Our NHS is under attack from all angles. People are living longer, we don’t eat well or exercise enough. Yet we expect more from the NHS; more people are visiting A&E departments and minor injury units year on year, and costs are rising.
How do we tackle this? What if we focus on marginal gains, the performance strategy that helped British Cycling to success in multiple Olympics?
This is an approach that focuses on “small incremental improvements in any process adding up to a significant improvement when they are all added together”. Could this improve patient outcomes and reduce waste in the health service?
One incremental enhancement we could seek in the NHS might be to improve our understanding of and response to the barriers to patient motivation. For example, could we find a way of encouraging stroke survivors to practise their rehabilitation exercises as frequently and intensively as they are prescribed? Patient adherence to rehabilitation regimes after discharge from hospital is described as “less than ideal”. By addressing these barriers, we will be more able to efficiently allocate therapy time, and thereby reduce GP appointments and hospital readmissions.
You might wonder what makes me an expert on this.
Lowering patients’ expectations of recovery can be extremely damaging
In February 2010, at the age of 39, I had a huge brainstem stroke and was diagnosed with locked in syndrome. I was on life support and in intensive care for nine weeks, and was then written-offin rehabilitation after a further six weeks. My husband received a phone call telling him that I would never walk or talk again.
Over eight painstaking months in rehabilitation, I obsessively willed my body back to life, practising actions or movements 450 times per week. Slowly I learned how to do basic things like eat again, and at the end of it all I walked out of hospital. I went for a run on the first anniversary of my stroke. I’m now a motivational speaker and go to the gym every day.
I never gave up pushing my body to improve: to speak, to eat, to run and to hug my kids. I managed to use my bad prognosis to galvanise my recovery, but the risk is that lowering patients’ expectations of recovery can be extremely damaging. Recovery should be measured in terms of improvements, not “getting better” – and that is always possible. My only focus, with three young children at home, was on when I would achieve my goals, not if.
Since embarking on my career in advocacy and stroke activism, I’ve found many reasons why patients lack the motivation to try to help themselves. They may be suffering from post traumatic stress disorder, which is common after a stroke and, just like depression, it affects mood and motivation levels. The side effects of the drug treatments for strokes – sleeping pills and muscle relaxants – can also affect motivation. After a brain injury many patients suffer varying levels of executive dysfunction affecting the set of mental skills that help to get things done, which can be mistaken for apathy or laziness. The overwhelming tiredness felt by those suffering from neurological fatigue can leave patients unable to complete normal daily tasks and therefore non-compliant with their treatment plans. It may be that some patients simply hate exercising or have no family support.
It is futile prescribing a stroke rehabilitation plan if – for any of these reasons – the patient is unmotivated before the therapy session starts or they are left at home trying to manage their own condition. The NHS should be offering hope and encouragement to motivate patients. And to do that, they need to listen to expert patients.
My advice to the King’s Fund Leadership Summit is that we need a better understanding of patient motivation to help rebuild the lives of stroke survivors. If patients adhere to clinical advice about practising their exercises as frequently and intensively as I did, just imagine how much we could improve their outcomes and reduce the waste in the NHS. But to do this we must understand the complex reasons why patients don’t do this already and listen to those who have struggled through similar experiences.
I don’t promise anything when I speak to people now – I just offer possibilities. I talk about how to optimise improvement, but never use the word recovery. After a life-changing event none of us will ever be the same as we were, even if we physically improve really well. We need to embrace that new self and strive to be the best version of ourselves that we can be, both in hospital and back home.
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Patients need motivation to recover. The NHS must offer hope | Kate Allatt
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