try park run or walking each morning? There's just no way he would've gone for it, but because he came up with a solution that was right for him and one that he could stick to, you know, he went with it and he, you know, it had this ripple effect in, in his whole life.

[00:28:05] And what we wanna do is kind of expand someone's comfort zone just by a little bit. Otherwise it's kind of too scary or too overwhelming. Finally, once we've discussed the options available, we'll ask the patient to come up with some action steps. This part is really important to spend some time in, and we want to ensure that the patient has made a plan that is realistic and achievable given everything else going on in their lives.

[00:28:27] So, If they've said they're gonna go to the gym three times this week, then what does that actually look like? What days will they go? What time will they go? How long will they spend at the gym? And the reason why I ask 'em to be specific is because if they fleshed out all of the details, then all they need to do is carry out the plan instead of deliberating, you know, every day like, do I wanna go to the gym? Can I be bothered? Am I gonna go today? No, maybe I'll just go tomorrow. You know, it's got rid of all of that stuff.

[00:28:54] Munir Adam: Yeah, A and also it gives you something appropriate to measure. Cuz isn't it very common for patients to adopt some sort of healthy lifestyle in the hope with the, the explicit target of losing weight. And then if they're standing on the scales and the weight hasn't gone down, they feel that they haven't achieved anything.

[00:29:09] Caroline: Yeah. Yeah. So it's just making those tiny changes and helping them to feel confident that they can do this rather than, you know, overhauling everything. It's making sure that these mini action steps are ones that are achievable for them and, you know, that can build up their confidence so that they can make a change and make them really feel like they're capable of doing this.

[00:29:27] Munir Adam: And I have to admit, I've been guilty many times of thinking that I'm suggesting something in a very sensible, incremental step, but actually not taking into consideration their paradigm. And so I might speak to somebody and advise them about starting by walking to the local shop and then build up gradually.

[00:29:44] And I think I'm doing it in a very caring and considerate and stepwise manner to make it doable and possible. But actually the example you just gave now, how am I to know that perhaps the right way for them is to start by walking up and down their garden? And then, you know, they'd have the, the ownership of that because they've prescribed the solution.

What to refer to a Health Coach

[00:30:03] Munir Adam: Okay. So is weight management the main area that is covered or are there other chronic conditions that would be managed by health coaches as well? Um,

[00:30:11] Caroline: Patients can be referred for anything that requires behavior change or lifestyle change to improve their health. So common referral reasons are obesity, type two diabetes, stress, cardiovascular disease, hypertension, anxiety, and depression.

[00:30:26] Munir Adam: Anxiety, depression, stress. Okay. Wow, that, isn't that more the realm of a psychologist?

[00:30:33] Caroline: The key is to make sure that it's low level anxiety and depression, and sometimes this is hard to determine and you know, especially if you've only got a really short appointment time with them. Um, but if someone's just feeling a bit stressed or they've got a bit of anxiety, but they're not severe enough to refer onto specific mental health services, then a health coach would be a good option for them. But , sometimes people do come through the net that actually should have gone to IAPT or community mental health...

[00:31:02] Munir Adam: But, in terms of the kind of support you'd be giving, would it be different from what maybe a psychologist or a counselor would do?

[00:31:08] Caroline: I, I guess it's similar, but it's, , it's more future focused. So if someone came with anxiety, You'd ask them to make a goal for a, for a start. So, if their anxiety was causing them to do things differently in their life, you could ask them to make a goal about how they wanted their life to be different.

[00:31:27] Um, just have really small steps to get to that goal. So it would work in a similar way to any other goal. But, if someone's got really severe depression and anxiety or other mental health challenges that you know, they need to see someone who is much more specific with mental health.

[00:31:43] Munir Adam: Yeah. Okay. Well, I can certainly see that role as being complimentary to the other service then,

[00:31:47] Caroline: Yeah, and some, sometimes this role can work really well alongside someone who is seeing IAPT or something.

[00:31:55] Munir Adam: Just one more question on in terms of what's actually going on during the session. Do you sometimes find yourself in a situation where they actually don't have the motivation to change? And so I'm here because my doctor told me about I really can't be bothered. What would you do in that situation?

[00:32:11] Caroline: Yeah, I mean, yes. I mean, if someone really doesn't have the motivation, they won't turn up to the appointment. If someone doesn't have the motivation, and those health challenges are really, affecting their life, usually they do have the motivation, but sometimes the defenses are up because they have been made to feel like it might be their fault or they should be doing more, or I don't know, for whatever reason.

