When I first became a GP, I decided that many of my patients who needed to make lifestyle changes also had undiagnosed conditions that resulted in problems with their understanding, memory and planning processes. There must be something wrong with them, so my reasoning went, because they left my consulting room chastened by me about their lifestyle choices, concerned about their impending doom, and clearly intent on turning their lives around….but when I saw them again they hadn’t done anything. In fact, some of them were even more unhealthy than before. Some cases stood out, like the man who was still popping out for fag breaks in between ward rounds on the coronary care unit after he’d had his heart attack. Or the elderly lady with furred up arteries in her legs who looked me straight in the eye and told me that she was more scared by the thought of life without cigarettes than she was by the below knee amputation that she was heading relentlessly towards. Surely the only explanation was stupidity or a death wish? Or so I thought.
Years have gone by and I have learnt a lot about people, which is an inevitable and highly desirable side effect of working in primary care. I have spent time talking these things through with patients. I have read round the subject of behavioural psychology (I highly recommend Nudge, Inside the Nudge Unit, and Think Small for a good grounding in this area), met with people from the Nudge Unit (or Behavioural Insights team, to give them their proper name) and spent time discussing these issues with psychologists and other colleagues. At Thrive Tribe, we are working with the Centre for Behavioural Change to ensure that all our practitioners are appropriately skilled in this area to help their clients, offering a service that is more than just education about giving up smoking or losing weight.
For the purpose of today’s blog post, I am going to share with you a small but important part of what I have learnt over the years. It’s not very clever or surprising. Neither is it difficult. Everyone can do it. It’s about having a plan.
Why do we need a plan?
Humans are not rational creatures. We assume that because we have been well in the past we will be so in the future. We cleverly avoid joining the dots with all that we know about what is likely to happen as we get older. We know that there are theoretical risks of things happening, like heart attacks and cancer and road accidents, but we assume that somehow we as individuals are exempt from this risk, unlike everybody else in the world around us. I’m sure you can see the potential flaws in this reasoning. When things unravel, they can unravel quickly. Even when things are not yet seriously unravelling health-wise, people are often still aware of their wellbeing issues. When people fail to make changes that are needed, it isn’t because they don’t know what to do. It’s beause they either don’t know how to do it, or they do know how to but have no plan in place to make it happen. I know that I would like to catch up with my brother for breakfast over the next few weeks. I also know based on the endless games of message-tag we play that via text, facebook messenger, what’s app and email unless we actually make a plan, it will never happen. It’s better to have a plan. It could be written on paper, or stored electronically – just as long as you can refer to it and review it whenever you need.
Do wellbeing plans work?
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Plans are not foolproof. Otherwise we wouldn’t refer to the best-laid ones or talk what the road to hell is paved with. They do, however, increase our chances of making and sustaining the changes that we want to. There are various reasons for this.
Accepting the need to make changes
Firstly, making a plan to change means that we have generally (perhaps grudgingly!) accepted that there is a change that needs to be made. Maybe you’ve been along to see your GP, practice nurse or health care assistant and a few issues have been raised that you concede might be worth a look at – that weight you’ve been meaning to lose for years, your need to quit smoking or reduce your drinking because of the effect it’s having on your health, or perhaps your worries about getting a bit fitter as you move into middle age.
Being specific about the changes
Vague plans are not much good. “I will lose weight/eat fewer biscuits/do more exercise” might work for a small minority, but for more people it will never translate into anything. Why? Because they have leapt straight to the desired outcome and are too vague. We need to be clear about what we are going differently that will result in those outcomes. Each step in the process needs to be considered, broken down into even smaller steps if required, to see how realistic it is and what needs to be done in what order. A plan makes it easier to achieve than a one-off mental note to self or vague intention.
A plan makes us accountable for the changes
If we have a plan, it means that we are accountable. Not just to ourselves, which helps a bit, but potentially to others, which significantly increases our chances of success. Letting other people know what you are doing and even asking one or more of them to be a referee and hold you accountable means you are more likely to follow through.
A plan helps us to measure success as well as failure
If we have been specific in terms of what we want to achieve, how we will achieve it and how we will measure our success, then this will help us by encouraging us when we achieve what we have planned (which increases the chances of making further changes and sustaining what we have already done) as well as maybe challenging us with the areas where it hasn’t quite worked out yet. The plan can always be changed when we learn as we go. Putting rewards into the plan for when we achieve each stage of success can be quite motivating as well.
