Effective Consultation Skills

The Care Planning Consultation

The principles and philosophy of the care planning approach can be applied to any consultation or interaction between healthcare professionals and patients.

The care planning consultation, which incorporates this approach, could be considered as an adaptation of the traditional annual review. The aim of this consultation is to discuss, prioritise and plan the forthcoming year of care. It is anticipated that this would usually occur annually, but the actions resulting from it may need to be reflected on and revised at shorter intervals. This could be due to a specific health or personal event, such as a pregnancy, heart attack or a significant change in working arrangements. These may require reconsideration of the planned care and a further care planning consultation would be appropriate.

The National Diabetes Care Planning Working Group has developed a model for effective care planning based on the vision set out in the Diabetes NSF and the Matrix report Good care planning for people with long term conditions commissioned by theNHS Modernisation Agency¹. The model draws on research in clinical practice, psychology and education to set out a process of negotiation and shared decision making between the healthcare professional and the person with diabetes. Where appropriate, family members or carers should be involved in this process.

Components of the model

The individual's story and the professionals story
Sharing and discussing information and negotiating the agenda
Action planning
Documentation

The individual’s story and the professional’s story:

The care planning model is based on the principle that both the individual person with diabetes and the healthcare professional will bring an agenda or ‘story’ to the consultation. In order to facilitate the making of mutually agreed informed decisions, eliciting and understanding the various concerns and perspectives of each participant is paramount.

The process provides the individual with the opportunity to raise concerns, ask questions and explore their position on topics raised. These topics may not necessarily be exclusive to their diabetes, but may include psychological and social concerns. The healthcare professional’s agenda will, at least in part, relate to the health prevention and biomedical management aspects of care.

How often have you had a phone call with someone and after you’ve put the phone down suddenly remember another issue you wanted to speak to them about, which may actually have been the reason why you made the phone call in the first place?

Frustrating isn’t it? - but then you could always email them or ring them back.

People attending a clinic have the same problem, exacerbated by it very often being a stressful experience, and may feel that they can’t actually get back in contact with you very easily. This frequently results in the ‘door handle question’ when someone remembers just as they are leaving the room that ‘there was just one other thing I wanted to ask you…’ Even worse the question may ultimately goun answered or their concern unaddressed.

This emphasises the importance of ‘gathering the stories’, which is usually done prior to the two parties coming together.

For the Healthcare Professional(HCP), this may be quickly scanning the person’s medical records prior to inviting them into the room. This minute or so reminding themselves of previous consultations and action plans, or reviewing recent test results, often proves invaluable in helping them understand what it is that they would like to catch up with or discuss during the appointment.

This also emphasises the importance of having the tests done, and results ready, before the consultation. How did we ever think it was acceptable to do tests after the consultation; to discuss and plan future diabetes care without crucial information such as the HbA1c being available to us?

For the patient, telling the HCPs about significant changes since their last appointment, and considering what they would like to get out of the appointment is vital, but may not be a task or skill that they are familiar with, usually because they have never been encouraged to do this in the past. Some people might have thought about this or come along with a list, but others may feel discouraged from doing so as they don’t wish to ‘bother the doctor.’

One solution is to actively encourage people to think about what they’d like to discuss in the appointment before they come and to bring a list along with them.

This could be done by the inclusion of a simple statement in the appointment letter, or by the use of specific prompts.

Possible topics for discussion:

Four broad domains are included in the model as potential areas for discussion. These are not intended as a checklist and may not all be relevant to each individual. They recognise the multifaceted impacts of living with diabetes, and any co-morbidities, and facilitate a holistic approach. This ensures one issue does not dominate the consultation at the expense of other potentially more relevant topics.

1. Learning about diabetes

This might include:

Discussing questions asked by the person with diabetes.
Identifying sources and means of obtaining information that are most helpful for the person²
Proactively considering future information needs and how these might be met.
Reflecting on the impact of structured education.
Discussing what learning has arisen for the person as a result of their day-to-day experiences and how this will affect their future behaviour in similar circumstances.
Practical demonstrations and information about new equipment and resources that become available.