[00:32:36] Sometimes the defenses are up and then, it's really kind of working on that rapport and making them feel safe and it's non-judgmental and you know, whatever, I'm not gonna tell you what to do. And, and usually those defenses will come down and then they will start talking and, you know, actually you can usually unlock that motivation, you know, help them to understand why they want to change rather than telling them they should change.

[00:33:01] Munir Adam: That is just so amazing because this is about making them realize that when they say they don't wanna change, well actually they do want to change. And you can facilitate them, get to that point of realizing that they do

[00:33:13] Caroline: Yeah.

[00:33:13] Munir Adam: and then actually help them to change as well. This is very patient-centered cuz it's entirely driven by their inner psychological state, their motivation, their interests, what they wanna achieve, their goals and the anecdotes that you share are very convincing.

Evidence for Health Coaching

[00:33:27] Munir Adam: But when you look at the hard data, does it support health and wellbeing coaching? And is there evidence of the benefit that can result from this?

[00:33:36] Caroline: So, unfortunately there's not loads of data to prove this works as this is so new in the NHS at the moment. You know, there's, there's loads of case studies and anecdotal evidence, but no large scale quantitative studies to back up the claims that this is a good thing. There are many studies of coaching in other workplaces outside of the N H s, usually in the context of managers taking a coaching approach with their team members.

[00:34:01] And these studies have shown that those have been coached perform better than those who haven't been coached. Um, but these, you know, principles of coaching hold true, no matter the situation. It's easier to change your behavior when you have the support of a coach, whether that's in health or whether that's at work or in life.

[00:34:19] I had one patient tell me that this was the best thing he'd ever done. You know, he never could have believed he could have achieved the things that he had achieved. And he told me he had always felt like a bit of a failure. And then when he made all of these changes that added up to something huge and the benefits were not just to his physical health, but his to his mental health and confidence too.

[00:34:37] And, you know, there's countless examples and anecdotal evidence, but there isn't a, a kind of definitive quantitative study that has happened in the N H s yet, unfortunately, or not that I know of anyway.

[00:34:51] Munir Adam: Well, as you say, it's early days and I'm sure that will come into your course. 

[00:34:54] How do we get it right? What would you say are the eligibility criteria? What are the situations where we should, and equally, what are the situations where we shouldn't refer? You already referred to not referring perhaps acutely psychiatric patients.

[00:35:11] Caroline: Yeah, so anyone who wants to make a change but has struggled to do so in the past is a good candidate for health coaching. Unfortunately but understandably, sometimes people are referred to a health coach as a stop gap to other services cuz they have really long waiting lists. You know, or sometimes people are referred because they keep turning up to the practice and they dunno what else to do with them.

[00:35:32] You know, These people have some sort of unmet need, but coaching isn't necessarily the solution. 

[00:35:38] Munir Adam: Yeah, that partly addresses is our unmet need as clinicians as well. Sometimes we really ask, talk, here's somebody we can refer you to.

[00:35:45] Caroline: Yeah. And, and people who should not be referred are those with serious mental health challenges and those with alcohol or drug dependencies. Different PCNs will have different criteria for referral depending on what cohorts of patients they'd like to focus on.

Nothing to lose - the Change model

[00:36:00] Munir Adam: Any downsides to it? What have patients got to lose by attending for health coaching?

[00:36:05] Caroline: Well, there no side effects of coaching like there might be with prescription drugs. So in that safe sense, it's really safe, even if it doesn't work for someone and it's not gonna work for everyone. There really isn't any danger to someone using the service. Even if the person doesn't make any tangible changes, the coaches no doubt sparks some thoughts, and I'm not sure if you're familiar with the stages of change model, but people go through a number of stages when making changes to behavior, and the first stage is contemplation where people aren't considering a change, they might be in denial. The second stage is contemplation. They become more aware of the benefits of making a change, but the, the cons of making the change, time, effort, fear of failure, et cetera, may stand out and this might create this kind of conflict, meaning that this stage can last months or even years.

[00:36:57] And the third stage is preparation. So the person might make a plan and think about how they might go about it. Fourth stage is action, and the fifth stage is maintenance. So even if the person doesn't make any tangible or physical changes, they've usually moved along the stages of change. They might have moved from pre-contemplation to contemplation, to contemplation to preparation.

