Ollie: Right, hello folks. ⁓ I'm absolutely delighted to be joined today by ⁓ the two people I consider ⁓ the most contemporary experts in the field of patient activation. ⁓ so I'm delighted to be joined by Professor Alf Collins, who I've known for many years for his leadership roles from NHS England in the chronic pain field and many, many other areas, and he will introduce himself in a second. And then ⁓ Jag Mundra, again, ⁓ a someone, a friend and a colleague who has been really dynamic and innovative in this area of. As many of you know, in Health Coaching and Beyond, we alternate conversations between the two of us, chewing over hot topics, latest news and emerging ideas, but also bringing you conversations with thought leaders and people we admire in the field of health coaching and beyond. This week, I'm joined by two true experts in the field of patient activation. In fact, I can't really think of anyone else I admire more for the development and championing of this approach. Many of you... patient activation and and how we turn things from theory into real life. ⁓ so perhaps Alf and Jag, Alf you start could you could more formally introduce yourself for our audience. We'll know that at Peak Health Coaching, we consider patient activation to be a key concept. It's a concept that emerged in academia and has stood the test of full application in real world practice over the last 40 years, driven and shaped by people like Alf and Jag. Patient activation is the skills, knowledge and confidence that people have to self-manage their own health. It builds on the principles of agency, autonomy and self-efficacy.

Alf Collins: Ollie, it's great to be here. It's great to be here with friends and colleagues, people that I really like and respect. a doctor. I worked in a pain clinic for many, many years, which we moved into the community. community pain management service. Alongside that, I've been a communication skills trainer for 40 odd years and got interested in the idea of activation over 20 years ago now. And I've done a lot of work in that space with various organisations.

Ollie: We consider activation at the individual, group and system level. We get to some really pragmatic and practical ways to embed activation in our current ways of working. As always, we hope this conversation supports your thinking and how important it is to support people to grow their skills, knowledge and confidence to self-manage.

Alf Collins: Health Foundation and NHS England. So Ollie, it's lovely to be here.

Ollie: Brilliant. And of course, you were the the clinical director for personalised care for NHS England for many years, weren't you?

Alf Collins: Yeah, I was there full time from 2016 to 2023 and activation was part of my portfolio.

Ollie: And we'll we'll come to all the ways you've brought it in across your career, Ralph, in a minute. Thank you. But Jag, perhaps you could introduce yourself to the audience as well.

Jag: Yeah, no worries, Holly. And thank you. It's such an honour to be here with you both. And thanks for inviting me. So my name is Jag. I'm Jag Mundra. And ⁓ I work for an organisation called the NAPC, the National Association of Primary Care, and also the ⁓ National Academy of Social Prescribing as well. And most of my work is kind of involved in trying to measure the benefits of prevention or preventative care, but also try to find ways to nudge people or increase patient activation and improve population health. ⁓ Involve them both sides to allow you to measure the data side of things.

Ollie: Thanks, Jack. So many people that have heard us talk will know that at Peak Health Coaching, we're really wedded to ⁓ activation and patient activation as a concept. And we define that as people's skills, knowledge, and confidence to look after themselves or engage in self-care. And tailoring our approach to that seems to be a really good strategy. But Alf, perhaps I could come to you and just sort of visit where where did it all start and where where did this concept of patient activation come from?

Alf Collins: So think we all know what you've just said, Ollie, some of us are better looking after ourselves than others. I it's just a common knowledge piece. And that's the case whether we have a long-term condition or not. Some of us find it a challenge to manage our long-term conditions or life with our long-term conditions. Some of us find it less challenging. We've known that there's this concept agency, which is to do with our skills, knowledge and confidence to... to manage in any given situation actually, agency is that, yeah, actually I'm in this situation now. It could be in work, it could be in sport, it could be in health. And I actually, I know how to work my way through this. So people of high agency do tend to produce better performance, better outcomes. So that concept's been around for 50, 60 years. It came out at the University of Stanford and there's a professor called Albert Bandura who did a lot of work in this field over, you five, six decades. ⁓ In his there were two people, one called Kate Lorick who was the person who put in place the expert patients program which I was ⁓ part of years ago. There's another person called ⁓ Judy Hibbard ⁓ Judy and started to think about how can we apply this concept of agency ⁓ to health and they figuring ⁓ this idea it's called self-efficacy. To what degree am I ⁓

Ollie: Mm-hmm.