My top tips for making your wellbeing plan
- Make it for yourself and only if you really mean it. Not to make your GP happy. If you’re not ready to make changes, let them down gently as early as possible and perhaps keep an open mind for the next time you have a wellbeing conversation.
- Make it simple. The more complicated it gets, the more likely you are not to achieve bits of it, which can be disheartening. Better to have simple success and build on it.
- Make it specific. Losing weight might be the overall desired outcome, but break it down into smaller chunks e.g. cycling or walking to work, cutting out snacks, shopping for and preparing more of your own meals, not eating after a certain time of day.
- Make it achievable. If you are inactive at present and break into a sweat at the thought of breaking into a sweat, don’t aim for 150 mins of exercise a week from the outset. Start with 5-10 mins a day every other day. If you want to learn about mindfulness, start with 5 minutes a day on your smartphone app or just spend the time reading a book or listening to music. I know a lot of people who say “I tried that” by which they mean they gave it a go a couple of times and gave up because it was too difficult or not immediately rewarding. Changes are more likely to be made if they are easy, accessible, social and timely.
- Make it rational. Think about what changes you can implement that are compatible with every day life and easy to sustain. It needn’t involve hours of your time every day or expensive kit, diet plans or gym memberships. It could be walking more briskly to the shops or whilst out with your dog, taking the stairs at work or working in the garden.
- Make it measurable. It might be weight lost, minutes of activity completed, amount of sleep you have obtained or personal goals achieved (e.g. taking part in a social activity with your friends or playing football with your children or grandchildren)
- Make yourself accountable. Tell people what you are doing e.g. work colleagues, friends and family, social media groups. Consider asking someone to be a referee who will check in with you regularly. Some people might ask their spouse. Some might prefer a friend or colleague depending on how much they enjoy being nagged!
- Make it a work in progress. Your objectives are likely to change over time. You will succeed in some areas and maybe not others. That might simply mean not giving up and then trying again, or it might mean learning from what has worked well and not so well, and coming up with a better plan for the future.
Wellbeing planning in the real world.
I thought I would finished with some real life examples.
- Last year, all the GP practices in my area took part in a local Cardiac Prehab scheme which I had designed with some of my colleagues for our CCG. Part of the service included identifying patients at higher risk of having a heart attack, stroke or developing diabetes and inviting them to an educational event at their GP practice. The evening included a presentation on wellbeing and finished with each patient signing up to their own personal wellbeing plan. These plans were collected and scanned into each patient’s records. When they were reviewed a few months later, the doctor or nurse they saw reviewed their plans with them and discussed what had worked well or not so well. The majority of the patients I reviewed had achieved at least one of their intended outcomes and were really pleased to see how well they had done, which encouraged them further. This year the scheme has been rolled out across our entire clinical commissioning group, with a patient population of over 600,000 people.
- Those of you that are kind/enlightened/fortunate enough (delete as applicable) to read my blog posts regularly will know that I talk a lot about Rangan Chatterjee’s Four Pillar Plan. Inspired by this, I have started to develop a welbeing plan template for EMIS (our computer system) which is based on this. I have shared it with my practice colleagues and am now using it to enter data into the patient’s record and give them a printed copy after our consultation, so they have something to remind them of what we have agreed and to document their progress. Rangan Chatterjee and Ayan Panja did an excellent presentation on Prescribing Lifestyle Medicine at last week’s Emis National User Group conference at which they showcased an early version of their own lifestyle medicine template which is currently in development and which will no doubt be snazzier than mine when it’s finished!
And finally, my own personal wellbeing plan
It is only right, of course, that I practice what I preach. For years I have meant to lose a bit of weight. For years I have surveyed my profile in the mirror in the morning, disappointed in myself for not having achieved anything and disappointed in the Six-Pack Fairy for not having visited overnight as I had hoped. So in the end, I made a plan. This included eating a lower carb diet (specifically changes to what I make for breakfast, making salads for lunch and cutting back on biscuits), exercising more regularly (getting up early to walk before work, doing HIIT workouts when I didn’t have time to ride or run), and doing press-ups as strengthening exercises each morning). I am also much better at getting enough sleep, although there is always room for improvement. I told my wife about this as I knew full well she would remind me if/when I lost track. The results? I have lost just over half a stone without feeling that I am depriving myself. I feel fitter and have more energy. I still don’t have a six pack and have decided that I was probably born without one, so maybe I will leave that out of the next version of the plan.
That’s all for this week from me. Weekly Wellbeing Round Up #10 will be out next week.
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Until next week, take care of yourself!
Dr Richard Pile