2. Managing diabetes

This might include:

Medications and treatments for diabetes and related conditions, as well as perceived and real side effects.
Monitoring and surveillance processes.
Self monitoring.
Managing situations such as illness or lack of medication.
Health-related behaviour such as smoking, diet and physical activity
Referrals to other agencies or health professionals.
Planning future treatment changes such as commencing insulin therapy or renal replacement.

3. Living with diabetes

This might include:

Day-to-day social, work and family issues.
Practical considerations such as travel and physical activity.
Managing the effects of medication such as hypoglycaemia.
Managing the effects of long term diabetes complications.
Psychological effects and coping strategies.
Planning for future life events such as pregnancy and retirement.

4. Other health and social issues

Many people with diabetes have other health and social issues. Including these in the care planning discussion may apparently increase the complexity of the process, but can simplify the totality of care for the patient.

Other health and social issues might include:

Other long term conditions. These should be part of the overall care plan, and may affect the agreed decisions.
Exploring concerns about other health issues which at any one time may take priority over diabetes but may be affected by it and vice versa.
Mental health problems such as depression, social exclusion, isolation or poverty may need to be addressed more promptly than diabetes itself.
People living in institutions or in prison may not be in direct control of their diabetes and need structured support from others.

Sharing and discussing information and negotiating the agenda

In the care planning review there may be several potential issues for discussion. Clarifying and exploring these issues in order to decide which are to be focused upon during the consultation requires specific skills. The healthcare professional’s responsibility is to ensure that the discussions and decisions are made in full collaboration with, and are appropriate to, the individual they are consulting with.

Healthcare professionals will need to develop and utilise particular listening,communication and consultation skills, especially when discussing difficult or challenging issues. They may have to learn to accept the patient’s choice to engage in potentially risky behaviours, such as smoking, and to become experienced in handling situations where there may be very difficult outcomes, such as rejecting support during pregnancy. The 'Partners in Care' guide offers a simple summary of the fundamental skills required and can be accessed from the link at the bottom of the section.

Action planning

At this stage of the consultation, the person with diabetes and the healthcare professional should agree a set of action points, decide who will be responsible for achieving each of the actions and agree when the actions will be reviewed. For the person with diabetes, the actions are likely to relate to aspects of self management. For the healthcare professional, they might include referrals, investigations etc.

Actions are more likely to be undertaken by either party if they are detailed and specific and set out within a given timescale. An action is more likely to be achieved if the person has a high level of confidence in their ability to complete it (efficacy expectation), if it has a personally desirable result (outcome expectation) and if they have the practical means and resources to undertake the action.

Documentation

The outcomes of the care planning consultation should be recorded in a document as in Section D of the Care Planning booklet or similar. However, it is important to recognise the distinction between the care plan and the care planning process. Care planning is a dynamic process of negotiation and shared decision-making. The care plan is a means by which the outcomes are recorded. This will include choices, preferences and action plans. The care plan should be available when the person with diabetes accesses any part of the service, including during an in-patient or acute episode.

¹NHS Modernisation Agency (2004), Good care planning for people with long-term conditions. This report is available electronically at: http://www.networks.nhs.uk/news.php?nid=289

²Our health, our care, our say contained a commitment to introduce Information Prescriptions for everyone with a long term condition or care need by 2008. These individual prescriptions – drawing on local as well as national knowledge and information – will point people to the relevant websites, telephone numbers and support groups for their condition. They will help people with long-term conditions to stay independent and take control of their illness. Further information can be obtained from the press release ‘Tomorrow’s patients will have information prescribed alongside medicines’, issued on 18 October 2006 and available from http://www.gnn.gov.uk/

This section has drawn from the Partners in Care guide produced by the National Diabetes Support Team and the Care Planning in Diabetes report from the Joint Department of Health and Diabetes UK Workforce fjoint Department of Health and Diabetes UK Care
Planning Working Group