[00:37:18] And this is a change. This is something that might not have happened. So the changes don't always occur when the person is seeing the coach, they may happen after. And those that do make changes, many times, they'll have the confidence to continue making changes long after they've seen the coach because you know, it's a change of mindset.

[00:37:36] And I guess going back to the original question. The only downside of employing a health and wellbeing coach that I can think of is that even though the practice or the PCN gets the salaries reimbursed through the ARRS scheme, there's still effort and time spent managing the coach, training them, finding room space and laptops, and all of the admin, you know, and that shouldn't be underestimated.

[00:37:59] To embed a coach into the PCN takes time and effort. And a change to the way that people work. And you know, as we know, most people don't like change. So you know, that's not to be underestimated.

[00:38:12] Munir Adam: Yeah, it's because we have changed so much in the NHS that we start to fear it, reorganize everything, do things all, all over again. Just when you get the hang of something.

[00:38:20] Caroline: Yeah. Understandable.

[00:38:22] Munir Adam: Yeah, it's great for the patient that they may change many, many months after they've had their health coaching, but it's a bit of a shame really for the health and wellbeing coach, isn't it really? Cuz you might not necessarily always see the benefits of your contribution. You may never get to see the outcome of that, which is.

[00:38:40] Caroline: Yeah, it's, it's certainly hard to measure. I mean, lots of people make changes, big changes, and you can measure that in weight or BMI or cholesterol or, you know, the. Blood pressure, you know, they're quite easy measures and you can see the differences. And HbA1c is a really good measure as well, especially if they've been referred for, you know, out of control diabetes, they're really easy things to measure, but a lot of the time, it's more of a mindset change and that's much more difficult to measure.

[00:39:09] Munir Adam: I think that as health coaches settle in and stay long term in, say, a particular P C N. Then the one could develop a system of giving that feedback to that particular member of staff by the clinician that actually sees that change many, many months later; can see what's worked. Yeah. Nice to, nice to hear that.

The Health Coach experience?

[00:39:29] Munir Adam: So who can actually become a health coach? Do health coaches have a particular professional background or training from scratch or? Is a health coach, somebody who maybe worked as a different type of clinician before you? You shared your background presumably health coaches don't normally come from the banking industry.

[00:39:45] Caroline: No. So it's really varied actually, in terms of all of the coaches that I've spoken to, because it's so new. It's, it's unlikely when you employ a health and wellbeing coach that they've been a health and wellbeing coach somewhere else in the nhs. So the, the variety of backgrounds is huge. There's lots of kind of other people that have come from different parts of the nhs, but in different roles: nutritionists, personal trainers, um, but really a health coach. When I guess if you're trying to employ a health coach, you want to look for someone who's skilled or knows about motivational interviewing, active listening. You know, they're really interested in behavior change, a good communicator. They build up rapport quickly. They're empathetic and kind and reflective, and they recognize what matters to people rather than kind of seeing what's the matter with them. Really non-judgmental and self-aware. What they need to do to become a health coach in the NHS is a PCI accredited training course, and that's a four day course, and they need to do that before they start seeing patients.

[00:40:50] Munir Adam: That's great. You've just spelled out exactly what any listener who's thinking of taking this on, what to put on their CV and what training to do as well. I'm sure we'll get lot more health coaches coming on over time because it's just so Im important. 

[00:41:04] This is probably quite a rewarding role, certainly when you can see those changes.

[00:41:10] Is it? Do you enjoy your role?

[00:41:12] Caroline: Yeah, I love it. It's, it's a real privilege being let into people's stories cuz people share these vulnerable thoughts and feelings and things they may not have told anyone before. And you know, they say things like that, you know, I've never told anyone this before and you know, You think, God, you've been carrying this around for kind of 40 or 50 years.

[00:41:31] And it's really rewarding to see people have an insight or a realization or a transformation. And I know that coaching's changed my life for the better, and I'm confident that my coaching has also changed people's lives as well. And yeah, it's, it's very rewarding.

[00:41:46] Munir Adam: When I hear about something new in the health industry, first thing I think is about myself, can I improve my health from this? But, but sometimes, Do you not come across patients where you just feel you're helpless? The things just can't change, and, and, and then does it become stressful?

[00:42:00] I know our, our job often becomes stressful especially when it's things that are outside our circle of influence.