Alf Collins: confident to what degree do I have the skills and the knowledge to manage life with my health condition. Judy started to think, is there a generic way of capturing people's agency when it comes to their health and well-being? and develop this idea ⁓ of activation. It's a generic health specific confidence, skills, knowledge, scale, really well validated. It's been around for 23, 24 years. We bought it into the NHS in a program I worked on called Co-creating Health for the Health Foundation 22 years ago. And actually we used the then 22 item scale. There was a wonderful survey by Angela Coulter of many thousands of patients, people living with long-term conditions, looking at their levels of activation and demonstrating 21 years ago now that there are four levels of activation and about a quarter of the population are at low levels of activation, about four in ten as we all know, are at moderate to low levels of activation.

Ollie: Yeah. Yeah, brilliant. So a and and this concept of agency, I think, so important across healthcare and all all segments, like you say. So and this this validated questionnaire. So it started with twenty two questions. It's got down to ten now, isn't it? I think a lot of us use the ten question one, don't we?

Alf Collins: Yeah, yes, yeah. It started at 22, went down to 13, went down to 10. Judy tried six, the six item measure. Yeah, they're academics. They like stuff that they can demonstrate in trials, fantastic work that they're doing. They're not, I'll just say this in the kindest possible way, they're not necessarily implementers at scale. So we do need a much, a much. more readily available smaller instrument than a 22 or a 13 or a 10 item instrument to actually take these concepts to scale. know Jan's going to talk more about this in the next few minutes.

Ollie: Absolutely. Well let's let's bring you in, Jag. So Judy did fantastic job from an academic point of view, didn't she? A proving case, getting this all validated. But Jag, I'm ⁓ you're ⁓ an expert in pragmatism and making things work in the real world. So ⁓ you've taken the concept on, you developed a single question measure to use pragmatically. Tell us, tell us a little bit about how you've built on the ideas of activation into a sort of pragmatic approach.

Jag: Yeah, surely. so I guess when I've been rooting around in projects trying to figure out whether they're working or not, you're generally trying to find a measure or something that will tell you whether it's had an impact or hasn't had an impact. So that's my kind of introduction into activation in the first place. And when I stumbled across it, I was just so ridiculously excited to find this concept. Because for me, logic model is, especially when comes to prevention, but for most things, firstly, people use a thing. then their behavior changes, then their health improves, then their demand reduces. So I'm looking for a behavior change metric that will predict future health and demand reduction. So stumbled across activation. I thought, ⁓ my God, this is amazing. Why aren't we kind of orienting? Why aren't we doing this everywhere? I was almost like, it's quite funny. I don't know what the question is, but I know the answer is activation. It just made sense to me as a person as well as an individual and also as a population. So then I came across the ⁓ the 14 question tool. And I think it was at the point where the license was just about running out. And as part of a piece of work I was doing for NAPC, we working in Calderdale, trying to measure different interventions and preventative care kind of stuff, the kind of the forerunner to integrated neighbourhood teams that we're seeing right now. And we thought, right, okay, let's try to implement a behaviour change metric that's going to tell us everything we need to know so we can learn quicker. ⁓ And what we found was is that none of the social prescribers we were working with wanted to use the full tool. And we tried a different set of things and they were really resistant to doing it. So we thought, let's just scrap it and instead ask them, with no agenda whatsoever, what question ⁓ would they feel comfortable asking ⁓ and would patients feel comfortable answering just on own terms? So kind of removing all the academic stuff. And they came up with something very similar activation on their own. but it just was asked with fewer questions. And that was ultimately, roughly, we iterate the questions a little bit, but it's how good are you taking care of your health or rate your health on a four point scale? ⁓ It was funny enough, a GP in Oxford who gave me the idea, he said, the best depression question I've ever used, Jag, is just asking patients if they're depressed. So we thought, let's just try this out. It probably wouldn't reach an academic standard of validation, but it might just be good enough as a precursor to full tools. So, and... we did a search for any PROM or PREM, that's a patient reported outcome in Calderdale before we started. And we found that about 0.02 % of patients had anything recorded. That's any type of measure, Warwick-Edenborough, ONS4 activation.

Ollie: Zero point zero two percent, so a fifth of a percent. Yeah, pretty much nobody. Yeah.

