Person Focused Primary Care
'Being person-centred means going beyond the provision of a roof over a person's head and regular meals. It is about listening to and understanding the dreams and hopes of that person; what makes them excited; what makes them sad; what they would like to do with their lives.' Dr Tony Stanley Principal Child and Family Social Worker for Children’s Social Care at the London Borough of Tower Hamlets.
' Relationships are crucial, affecting both our mental experience and sense of self. Our modern culture has a 'lethal lie' at its heart - that the self is separate and relationships play no part in it. Relationships are not the icing on the cake- they are the cake.' Professor Dan Siegel, Mindsight Institute, A Truly Connected Life
'It is the quality of relationships, together with the building of life skills across communities with kindness and compassion that make a difference' Dr Julian Abel, Consultant in Palliative Care
‘Inclusion is the condition where humans flourish best’ Ruby Wax, How to be Human
'Relationships are key' Professor Eileen Munro, London School of Economics
One aspect of Person Focused Care we often miss as health professionals is using a time line to map health and care experiences from conception. This method can make it easier to see patterns such as the link between environment, genetic expression, breakdown in relationships in childhood and both physical and mental health outcomes as an adult. For those of you who are GPs have a think about any patients on your list with a diagnosis of Personality Disorder - try looking back through their records holding Adverse Childhood Experiences in mind. Time lines can help us see patients as people relating with their family, community and wider society.
Al Aynsley-Green, former President of the BMA, writes in his most recent book ‘The British Betrayal of Childhood‘ (page 129) that the overarching conclusion of much research is that childhood stress changes the normal development of neural networks in the brain and neuroendocrune systems, in turn influencing cell development in key organs of the body. He adds that there seems to be a mechanism whereby maternal stress before birth and maternal depression and domestic violence after birth effect the genetic structure through ‘epigenetic’ effects.
Professor Jack Shonkoff, Harvard University further explores this concept of toxic stress and the effect on developing brain architecture as well as biological systems and argues that to improve health outcomes into adulthood programmes need to educate families and communities about the effects of toxic stress on development and build life skills and capabilities (starting with impulse control and executive function) in adults around children such that toxic stress is reduced.
Professor Dinan, Cork University is advocating a person centred approach to diet and exercise as evidence based adjuncts to anti depressants in people of all ages including elderly who have anxiety/ depression. In a recent talk at The Medical Society in London he shared the fact that almost all the neurotransmitters in the brain are also produced by bacteria in the gut and that the particular flora in any one person's gut is dependent on diet, exercise and environment. In addition we need healthy gut microbia for normal myelination and development of the brain. There is a concept that the link with particular gut microbia and the brain is through the vagal nerve.
Inspired by my work over several decades as a GP with a special interest in children’s mental health as well as my experience of being a patient through cancer treatment, I have developed a strong interest in the role of social relationships within Person Centred or Collaborative Care. I believe that as a profession we have drifted into putting more and more emphasis on cognition and intellect as well as 'fixing' and 'tasks' (measuring, referring, documenting) and in doing so we are losing the ability to hold relationships in mind within our consultations. The experience of life on a day to day basis for Daphne who is 80 years old and has significant multi morbidities is crucially linked with the wellbeing of her husband and carer and his wellbeing in turn is depedent on his relationships with their family and the wider community. The life chances for Sophie age 8 with cerebral palsy are significantly affected by the wellbeing of her Mum and her family all of whom in turn are affected by the relationships they have within their community. Adam, age 4, is already displaying early anti social behaviours - he is living with his Mum and her abusive partner. His Mum has a longstanding history of severe and enduring mental illness and strugggles to socialise normally because of changes to her brain architecture caused by her own exposure to domestic violence and toxic stress as a child. Adam's brain architecture and biological systems are already affected by toxic stress.
Too often as doctors and associated health professionals we forget that the human brain is fundamentally a social organ and that we have a human need for connection and belonging. We often focus on the patient and disease without taking in to account relationships, connections and wider social context. Community based innovation is often very much better at this aspect of care than we professionals are - for example Best Beginnings are enabling effective engagement with the needs of the foetus in utero in a way that decades of professionally provided antenatal care has dreamed of. SafeWise are building skills and capabilities in children and young people with active enhgagement in an immersive environment of mock up houses and streets. Essential Parent are providing high quality video footage for the new digital version of The Red Book given to all pregnant women in the UK.