[00:42:07] Caroline: Um, I guess the, the stressful part comes when you hear of people telling you really awful stories, things that they've experienced and you think, you know, well, no wonder you've got these health problems. You know, if I'd experienced what you are experiencing or what you have experienced, then it's completely understandable and you know, that can be really sad, I guess distressing rather than stressful, really.

[00:42:34] I think most health coaches that I speak to get huge enjoyment out seeing patients and helping them on their journey. And I guess that's the kind of easy and enjoyable part. But you know, there's, there is teething problems with the role and there will be teething problems with the role because it's new and, but sometimes there's, you know, things like incorrect referrals, or not enough referrals, or too many referrals or coaches feeling isolated, especially if they're working virtually, you know, not feeling valued, not having enough support, having too much autonomy, or not having enough autonomy and., Not getting supervision. And these are problems that, um, won't be present in many practices, but, but sometimes are.

[00:43:17] Munir Adam: And, and could affect any profession, but I'm just adding those things onto the CV now that we talked about. So empathy, resilience, and assertiveness.

[00:43:27] Caroline: Yeah, absolutely.

Health coaching expansion in the NHS

[00:43:28] Munir Adam: Okay, so that's a bit about what a potentially interested person should do, but how much of a demand is there for the role in terms of availability and funding?

[00:43:39] Caroline: Yeah, so the role has been adopted, but it's definitely still scaling. There are far fewer health coaches than social prescribing link workers, for example, who are also a personalized care. ARRS role. This is no doubt because the link worker role has been around much longer. You know, they're both valuable and vital roles that work really get well together.

[00:43:59] But, they're part of the ARRS role scheme. So sometimes PCNs will choose to spend that money on other roles. You know, there's loads of different roles they can spend on. So it just depends on what their priorities are really. I know that there's around 80 coaches in London. I don't know about, I dunno the exact number in England, but I know that Devon and Cornwall are really leading the way in terms of numbers of health coaches.

[00:44:21] They've definitely got the most in terms of, you know, the, the spread throughout the country.

[00:44:25] Munir Adam: Hey, well done to Cornwall and Devin. Yeah, that's a nice shout out for that. And I think that's great and it's important to hear that because we need to learn from different areas and see how we can improve and get the priorities. 

What YOU can do in your consultation

[00:44:37] Munir Adam: Okay, let's now think about the busy frontline clinician who will be encouraged to referring patients for health coaching where such a services is available. Perhaps if there are those listening who actually have some influence, they can help develop those services and make that possible. Maybe if it's a senior GP or a PC N director, but many of us, we still have our busy day-to-day work. What is it that we can do within the confines of our 10, 15, or 20 minute appointment to make that difference?

[00:45:08] We're clearly not gonna be able to provide the sort of expertise that you would in that respect, but is it just a case of referring or are there small things that we can also do?

[00:45:18] Caroline: No. So anyone can take a coaching approach in their role, whether they have a health and wellbeing coach or not, and there are other shorter courses that will allow anyone to learn some coaching skills to utilize within their role. 

[00:45:31] I guess taking a coaching approach within your role can increase a patient's sense of personal responsibility for their health and reduce their levels of stress through an increased feeling of personal control and increased self-confidence. And it's incredibly empowering. It keeps people engaged in their care, so it's really important. I guess coaching is based on this innate belief that the individual being coached is the expert on themselves and their scenarios, and that they already have the answers they need. And the role of anyone taking a coaching approach is to facilitate these individuals to uncover the answers that are right for them, drawing on their existing knowledge and strength and experience. So, How can other staff include this in their role? So I would encourage anyone to go on a coaching skills course.

[00:46:20] But until then, I guess there's kind of three really simple things you can do to begin implementing a coaching approach. So the first is ask more questions. So ask about anything in their life that might be affecting the problem that they're presenting with.

[00:46:35] So for example, if they're here for poor diabetes control, ask about stress, sleep, work, family life responsibilities, you know, all of these things will be affecting their condition and questions can challenge the patient to think in new ways and help them to break out of repetitive cycles. 

[00:46:55] And then the second thing to do is really listen to the answers. And now this sounds really simple, but actually listening and not thinking about what you're gonna say next or preempting the answer or thinking about what's for dinner or the number of patients you have waiting, just quieting that internal dialogue and focusing on them takes a bit of effort and practice to get right.

[00:47:17] Munir Adam: Absolutely, because we're very good at pretending we're listening, so.

[00:47:20] Caroline: Yeah, absolutely. Yeah. Everyone does it all the time, don't they, when you're thinking about other things. 