Jag: Yeah, nobody. Basically nobody. Pretty much nobody. And within about six months, we had one in two patients receiving social prescribing and capturing. So it's from zero to about 50%. So they really took to the tool. And in their own words, they found it useful across three domains. They found it useful as a tool. So something they wanted to ask and answer because it helped them deliver better care, better preventative care. ⁓ And it was then... So it was useful as a nudge and a prompt. It was useful as a triage tool, which is this intended purpose. And thirdly, it was useful as a measure. So it helped them with QI and evidence in benefit. So we solved firstly the uptake problem. Then we looked at the data from the activation scores to just check. I'm like, oh my God, is this actually going to look right? Like I've said, 25, 25, 25%. And it was good enough. There was a bell-shaped distribution. And so, okay, so at least not everyone understands and answering the question normally. They're not all just saying, I'm activated or not activated. then, so the distribution was good, so check uptake, check distribution. And then the third step, and there's two more steps, is that we then start to look at the correlation behind activation and things we care about, like GP contacts, hospital contacts, health, medicines. And it was positively correlated, or negatively correlated to all of those things that mattered. So higher activation, lower meds. higher activation, lower GP contacts. And that's in the literature as well, but the single question was doing the same kind of work. There was a little bit of difference with activation in BMI, but we think that was probably a health literacy issue. And then as part of that analysis, no.

Ollie: They don't entirely match, do they? Health activation, health literature is slightly different things, aren't they? Yeah.

Jag: They are. And what we found was that higher activation was associated with people's self-reported diet being better, but their BMI also rose. So we think that that's probably a health... We don't all know what ⁓ a good diet is. ⁓ And the final thing to mention is that ⁓ we're at this state... We ⁓ something called a ⁓ multiple regression, basically controls for age, clinical ⁓ mental health and need, and then says, does activation explain... GP contacts or does it tell you something about future GP contacts once you control for those things? And it did. And in fact, out of all the things tested that talk about future ⁓ healthcare utilization, ⁓ patient activation could be the strongest modifiable we've got to affect it. we're marrying together a outcome with a clinical. that's well controlled. so in simple terms, we've done the stats to try to get as causal as we can, but it isn't causal yet. So that's the final step we're going to test now, is whether raising somebody's activation actually then lowers their GP demand, because at the moment we've gone as far as we can with the numbers. So that's a bit of a kind of a history of how we've arrived at the single question.

Ollie: Brilliant. And just to recap then, so the the current wording in that is just literally asking people how good are you ⁓ how good are you at taking care of your own health? And there's four responses, I understand it, which is not very, okay, good, or excellent. And actually just asking that very simple question, that format with those four answers, ⁓ is really enabling for a system, like you say, to to to sort of ⁓ respond in a very different way.

Jag: That's right, Ollie. But I think the emphasis here is that it's not a validated measurement tool. That's quite distant. It's a tool that people should own alter in the way that feels right, because the first step is ⁓ ask it and answer it. And if you feel that ⁓ person you're talking to doesn't understand the question or you arrive at that answer together, that's fine. It doesn't have to be a perfect measure. That's not really what it is. It's just giving you an indication. of what might be happening. And so we don't try to go up against validated tools. They still remain and they're extremely valuable. This is something that can start a conversation where otherwise there wouldn't be one.

Ollie: Yeah, I love that. I love that sort of pragmatism there and the sort of difference between, yep, sure, you know, really robust validated measures are really good. And perhaps we could argue, as as we did, Alf, didn't we, with NHS England, that we should be investing these and prioritizing these. But sometimes they're difficult to put in their full, full format and patients and staff don't like it. So some more pragmatic, kind of easy use tools, perhaps as an entry starter of a conversation, is is is good to have as well in the system. Yeah, do Alf.

Alf Collins: Can I come in on that, Ollie? I started using the 22 item PAM and then the 13 item PAM 21 years ago now. And we ran a program called Co-Creating Health. Actually, one of the sites was Calderdale. We had eight sites where we were teaching people what we now call health coaching. And we were teaching people to deploy questions like, how good are you at managing your health? How confident are you at managing your health on a daily basis? And nevertheless, we were using the 22 item tool and that people people didn't like it. I mean, even then, 21 years ago, they were deploying the questions that now Jagger's really made this massive leap forward. But they were then also alongside that using this really frankly cumbersome tool. And that was the major blocker to widespread adoption of these ways of working was the fact that the tool was too long. So I just want to pay tribute to the your work, Jag. This is certainly in 20 years of patient activation measure work, I think it's the biggest leap forward we've had. So thank you.

Ollie: Yeah, it's certainly certainly something we use in our practice. We use it now in the pain clinic I work in. ⁓ we use it in our social prescribing service. Yeah. And it's it is that difference in real life, isn't it? Between you want the robust research, and it's fantastic to have had the work that Judy Hibber led to to kind of prove concept. ⁓ but actually you need to make it doable and pragmatic in real life. I think that's the the the the winning formula, isn't it? so we we've talked ourselves, haven't we, the three of us,

Jag: I know, problem.

Alf Collins: Yeah, yeah.

