Will self-management be panacea for NHS?
By Daniel Cressey
Part of being a GP is to grumble about the frustratingly large number of consultations that don't really serve any purpose.
GPs are bombarded by
sicknote-seekers and those with psychosomatic illnesses, and they also spend a hefty chunk of their time managing patients who could manage themselves.
That at least is the Government rhetoric, with ministers becoming increasingly convinced that patient self-care is key to relieving pressure on an overstretched NHS.
A new report by the Proprietary Association of Great Britain makes clear the extent of Government ambitions.
'From a baseline where the GP was considered as the starting point of healthcare, in the past two years no fewer than eight major Department of Health publications have embraced self-care as the foundation of public health policy,' the report says.
And it concludes: 'After 58 years of the NHS, the pharmacist has the opportunity to take on the GP's role as gatekeeper.'
But quite how much capacity there is for patients to manage their own conditions is unclear. There is still controversy over whether self-management is a real solution, and the extent to which ministers merely want
to encourage use of over-the-counter drugs, with their associated savings for the NHS.
Dr Fiona Jones, senior lecturer at the faculty of health and social care sciences at St George's, London, says: 'It's very attractive to the Government because it thinks "it's going to save us lots of money". It's not going to mop up everybody.'
But Dr Jones is nevertheless enthusiastic about the potential to educate patients to gain confidence in managing their own conditions.
'There's a lot of scope for interventions that help people develop skills in self-management. It's being able to problem-solve, being able to make decisions.'
Professor David Fitzmaurice, professor of primary care research at the University of Birmingham, is similarly keen.
'I can't think of anywhere it wouldn't be appropriate as long as training and support is in place. One obvious area it could expand into is blood pressure control for a large minority of patients,' he says.
But the extent to which patients are handed control of treatment decisions is contentious. Just a few weeks ago, a Cancer Research UK study found women with ovarian cancer felt 'confused and concerned' when offered choice over treatments.
Last week Pulse reported
research suggesting that self-monitoring of diabetes brought similar anxiety, perhaps by
forcing patients to think about their condition more often.
Neither were there any benefits for HbA1C or BMI.
Study leader Dr Maurice O'Kane, consultant chemical pathologist at Altnagelvin Hospital in Londonderry, expresses reservations about the value of self-monitoring: 'It is widely advocated in type 2 diabetes, expensive to the NHS and considered an inconvenience by a proportion of patients.'
It is a view shared by other experts in the field – in some cases patient empowerment to self-care simply doesn't work.
Dr Ahzar Farooqi, a GP in Leicester and diabetes lead for Eastern Leicester PCT, says: 'The difficulty is the majority of
patients don't do anything with the test – they don't use it to change their lifestyle. I would say routine use of blood glucose monitoring is not indicated – that's supported by research.'
Diabetes is not the only area where benefits are unclear.
Dr Rupert Jones, a GP in Plymouth and head of the Respiratory Research Unit at Peninsula Medical School, says: 'There's very good evidence in asthma. In COPD it's rather different – the Cochrane review and the major studies don't show major benefits for self-management.
'That people need to be counselled about what to do if they get worse is beyond debate in a disease where people have exacerbations, but if you're looking at specific interventions sometimes the evidence is lacking.'
So self-care looks unlikely
to be the cheap, easy fix the
Government perhaps hoped. Helping people to look after themselves does not mean they no longer need a doctor.
Self-management pros and cons
• Evaluation X-pert programme for type 2 diabetes found significant benefits for glycaemic control, cholesterol and body weight
• BMJ study of 443 patients with poorly controlled anticoagulation found self-management brought significant improvement
• Study presented to the European Association for the Study of Diabetes conference found self-monitoring appeared to raise levels of anxiety
• Study of 617 patients in the British Journal of Haematology found self-management was unlikely to represent value for money for the NHS
• Self-help programme for patients with moderate to severe depression did not improve depression scores: study in Psychological Medicine