My guess is that if you did a straw poll of clinician views on the subject of self-care and co-management by patients, a majority would be in the ‘fine if it happens, but I can think of many patients who can't do it' camp. There would be some who would believe it is an unrealistic expectation, and others who would be strong advocates.
Self-care is not just a ‘nice' thing to do. It leads directly to improved clinical outcomes. Practices will also gain both in terms of patient appreciation of their services but also through efficiencies created in the utilisation of their staff and services.
The NHS is not sustainable unless we embrace more actively the users (and indeed shareholders) of the service in care itself and it is now a necessity. It does not need to be GPs themselves who undertake the lead in helping patients self-care, but CCGs or practices should identify those at the front line who need to receive the necessary training, and link that to HR appraisal and their strategic plan.
As professionals we are not taught how to transfer knowledge to patients. Most of us feel our way and many may hesitate because they see it as time consuming. Firstly when I began as a GP the definition of a professional was a possessor of knowledge. Now I am an interpreter of knowledge because that knowledge is more widely available to people.
However it does not need to be the GP who is the progenitor in conveying knowledge for self-care. That could be the designated contact in the integrated care team for a particular patient. Whoever that person is does however need to understand the techniques that best help patients to gain knowledge. The care plan is the written documentation of what to do when, but techniques such as motivational interviewing, or the Health Foundations co-creating health, or the Diabetes Year of Care self-care tutelage (now focussed on multi morbidity), are the mechanisms for the how.
I would encourage CCGs and community service providers to identify people for that training. The LTC QIPP workstream is providing such opportunities around the country sequenced to follow on from our main programme.
I am in the latter group and in this article I want to set out the reasons why on clinical, organisational and system grounds.
Clinical
The evidence base is increasingly strong that patients who understand and help manage their own conditions have better clinical outcomes.
For example:
· 29% reduction in heart attack recurrence;
· 34% fewer arterial disease-related deaths;
· statistically significant improvements in BP and cholesterol levels;
· statistically significant improvements in exercise, diet and smoking;
· patients self managing their anticoagulant therapy showed a 50% reduction in number of clots and a 36% reduction in deaths c.f control.
It is also the case that patients who feel involved in their care and have knowledge of it, have a greater sense of well being and at ease.
A positive patient experience is associated with better long term outcomes (shown for patients with myocardial infarction but likely to be generic)There is some evidence that the mental health of patients with long term conditions, (anxiety and depression) is better in patients that contribute to their own care. And it is in patients with long term conditions that the greatest benefits and maximum impact can be seen. These benefits extend to practices themselves.
Organisational
The following is documented in the literature as benefit accruing to organisations that empower patients to self-care, or co-manage their condition.
At a basic level the experience of patients is improved, and the satisfaction ratings higher. Reduced visit rates have also been reported as have length of stay in hospital. In addition maximising self-care by including patient access to their electronic medical record, gives substantial gains.
One unpublished study shows for those patients who have access to their own medical records, reduced consultation rate with doctors and nurses, reduced visits, and substantial reduction in telephone contact. Translated into efficiency gain for staff, if 30% of a patient list accessed their medical record in a practice of 16000 there would be a £54,000 saving. Or nearly £3.50 per patient on your list.
I can also say from personal experience that the dynamic of the consultation is on a different level. Patients are prepared, informed and up to date with where they are. The consultations are focussed, productive and enjoyable. In short creating the mechanisms to maximize self-care or co-management is a no-brainer for practices – not least for the business case.
System
Finally there are enormous benefits to the system as a whole from maximising the number of patients who can contribute to the management of their conditions. Many readers may have heard me talk of the tsunami of need heading our way because of demographic shift: a 252% rise in those with long term conditions by 2050. The majority of over 65s now have two or more conditions, and the majority of over 75s with three or more.
If we do not change the system of management for patients with long term conditions and move away from disease specific silos our health and social care systems are not sustainable. Embracing the most underused resource in our system, our patients, is essential in meeting this challenge.
There are three drivers that the distillation of evidence indicates will improve quality, and reduce duplication and unscheduled admissions. These are: risk-stratifying the population with long-term conditions and identifying those in the top 3-5% of risk; having local integrated care teams between health and social care proactively managing these patients but seeing them as a whole and not parts; and systematising the mechanism to maximise the number of patients who can co-manage their conditions. All these need to be in place but the third element – systematising co-management is vitally important.
Sir John Oldham is a GP in Glossop, Derbyshire, and national clinical lead on quality and productivity at the Department of Health