Ollie: ⁓ even in writing to advise NHS England around how you could use activation in different domains. So you can think about it at a sort of personal level. You can also think about how it affects group dynamics and the behavior of clinicians and teams and even at a community level. I don't know Alf if you wanna come in on that around how we can use ac this concept of activation at different in different domains in healthcare.

Alf Collins: Yeah, so there is something, isn't there, about the fact that, you know, healthcare is a complex system sitting within this even more complex system called the world. And we all have conversations with each other on a daily basis about our health. But kind of homing in on the healthcare system, we've known for many, many years, if you want to bring about

Ollie: Yeah, very complicated.

Jag: Yeah.

Alf Collins: a shift the conversations that people have, ⁓ the shift has got to happen in individual. patients, I'm going call them patients here in terms of people interacting with the NHS. There's got to be a shift in the way clinicians think and do things. And there's also got to be a shift at the system level, the health system level. And of course, the health system sits within this wider think-all community. For those people who want to think more about this, there's something called the Wagner model. And the Wagner model, again, was brought in over 20 years ago, and it graphically describes. exactly what I've tried in a kind of fairly clumsy way to describe there. So what we'd like to see is activated patients, people, we'd like to see activated clinicians working in an activated system within this ⁓ hinterland of an activated community. That's Nirvana, isn't it? That's Nirvana.

Ollie: Yes, it is. And I I have to say that I I you know, I ⁓ not because you're here, but I was, you know, really grateful for the work you led with NHS England and around introducing person-centered care roles. So I know we both ⁓ teach health coaching, we have a vested interest in there to a degree, but we've seen how bringing in skill sets like health coaching and roles like health coaches and social prescribing link workers to help kind of build agency across social sectors, activation across social areas. ⁓ and care coordinators that help the most complicated people to regain control and agency. ⁓ we we've seen a real we saw a real effort to try and drive that, didn't we? And I and I f I feel like we made a lot of progress with that. And I know, Jag, a lot of your research in Calderdale, where you've used the single question Pam and and other other markers around that has shone a light on the benefit of these perhaps slightly periphery areas in health care and social care.

Alf Collins: Yes.

Ollie: being the ones that have real impact in building activation and and the and the lead on consequences of that.

Jag: Yeah, that's right, Ollie. And that's, it's almost the reason why I'm here in a way, because you, when you start measuring things, you inevitably look at the results and you think, ⁓ my God, I've spent 20 years measuring this and all of this stuff is really not making very much impact at all. But then I've come across health coaching. I think it was the symphony data set. And I just looked at the ROI and the benefits. And of course they've got this activation measure alongside what they're doing. when you talk to health coaches, you feel really sane. because they're talking about the basics of what makes sense to me as well. Then I saw the impact they're making on healthcare utilization, on activation, and I was sold and I've been kind of pulled in that preventative care direction since then. But yeah, so I think, you know, I've got to say, you know, just a kind of big thank you to you both for that perspective of pioneering that work. And I think now is almost an equally exciting stage, which kind of is about kind of scaling it. And I think the concept and the culture, I don't think we're starting from nothing now. I think it's there not just amongst health coaches and social prescribers and the other are ours roles, but I think it's there present in most people's minds because I think we've run out of road in terms of making change at the clinical end. We've almost got nowhere left to look other than those kind of those tears that Alf described in activation at all of those levels.

Ollie: Thanks, Jack. And we I know you've got some ideas about practical approaches at a neighbourhood level, but maybe Alpha just come back to you around, you know, the the person but the personalised care programme that you led for seven years and the progress around these new roles. When you you think about the progress that was made and what worked and what didn't, what what when you look back on that now, how what's your thoughts on it?

Alf Collins: Yeah, it's interesting, isn't it? So I was there when actually it's interesting you talk about Symphony Jag. I was working with the commissioning team in Somerset when the commissioning, when the Symphony program kicked off and I was watching what was going on with Symphony and thinking, my goodness, this is making a real difference. Alongside that in Somerset, we had the Frome team who doing a lot of work around social prescribing and again using the activation measure and demonstrating massive shifts. yeah, it's written up in the BJGP a few years ago that, you know, social prescribing leads to improvements in activation leading to reductions in unscheduled admissions and GP appointments. So I kind of got all that experience and understanding and knowledge and the idea was in NHS England we just flood the system with as many of these, what are called personalised care roles. I don't like the phrase actually, I think we should all be working towards a personalised care agenda but they're broadly called the personalised care roles. Yeah, if we flood the system with them and support the system to support them in their role, to be clear about what their role is, to be clear that, you know, that they're not a dumping ground. I can't think what to do with Mrs Jones or why don't I get them to see a social prescribing link worker. So, you know, at the centre, what you don't want to do is at all dictate what should be done, but provide some kind of guidance and direction and support. I think we did an okay job on balance. And I'm grateful for lots and lots of people, Jag included. There's lots of work coming out of Oxford now demonstrating, particularly for social prescribing, that it really makes a difference, particularly for people in our more deprived community. yeah, looking back, frankly, we didn't really know as much about what we were doing as perhaps we ought to at the time. But it seems to me that the system itself... taking this by the scruff of its neck, personalised care, the concept of activation and doing great work. Thanks to the likes of you and Jag. Again, thank you.

