Learning from experience may be nothing more than learning to make the same mistake with more confid

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Learning from experience may be nothing more
than learning to make the same mistake with
more confidence
Patients as Teachers - a primary caremethod for
research and service change Dr. Brian Fisher
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DOCTORS AND PATIENTS WANT DIFFERENT THINGS

• Practice services
• Quality of care
• PrioritiesSO DOCTORS CANNOT ASSUME THAT WE ARE
  PROXIES FOR PATIENTS

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PATIENTS AS TEACHERS(PAT)

• Finding a way of redefining clinical
  effectiveness from the users points of view
• Working with patients to change the clinical
  behaviour of clinicians.
• Used in the fields of cardiac disease, mental
  illness and asthma
• Diabetes and the elderly (SAP) soon

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THE PAT APPROACH

• To find a methodology that
• would be enjoyable for patients
• would be useful for professionals
• would be generalisable
• What worked for you
• looks at success
• avoids blame

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INITIAL FOCUS GROUP

• WHAT WORKS FOR YOU?
• what has been most effective in your experience?
• Broken down according to relevant areas eg
• communication
• reception
• treatment
• Each person tells their own story

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1st focus groups
Follow-up focus group
2-3 delegates from each group meet with 15 GPs
and external facilitator
Asian
Men 45-65
Women
Each delegate now represents the views of the
focus group, not their own views
Elderly gt65
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APPLYING THE PROCESS

• Change in clinical behaviour
• A set of user-defined outcome measures
• These measures can become part of performance
  management
• They can become a user-defined guideline
• Beyond the Expert Patient

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VARIANTS OF THE APPROACH

• Teaching professionals how to carry out the
  Single Assessment Process better
• Working on depression recruiting experts
• Working on redesign patients teaching
  professionals how to improve the patient journey

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PAT IN DEPRESSION

• Identify 6 researchers from practice lists and
  VOs
• Develop questionnaire from the question what has
  worked best for you?
• Train researchers in working with
  semi-qualitative questionnaire
• Identify other patients with depression from
  practice lists
• Researchers ask them what has worked best for
  you?

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OUTCOMES

• 48 attending, 17 returned forms. No information
  about non-attenders
• Researchers have gained in confidence and gained
  jobs
• They have challenged the payment structures of
  the PCT.

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QUALITATIVE THEMES FROM FOCUS GROUPS
The practice needs to be accessible for crises It
should be easy to get through on the phone and
the phone system should be easy for patients to
use 7 Receptionists help patients, not
just protecting the doctors 9 Enable phone
consultations appointments may not be needed
10 Information available about out-of-hours
options 8 GPs and nurses need to ensure
that the first and subsequent contact is
supportive Patients being treated with respect
10 Acknowledge how hard it is for
patients to speak of their depression 7
Depression recognised as a serious issue, not
trivial or time-wasting 7 Working with
other agencies to improve economic and social
factors Consider jobs, money, housing work with
and refer to advice agencies 6 Consider
alternative therapy, timebanks, social
prescribing project 8 Develop a buddying
system for mutual support
1
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QUALITATIVE THEMES FROM FOCUS GROUPS
Patients need follow-up and continuity Telephone
instead of an appointment which can be just as
effectively done by a nurse.
5 Counsellors ensure
patients are followed once sessions are finished
6 Clinicians need to be honest about the
diagnosis of depression and offer
information Offer information about condition,
management and prognosis (see ICE leaflet)
5 Offer information about other sources of
support (e.g. the MIND Infoline)
7 Counselling is helpful Talking
therapies available, particularly those with an
evidence base, such as CAT/CBT 6
Counselling used for making a diagnosis and
advising on treatment 8 Group work
possibilities (plus, in 1 surg, discussed but
unable to implement) 2
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QUALITATIVE THEMES FROM FOCUS GROUPS
Medication needs to be decided with the patient
and information about outcomes and side-effects
provided Use medication in combination with the
other interventions described above (plus 1
surgery already doing it) 7 Use the EMIS
Depression Template (1 surg unclear what it is)
4 Changes in dosage or drug explained and
justified 6 Patients needs monitored and
adjusted in line with their circumstances and
experiences 6 The doctor acts on
feedback from the patient 7 Shared
decision-making is best Use the EMIS Depression
Template, developed by Lewisham PCT 4 ((see
above comment) Discuss medication and any
changes, using the Depression Template 4
Discuss the diagnosis and prognosis 7
Discuss other options the patient might want
8 Discuss other options the
clinician recommends, such as exercise 5


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NEXT STEPS

• PAT researchers developing the Depression
  Programme
• Researchers will be key teachers in practice-,
  neighbourhood- and PCT-based training.
• Disseminate both the process and the guidelines.