Over the last four years EHCAP has worked with Public Health, Somerset County Council to develop a psycho education tool - Mindful Emotion Coaching working initially with professionals, building skills and capabilities in impulse control and executive function as well as an awareness of the effects of toxic stress in childhood. Cascading to parents, young people and communities develops an understanding of the key importance of relationships and moves us all away from process driven thinking. Creating a common language across professionals working with children and young people as well as with parents and young people themselves involves finding something that everyone gets engaged with and which has a commonality to everyone. Even those staff who are exhausted or deeply disinterested in person focused approaches are interested in the neuroscience of relationships and early brain development. We often find that staff initially engage because the tools we are cascading support them in building a more harmonious home life - once the effectiveness is experienced and embedded the cascading process begins. To keep fidelity and enable this cascading we provide FREE access to on line materials. The home page domain is deliberately easy to remember www.emotioncoaching.co.uk . There are nearly 1000 learners signed up to our free elearning modules. EHCAP also receives funding from Somerset CCG as part of the CAMHS transformation project SHARE Somerset.
At our most recent network meeting Shane Dangar shared his experience of contact with health and care servivces as a child and young person and how Emotion Coaching supported him into the role he now has. Jenny Hartnoll's team of Health Connectors in Frome, Somerset have worked with us from the start of our project - we based our Mendip training in Frome Medical Centre in 2015. Health Connections Mendip is funded by the CCG. The Mendip Community Connector Service is part funded by Frome Town Council with Mendip District Council giving a day of their staff time. Health Connections Mendip have trained 921 Community Connectors and on average each Community Connector makes 20 signposts a year - this means that thousands of people have been supported in Mendip by having a signposting conversation. Public Health, Somerset County Council are coming on board too. The joining of Local Authority and CCG staff in a project with a common purpose and vision enables sustainabilty.
In 2017 we worked with sixth formers in Frome, cascading the neuroscience of resilience and reaching this generation of young people as well as the next. In August 2018 two of the Frome Health Connectors registered with EHCAP as Wellness Coaches and we will support them with on line coaching to facilitate a Tuning in to Teens Emotion Coaching Parent / Carer Group in the New Year. This will be the first primary care funded person centred approach to children and young people with emotional and mental health difficulties in Somerset.
Jenny Hartnoll, Health Connections Mendip- Service Lead
'The Health Connections Team work with people who are 18 and over but when we heard about EHCAP's work we really wanted to get involved. Our team trained with Sarah to enable them to support the adults around the young people in our community. The training created many ripples across our work - it influenced how we work alongside adults but also how we work as a team. We then went on to invite sixth form students to get involved, the Youth Patient Participation Group and now we have two of our team trained to deliver Tuning in to Teens. It is a grass roots approach where the young people involved 'own' the work and cascade it to peers. Parents and carers feel empowered to support each other and young people rather than relying on paid 'professionals'- young people and the adults around them are the experts. One young person has even been inspired to write about living with anxiety alongside friends who have other issues that are affecting their mental health.'
Practice Manager, Primary Care
'The workshop helped staff (GP receptionists and team members) empathise and understand the behaviour that patients may display and then to appropriately work with them to get them the help they need'
Lucy Beney, Counsellor wth EHCAP
'I joined the EHCAP team as a student counsellor in placement in 2017. Forming and modelling good relationships is fundamental to my counselling philosophy and it has been enormously rewarding to be part of a pilot project building on emotion coaching work in schools by offering one to one counselling to parents and staff. I have also counselled some teenagers providping support, understanding and encouragement to approach life's challenges differently. Having now delivered over 160 counselling sessions free of charge in Somerset schools it is a priviledge to have been able to build meaningful working relationships and see a growth in their confidence as well as gaining a better understanding of how adverse childhood experience affects physical and mental health. I am now working on a sustainable way to be able to continue and expand this work in the future.'
A community approach to wellness is all about the quality of relationships, enabling inclusion, building life skills with kindness and compassion across communities.
Quotes below are adapted from Maine Department of Health and Social Services - Person Centred Thinking.
Person Centred Practice is a well established way of enabling health and care staff to respect and involve people who use services
It's about doing things with people rather than to or for them
It's about relationships, it's dynamic and it's always changing
It focuses on the person and their individual capacities and interests
It makes sure everyone knows who the person's support network are
It means the person and their support network make decisions, seeking professional advice as needed
It focuses on quality of life as defined by the person
Can only come from respect for the dignity and completeness of the person
It organises communities to be more inclusive and accommodating
Roles are fluid according to what makes sense for the person
It helps us all work together better
The Government aims for there to be 'no decision about me without me' for people accessing health and care services.
Person Centred Practice is a well established way of enabling health and care staff to respect and involve people who use services.
NICE: Mental Wellbeing of older people in care homes (QS50)
A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to older people in care homes. The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning services.
Person Centered Planning Manual for Facilitators