Ollie: Yeah, well it's it's tough, isn't it? It is tough and these things go in cycles, don't they? And you know, I know ⁓ from a point of view, there's limited levers you can do, isn't there? You know, you you can suggest these roles should be there, you could provide some funding, but it takes time for the mindset to to bed in, doesn't it, that this has value and how it fits alongside what people have been doing and got used to in their professions and in their systems.

Alf Collins: And I was always cognisant of the health trainers, what happened to the health trainers. For those of you don't know, health trainers were brought in by the Deputy Chief Medical Officer Fiona Adsaid ⁓ in the early 2000s to work to support behaviour change in our most deprived communities. And they did great work, but the lesson there was that they weren't really supported broadly, they weren't really supported locally. And their work began to kind of wither on the vine and I really didn't want that to happen. with health coaches, social prescribing network, as care coordinators. And I don't think it has. I think they've got a clear, defined place now.

Ollie: Yeah, that's great. That's a great legacy from that from that work. And we're in a sort of regroup phase almost, aren't Now we're moving from perhaps primary care n ⁓ networks to to neighborhoods and thinking about further again about how we can integrate across health, social and self care. And and Jag, you you when we wrote that paper together, you and which we will link to actually, you know, you talked about sort of four areas that we identify, we intervene, we integrate, and then we measure impact. Do you want do you want to talk a little bit to that? 'Cause I know that's some some sort of pragmatic thinking from you again.

Jag: Yeah, Yeah, surely. So I guess maybe I'll frame it this time in terms of, guess, at an operational tactical level, why aren't we a prevention first system already? And so I'll just start there because I think it maps onto the same kinds of things, maybe not quite as many. But I think this is an exhaustive list, but it's just a set of kind of tactical things that are addressable that I think can contribute in a complex system to the outcomes we see at the other side. I think number one, is that we don't have a systematic way of identifying the most impactable people. They're hidden to us. And when we reach them, we reach them too late or not at all. So we need the way of doing that. And the second thing is that we deliver a lot of the work, both clinical and preventative, in a one-to-one way of doing things, because we've just learned it from the NHS. So that one-to-one prevention dominates, whereas one-to-many models remain marginal. And one-to-one prevention is good. ⁓ when it comes to taking away money from an acute, it's got to be really, really good to take a chunk of money. It's got to be consistent. And number three, we don't have a cheap, effective way to measure impact in a cost benefit comparable way. Because even if we can prove something works, we need to continuously prove that it works for the acute to move cash because they need to performance manage the thing that they're looking at in the same way they perform to manage the things that are under the umbrella. So it's about identification, intervention and impact. That brings me on to the kind of the hope here, I think, is if we can start to look at alongside one-to-one work, one-to-many work can help activate larger numbers of people, we stand a chance of shifting the whole of population's destiny or their health. at the moment, know that with a health coach doing wonderful work, their caseload is only going to be a small fraction of the total population. So it can't change the big number that somebody will pay attention to. And yes, they can activate the wider clinical team, but they don't have the structure to start to systematically activate everyone because it's a threshold based business, isn't it? So people above a certain threshold. So the exam question is, is there some way we can offer something to everyone to help activate them and remove barriers in an environment of low to no resource?

Ollie: ⁓ That's the exam that's the exam question. Sounds like you might have an exam answer as well, Jack.