[00:47:25] And then the third thing is just be open to learning from them. So when you start questioning and listening more, in many cases, the patient will have new and creative approaches to their care, and a lot of the time, Any small changes being made will have this ripple effect.

[00:47:39] So if you can help them to make one small, tiny change and they're successful at it, they'll feel confident in making more changes and have the belief that they can do it. But I guess it's probably also important to recognize when a coaching approach isn't appropriate and when it is.

[00:47:54] So coaching works best for topics that are open and subjective, and you'll need to use your judgment to decide whether the situation is one, which is a gray area or not. And as gonna be, you know, many examples where someone comes to you with a problem that can be affected by lifestyle change. And this is a great place to use a coaching approach.

[00:48:15] But there might be other situations too, even kind of seemingly simple situations where someone comes to you and wants a prescription and you know, you may be thinking, well, you might not need a prescription for that. this thing might get better without a prescription. But you know, if you can just hold back on that judgment or expressing that judgment to them and actually understand, like why do they want a prescription so much, you know, what's that underlying, what's underlying that need for a prescription? And actually having that dialogue with them. You know, you could be butting heads if you are saying to them, you don't need a prescription. They're saying, but I want a prescription. You are the doctor. Give me a prescription. 

[00:48:58] Actually, if you can kind of understand what are their motivations for really wanting that prescription, then actually, The end result might be the same. They still might go away with a prescription slip, but on their way home, they might be thinking, well actually, you know, maybe I don't need this prescription.

[00:49:16] Or maybe I'm not gonna go and pick it up because actually I'll, I'll probably, you know, it sparks some thoughts and you know, may, maybe I'll change my mind. You, you know, you'll never know. But instead of them going away feeling angry and annoyed that they're not supported, they'll go away, with a different kind of mindset.

[00:49:31] Munir Adam: You know what? Every time you just use the word prescription in the last minute, I was converting that to a med three, you know, a fitnote. That's the first thing I would wanna do if I have a health and wellbeing coach in my P C N. There's no shortage of patients that I would like to send, because that's a big challenge where they ask for a fit note, they can't work, or they feel they can't work, and the clinician feels that they probably can work.

[00:49:55] And fitnotes are now available for, being issued by a wider range of health professionals than previously. And that's a big area we're not very good at empowering them and making them think about what they can do rather than just conceding to the, to the opinion that perhaps they can't do any work at all.

[00:50:13] Caroline: Yeah, that's interesting and you probably don't have the time to delve into it either.

[00:50:17] Munir Adam: True. Yeah, that's certainly very true. Well, well, well, so I'm quite convinced that that risk was actually paid off. You know, the remark I made at the start about how we know things, but we just don't do them. So this really is it. This is absolutely the way to make people make that change. Wow. It's so important and yet surprisingly, such a new role.

[00:50:41] Caroline, it's been fantastic learning from you and hearing from you why this is so important. Over the last couple of years I've come across a number of emails, which have been about sessions to help us understand the difference between the three different type of ARRS care roles, and now I am starting to understand this much more clearly.

[00:51:00] So fantastic, and thank you for joining.

[00:51:02] Caroline: Thank you so much for having me. I've really enjoyed it and I've loved, you know, imparting all of my, , passion for health and wellbeing coaching.

[00:51:10] Munir Adam: Yeah, well I've got your number, so when I am feeling ready to quit chocolates, I know where to come. Yeah.

[00:51:15] 

[00:51:19] Munir Adam: If you happen to have the right influence, you may well want to think about recruiting a health coach into the PCN or your organization. They really are worth it. But for the rest of us, I hope that you feel more informed about the role of a health coach, how to work with them, and also have picked up a few tips about how we can conduct our consultations differently so that they're more effective.

[00:51:42] And interestingly, I noticed that it isn't just about spending more time because that's what we don't have. But in some situation it's about things that I need to stop doing in consultations, like specifying exactly what type of exercise they should do and how often. That's going to save time, right? So in summary, I would say that we definitely need more health coaches in the NHS and certainly in primary care.

[00:52:05] And also all of us need to think about adopting health coaching to whatever extent that we can in our day-to-day work. And you may wanna have a think about what you can do from now on in the confines of what's available to you, both in terms of time and resources. 

[00:52:20] But that's it for today. Do rate us on Apple podcasts. Do spread the word. We need your feedback as well. Thank you for listening, and until next time, keep well and keep safe.

Disclaimer

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