Four evidence-based models of self-care
Professor David Peters discusses the options available to GP commissioners as they aim to ease pressures on the NHS
Of the 57 million consultations that involved a minor ailment in 2007, 51.4 million were for minor ailments alone, according to the Self-Care Campaign. A recent King's Fund report highlighted self-care as one of the top 10 priorities for GP commissioners as they attempt to ease the burden on the NHS and control costs.
Most of us would agree that self-care is crucial to sustainable recovery in chronic relapsing illnesses – in effectiveness gaps such as irritable bowel syndrome, mild to moderate depression and back pain, where lifestyle, stress and exercise can make or break recovery.
These complaints are often also at the root of GP consultations for patients who have a chronic disease such as diabetes, ischaemic heart disease, chronic congestive heart failure and COPD. Often the same sorts of ill-defined, hard-to-treat symptoms undermine quality of life more than the primary condition itself.
The evidence is clear that peer-led self-care works. More than half of patients questioned in the Department of Health's public attitudes to self-care baseline survey in 20051 said they would be confident about self-care if they had support from people with similar health problems. A major DH review2 found the most sustainable self-care initiatives involved either formal or informal groups, that self-care was most beneficial when people talk, and that support from friends and relatives is almost as powerful as support from health professionals. Here are some models shown to be effective.
Peer-led self-management groups
The Expert Patients Programme (www.expertpatients.co.uk) is a community interest company providing lay-led self-management courses throughout England and online, offering patients with long-term conditions the tools to manage their condition and become less reliant on health professionals.
Courses run for two to three hours over six weeks and are delivered by former participants who have been trained as tutors. The programme provides a robust quality-assurance system for courses and accreditation procedure for tutors.
The Expert Patients Programme works with commissioning partners to target specific groups and work with hard-to-reach communities, with some courses being delivered in nine other languages. It is particularly relevant in areas where use of health services is very high.
In 2007, DH research concluded as a result of an randomised controlled trial that the programme improved quality of life. Key outcomes such as a 7% reduction in GP consultations and a 16% reduction in A&E attendances made the programme fully cost-effective. Where the intervention is targeted at patients with higher use of health services, its impact on costs is even greater.
Recent research shows a return on investment of £3:1 for a generic self-management programme, and for a condition-specific programme a health and social return on investment of £6.50:1.3
Community engagement – green gyms
The term ‘green gym' was first coined in 1999 by Dr William Bird, a GP at the Sonning Common Medical centre, after the success of his award-winning Health Walks project. In its evaluation by Victoria Reynolds in the same year, she found the green gym had both preventive and curative effects on physical and mental illness.
Patients attended half-day sessions, usually in the morning, outdoors in the countryside or a park. After a quick warm-up and a briefing session on what jobs are available and how to fulfil them safely, patients got to work on a group task, such as a conservation activity.
People who regularly attended the green gym increased their bone density, and so were less at risk of osteoporosis. They also reported finding day-to-day activities easier, felt fitter and had more energy than before, and had a general feeling of wellbeing enhanced by being in the fresh air and working in natural surroundings.
Long-term adherence rates were encouraging, with 72% of the participants involved in the research still active after six months despite the fact 82% had not taken part in any previous conservation activities.4 The cost of setting up a green gym group ranges from £17,000 to £30,000 per year for the first two years, with costs then falling. But if you can train committed volunteers, set-up costs can be much lower.5
Community into practice
Dr Michael Dixon's Culm Valley Integrated Centre for Health opened in 2007 as a primary care centre for a relatively deprived part of mid-Devon, based on a family practice and community centre at Bromley by Bow in east London. The centre has an innovative design that made it suitable for development as a ‘community hub' pilot.
A new café became a magnet for patients visiting or working in the centre, and a health facilitator was employed to engage with staff and patients about self-care. The café became a forum, an intelligent waiting room, with activities often led by patients opting not to sit passively waiting for their appointment.
There were overt health activities like exercise sessions, evening classes on relaxation techniques and healthy cooking, a gardening group growing vegetables for the café, and a demonstration herb plot of simple home remedies. Especially productive were the health question time panels, where audiences engaged with experts on topics such as back pain.
Using a Google calendar, the practice invited community leaders to promote relevant activities of their own, now modelled as a new community prescriber facility that can be tailored to any GP area.
Clinicians at Culm Valley have already seen changes in patients' expectations. Anonymised evaluation forms found patients appreciated the health facilitator role for ‘immensely helpful support and advice'. One patient reported that the facilitator was ‘the only person who got through to me on health issues in 10 years'. Responses to the café were also positive, with patients remarking that it felt like part of their treatment.
Evidence-based self-care information
The Self-Care Library (http://selfcare-library.info/) is designed to provide self-care information about common chronic illnesses seen often in practices.
Researchers at the Peninsula School of Medicine and Dentistry surveyed 3,000 people on GP lists and found self-care for common problems was already widespread, particularly among those most bothered by their symptoms. They also found doctors and health professionals were the most trusted sources of advice, that getting a diagnosis was a powerful tool for encouraging self-care and that friends and relatives were powerful influences.
The project produced a series of evidence-based leaflets explaining each condition and rating the options (exercise, relaxation and diet; over-the-counter medicines, supplements and natural remedies; classes and therapies) for likely benefit, safety and cost.
The next phase will include webpages on diabetes, cancer support and cardiovascular disease. The information is available at an interactive website, mainly using PDFs for each condition. In future, the library could be developed as an iPad app and adapted for touch-screen computers in libraries, pharmacies and waiting rooms.
GPs at Bromley by Bow and Cullompton practices used leaflets about the library with patient groups and adapted the leaflets during the test phase. Feedback has shown the majority of users found them useful or very useful.
Dr Andrew Tresidder, a GP in Somerset, and Dr Trevor Thompson, a GP in Bristol, both praised the website. Dr Thompson said: ‘In an inner city where demand is high and time is short, your guides are a blessing as they bring together good-quality evidence in a format most patients can understand. Often people just want something they can do to feel in control.'
Professor David Peters is clinical director of the polyclinic at the University of Westminster and co-chair of the College of Medicine's faculty of self-care.
1 Department of Health. Public attitudes to self-care: baseline survey. 2005
2 Department of Health. Research evidence on the effectiveness of self- care support. 2007
3 Expert Patients Programme. Healthy lives equal health communities. 2011
4 Yerrel P. National evaluation of BCTV's Green Gym. 2008 www2.btcv.org.uk/display/greengym_research
5 BCTV Factsheet. Setting up a gym. http://tinyurl.com/7achmcs