Jag: And I just want to two examples. Yeah, well the two things that give me a huge amount of hope, or the two mechanisms, or the two kind of, I don't know, it's a little bit like a free energy in a way that we've just not tapped into. And one is nudge, and one is the power of the groups. There's a piece of work done by Oxford that looked at brief interventions done by GPs to talk about weight loss. And they found that when a GP talks to a patient about weight loss for 30 seconds and refers them and they take up that referral, they lose two and a half kilos. Which is great, you know. So the brief conversation works. But the most interesting thing about that is patients who received a brief conversation but didn't get referred and didn't take it, they lost a kilo. So the conversation generated one kilo at 30 seconds and then the whole intervention generated two and a half kilos. And I thought, ⁓ my God, because a 30 second conversation isn't a difficult thing to have. ⁓ Well, it can be in a primary care setting, but it highlights how powerful nudge could be for patients below a certain threshold, not patients who need help. And then similarly with group-based work, when we've got health coaches working in large virtual groups. So think... Thursday evening, 6.30, Netflix time. So lots of, know, not the main intervention, but like a precursor intervention. So what it's saying, we deliver everything digitally. We find that the cost per kilo weight loss is three times less than National Diabetes Program or the National Digital Weight Loss Program. And also uptake is three times higher and it's always coming down. So when we've got ours roles working in one too many style approaches like bulk nudge, and virtual groups, the cost effectiveness shoots up to the point where it's really, really hard to ignore. And these are really easy things to get started with.

Ollie: Yeah, no, it's some great ideas there. We might dial down into a to a bit around that, around some specifics as well. And Alf, what what's your thoughts around that? Around this sort of you know it it's about systematising our approach to activation, isn't it? Sure, it great if we can have intensive one to one stuff and that really works well, but how can we make this really big scale mainstream?

Alf Collins: Yeah. Yeah, we're onto something here, aren't we? We really are. So digital clearly has got a really big role. I think digital can I talk about offloading the clinical conversation? So if you just have a 30 second clinical conversation and just as you say, Jagan say, you might want to think about this. Shall I I shall I signpost you to it? then the digital can kind of step in and do a lot of the work for us. Digital systems now, there's quite a lot of them out there that we know, not just by the kind of work that you're doing, Jag. There's something called the HOPE program out of Coventry University in the southwest. ⁓ 10,000 people have gone through the digital HOPE program ⁓ and there's been massive shifts in activation there. ⁓ There are other... I won't mention them all, but there are other digital interventions that have been shown specifically to improve activation. So that the kind of one to many is absolutely the way forward. I just wanted to say one more thing about group work and it goes back to Bandura. So, you know, the person who brought out this idea of agency, Bandura had four core principles when it comes to supporting people through behaviour change. One of them is do it in groups. So my sense is that our core intervention should, wherever possible for health coaches, should be group work.

Ollie: Yeah, it's really interesting, isn't it? And I you know I did some work when I was a GP leader at Sloan Medical Practice. And I for me the key was always around tailoring to, you know, get this concept of activation that building people's agency is so important. But that that actually it's a different modality depending on where you're at. And, you know, if you're perhaps a little bit more highly activated, you will engage with groups and peer support and so on. ⁓ and that then frees up resource to be more intensive with those people at lower activation, perhaps, who where, you know, they may not respond or may not want to join in group work. ⁓ so I think for me the real key is to be sophisticated enough you can tailor your approach and tailor your resources to the audience you're working with. I dunno w how how you you've reflected on that.

Alf Collins: So that makes complete sense to me. There are clearly some people who don't feel ready to join a group. That said, there are people at level one who, with a little bit of support, do go into groups. And the evidence, once they do get into groups, is that they seem to do as well as or better than many other people in the group. So I got this phrase, those with most to gain do indeed gain the most if they're exposed to support.

Ollie: Yes. That's brilliant. Yeah, and in fact, of course that alludes to the fact that ⁓ also know from the evidence, don't we, that although it might be harder to sort of build people from a lower level of activation up towards that those early changes from the lowest level of activation, level one to level two, is where you get start to get the biggest return on investment, isn't it? So ⁓ you know, really thinking ⁓ about how you do that activation piece at low levels of activation is just so crucial, isn't it?

Alf Collins: Yeah, yeah, What I would say, this is not an advert for the digital hope program, but 60 % of that 10,000 people in the Southwest that enter the digital hope program ⁓ were at activation level one. So, you know, if people at activation level one can move into that, just as you've done in your Sloan Medical Center practice, if you can individually support them when necessary, if they do then move into digital support, my goodness, they can come on leaps and bounds.

Ollie: Yeah, yeah, that's brilliant. And I th I think it also plays into this value of peer support, which we also are all the three of us have all talked about, haven't it? That that it doesn't always necessarily need to be a professional who's providing the health coaching style support. And ⁓ you know, often people with lived experience ⁓ add an ad additional value, don't they? You know, you teach them some simple coaching skills ⁓ and they bring in their life experience and their authenticity with that, ⁓ it has an additive effect and Maybe again I think opens the door to people who might not have wanted to join a group but will will feel less intimidated 'cause it's led by someone who's who's like them.

Alf Collins: I was closely involved with the expert patients programme for many years and you know saw the value of that. I was an expert patients programme trainer for many years. It was not a perfect programme by any means but it was peer-led and my goodness the value of that.

Ollie: Course, they never are. Yeah, absolutely fantastic. And they and so Jag, I know you've been doing some really innovative work, ⁓ I think down in Cornwall, haven't you? You've been doing some well, you'd mentioned the symphony work, but you've been doing things across the country, experimenting with different nudge modalities. tell us a little bit more about sort of where you would go with things. You know, what what if you were kind of thinking of, you know, how ⁓ perhaps someone, you know, trying to think about how they can apply this in the NHS or maybe even in a workplace or at a neighborhood level, what sort of ideas are going through your head?

Jag: the you apply in complex system that is ⁓ a sign that small things done consistently, working together, can generate complex, wonderful outcomes. But you can't understand why it happened. It's difficult to. but you've got to focus on the ingredients, the small things everyone can do right now that might build into something complex. So with that in mind, we've tried to do is say, what could we design that neighborhood health teams, GPs, clinicians, social prescribers can do that's just really easy to implement some of this stuff? So I'll just take you through some work that we've done across a range of pilots in different ICBs, probably about seven in total, but working. probably quite closely with CornWarp over a two year period to implement some of this stuff with NAPC, but also with ⁓ NASP as well. And the pathway looks a little bit like this. We've got multiple different pilots doing it differently, but one common pathway is this. So let's say after a GP appointment, everyone who's had a GP appointment in the last week, subject to certain exclusions, we're going to send them a text message. And this might happen in a chronic disease review, quite difficult to fit it into a GP. So can ask these questions verbally in a Diabetes, with a nurse in Diabetes review, that's going really well. We're getting 100 % penetration there. Or we send a text message after the contact, everyone in the last week, and we're getting about 30, 40 % uptake, but it's always rising each time we improve it. And those questions are, how good are you taking care of your health on the four point scale? And what's the one thing that you need or we could do? to help improve your activation, some sense of words. So a numbers question and a words question of what they need next. And there's a third question as well, which is something called EQVAS, is a, do you feel your health is today? And that lets us do the economics side of things. So it's three questions, so dead easy to answer, to ask an answer. And what the idea is, that if we can systematically, we can now systematically do this for everyone. all of the time and the data lands in EMIS and system one and the clinical system. And as you've outlined, Ollie, then you're immediately getting new data about people, their baseline position and what they need. So for low activation people, for example, who said I want to move more or I have a housing problem, you've got health coaching, one-to-one health coaching and social prescribing right then and there. You've now, you know, you've addressed that first challenge. You've found people out of the ether and what they need as a function of normal care. Then of course if people are high activation and they've said look I don't need a program I just want light touch advice and reminders and goal setting then you've got large groups of follow-up text messages to send them and so we're looking at the data and saying look look at these four or five groups of people and their responses let's design a digital pathway of what to recommend or say to them next. key thing is it's all human it's all in human relationships so I just saw my GP this week So when I receive the text message, I'm thinking of my GP because we refer to it. And similarly, we try to keep it human all the way through. So there are videos of real people, real social prescribers. So my social prescriber, my GP. And at any point, you might off board into this digital pathway back into one-to-one social prescribing or group work. So it's really digital second, human first, and local human first. That's the main thing. And so all of those tools are near zero cost to try ⁓ And just a quick stat, just a link to what you both said and what you just said about ⁓ the power of the group and what people need or how small could be. One of the implementations was in Gospor we did these questions around weight management. So not general activation. was more about activation around weight management. And it was so surprising. We found that 64 % of people said, I know what I need to do. I just want light touch advice and reminders or some version of that. Only 7 % of people said they wanted typical programmatic weight management. I just find that astonishing because we've got a system that's catering just for the 7%. And those 7 % of people were people who had already been through a weight management course. So there's a kind of... kind of weird sense of creating a dependency, benefits but also a dependency as well. So there's certainly demand out there for these new techniques whilst keeping them human. So the final things I mentioned are that it's these those questions that we've been discussing, the activation questions or versions of it and some of the others that we've spoken about, they're part of the National Neighbourhood Health Improvement Programme and the National Neighbourhood Health Index. That's how that programme will be delivered and measured. And also a recent project I started to do was working on government guidance for ⁓ something aligned to the Green Book. The Green Book is how the government ⁓ measures things for investment. And we're working a project ⁓ have a supplementary bit of guidance that helps non-clinical health coaching style interventions show their value. And ⁓ they will be using those kinds of questions. So we're getting ⁓ great attention from the national reputable bodies that is the right approach as well. And then, the final thing to say is that I think ultimately, think Alf, it'd great to your point of view on this, but I think almost that the utopia of this is how do we scientifically start a social movement? I think that's ultimately our end game here. All these little things hopefully work together to snowball and compound, and then this just becomes normal for us, but we won't know how. But I think the word social movement is the one that I kind of hold in my head the most.

Alf Collins: Thank

Jag: Yeah, so that's what we're doing in common with other places.

Ollie: Yeah, brilliant. Well, I love it, Jack. And there's something about when it feels doable that often breaks down some of the barriers, isn't it? And but Alice, what what's your reflections on that then? Hearing hearing all those ideas.

Alf Collins: so much good stuff there. And I just love the fact that you're grabbing this by the scruff of the neck and doing some fantastic varied work. It's wonderful to hear. A couple of things. One very specific thing comes to mind when you talk about weight management. There was a paper by Trish Greenall and team from Oxford three years ago now demonstrating that people in the more deprived areas around them. I just didn't want to join kind of weight loss programs. They got a suspicion about these formal services. But what they did do was they worked with social prescribing link workers to move into community based activities. it made a really big difference. So there's something about. ⁓ deprivation, inequalities at the core of all this, that we're only now starting to demonstrate that sometimes statutory services aren't the right services for people in the more deprived areas of our country. You're demonstrating that. It's absolutely wonderful. ⁓ I think the other thing that comes to mind is around social movements. And ⁓ it's not us that are going to start the social movements. ⁓ It's all those people in and... Calderdale. How do we create the conditions where they can not only join up but spread the good news? Yes and thoughts.

Ollie: Yeah, it's and it's so interesting, isn't it? That how and I like the fact that you're c holding the human relationship at the heart of this Jack. And I think that really is the core thing. I keep reading that and we've been reading some reports around workplace support and the work well pilots and so on. And actually it's the human relationship part that is the real catalyst and the enabler. ⁓ but then we can wrap around all these digital support tools and all these kind of like amplifiers, group work, peer support work. ⁓ but we need we need to build it around human relationships. ⁓

Jag: Yeah, that's right, Ali.

Ollie: Goodness, we we I can see we've gone we're we I could I could just listen to you guys all day. It's been v fantastic. But we probably ought to wrap up. So I'm just wondering if that each of you's got any last sort of thoughts around you know, this principle of activation, you know, around building people's agency. ⁓ what's what's your final closing thoughts? Maybe Alf, start with you. Go on, Alf, you go.

Alf Collins: You want to go first or shall I come in? Yeah, I mean, this is such a core and important concept, as Jagger so clearly said. One of my little metaphors is think of low activation the way you might think as a clinician about a diastolic blood pressure of 120. You know, we can't allow.

Jag: You can go.

Alf Collins: people to walk around the streets with a diastolic blood pressure of 120. We shouldn't allow people at levels of activation, levels one to walk around the streets without us providing them with tailored support. It's just not right. It's just not right.

Ollie: That's pretty clear Alfred and Jack, any last some messages from you?

Jag: Yeah, thanks, Alf. And then I think for me it would be, I almost wonder what the smallest action that we can do or staff can do that might start this virtuous circle. And for me, I think it'd be to try something that we've discussed and see how it goes. Most people think they've got to put effort into it and get prepared, they need resource and need time. And I think if that feels that way, it feels too hard to make that first step. it's probably a sign that the first step is too big, so make it even smaller. And that's how activation works. The same principles that help us change behaviour with people, which is, you know, start small, kind of hook it, have a relationship and compound. They apply to us as professionals as well. So if you can do any of this stuff, make it feel easy, enjoyable, if it doesn't make it smaller. And maybe the smallest thing you can do is why don't you try asking one of these questions in front of a person, a patient, a person or a family member. or sending it on a text message. And even just one patient starts a learning loop because you'll get something back and that data will give you something to say to somebody different. And then maybe next week it's five and maybe that you can group and you can say, look, I've made this change. And that's how the snowball happens. It starts from an actionable first step. So yeah, my recommendation would to it as small as possible so it feels really easy to start when there's no time or energy or money.

Ollie: Brilliant. Thanks, Jack. Brilliant. And I hope that people listening to this will it will have sparked something in their mind that they think they can do. ⁓ but but the bottom line is is do something, isn't it? ⁓ and ⁓ it's it's wonderful collaborating and learning with you. We're all we're learning as we go, aren't we? All all the way along. Like you say, we we we discover, we practice, we put things into action, ⁓ and it's by doing stuff I think that we really learn. So thanks for your inspiration, guys. ⁓ pleasure talking to you today.

Alf Collins: you Absolute pleasure. Thank you.

Jag: Thanks, both.

Ollie: Thanks.