The benefits of self-care initiatives cannot be denied, but most GPs have yet to embrace this area. Emma Wilkinson identifies the pros and cons of different approaches.
We have all seen the startling figures – 30% of people with long-term conditions account for 70% of NHS spend; by 2025, there will be 18 million people in England with long-term conditions; they account for 50% of GP appointments, 65% of outpatient appointments and 70% of inpatient bed days.
Self-management is a topic that has been high on the political agenda for a decade or more. Back in 2002, the Wanless report claimed that for every £100 spent on encouraging self-care, around £150 worth of benefits can be delivered in return.
Yet there has been a disconnect between the political rhetoric on self-management and any real change in the management of long-term conditions.
Adrian Sieff, assistant director at the Health Foundation, says clinicians have been sceptical, and the change requires a ‘fundamental shift’ in the medical model of doctors traditionally leading and patients following.
‘There has been reluctance from health professionals on self-management because they don’t think it works or is going to make a difference,’ he says. ‘They may also not know how to do it in practical terms. You have had different specialties trying to work out how to fit this into their daily routines, but not working together. We need to
re-educate the workforce at all levels about why this is important.
‘With shared decision making there is evidence that a lot of clinicians say they really support it and are adamant that is what they are doing, but when their consultations are independently monitored they are not doing shared decision making at all. They simply have a different concept of what it really means.’
But 50% of medications prescribed for long-term conditions are not taken, so the current system is not working, he adds.
In the 2011 report for the Health Foundation, Helping people help themselves,1 Dr Debra de Silva from The Evidence Centre points out that there is high-quality research supporting self-management, particularly strategies focusing on behaviour change and supporting self-efficacy.
Self-management does have the potential to alleviate growing pressures on an already-stretched health service, she says. But one-off interventions are unlikely to have any real impact, she stresses. The challenge for commissioners is to apply best evidence to alter how care for people with long-term conditions is delivered.
The solution is likely to be a combination of strategies taken from those shown to have a positive effect.
Giving people information about their condition, whether in books, leaflets, emails, websites, text messages or by phone, can be useful, evidence suggests.
But, says Dr de Silva, giving leaflets in isolation ‘is not going to make people responsible for their health’.
• May help people be more confident in asking about their condition.
• May improve knowledge of the condition.
• Is especially helpful if personalised and used with other initiatives.
• Unlikely to have lasting impact on health behaviour if used alone.
Decision support tools
Decision support tools such as flow charts are still about giving people information, but may require them to be more involved in the process of taking that information on board. The tools may also help clinicians follow agreed protocols, says Dr de Silva.
• May encourage patients and carers to take more responsibility.
• May help patients feel more in control.
• May improve quality of life.
Evidence suggests the main impact is on patients’ attitudes and knowledge, not behaviour.
A recent report from the RCGP on care planning2 states that clinical staff have been reluctant to provide active support for patient engagement in consultations about their care. Care planning is common in the UK, but the norm is for this to be clinician led. As a result, it says, shared decision making is less common in the UK than in other countries. It is this lack of engagement by patients that leads to poor uptake of patient education, poor adherence to medication and is likely to contribute to higher than necessary healthcare costs through factors such as high admission rates.
With proper care planning, the patient is given their own results, such as HbA1c and blood pressure, before the consultation with an explanation of what the numbers mean. They are then encouraged to set their own achievable goals, with guidance and support from the health professional.
• Increases patient engagement.
• Some studies have shown measurable improvement in clinical outcomes – for example, improved HbA1c levels in patients with diabetes.
• Patients may be more likely to achieve personally set goals.
• Attendance may be improved.
• Improves take-up of education programmes.
• Requires a large change in mindset of health professionals involved.
• Additional staff training may be needed.
• Patients may not want to take part in the care planning process.
• Clinicians may struggle to take a back seat in goal setting, preferring ‘doctor knows best’.
• Requires follow-up for action planning to have an effect.
Individual and group education programmes have been widely evaluated.
One-to-one education does seem to have an impact on improving knowledge, but for a significant impact on clinical outcomes it would need to be targeted, specific and long term, says Dr de Silva.
Group education and peer support programmes have also proven successful in some cases, particularly courses on improving ‘self-efficacy’ – that is, the patient themselves feels empowered and motivated to manage their problems because they are confident in their ability to achieve this goal.
• Individual and group education programmes have been shown to benefit people in managing hypertension, heart failure, arthritis, diabetes and asthma.
• They can be carried out by a variety of healthcare professionals, including nurses and pharmacists.
• Group education can improve self-confidence, clinical outcomes and even health service use, studies suggest.
• Education alone may increase knowledge, but needs to be targeted, specific and long term to have an impact on behaviour and clinical outcomes.
• Not all programmes have been shown to be successful.
Self-monitoring and telemonitoring
In December, the Government announced as part of its life sciences strategy that
3 million at-risk patients would receive
hi-tech equipment in the home. Most studies on self-monitoring identified by Dr de Silva had positive outcomes.
Having a tangible measure of their condition can really help patients engage with the management of their illness, she says.
But as with all the other tools, just relying on that alone will not produce better outcomes and it needs to be part of a range of measures.
• Self-monitoring may help patients feel more in control.
• Some randomised trials have found clinical benefits, including in diabetes and hypertension.
• Self-monitoring may be inappropriate or unfeasible for some patients.
What is clear, says Dr de Silva, is that there is no silver bullet. Providing patients with information and technical skills is just one part of the jigsaw and initiatives that ‘recognise motivations and needs, take account of patients’ level of desire to change (or stage of change) and support them emotionally and psychologically’ are the ones most likely to produce sustainable effects on behaviour, clinical outcomes and healthcare resource use, she adds.
Dr de Silva also warns commissioners that success will need to be measured in the long term, as although patient satisfaction may improve quickly, benefits for clinical outcomes are likely to take far longer.
‘My main tip would be that we need to re-educate the workforce at all levels. Without buy-in none of this can make a difference,’ she says.
Mr Sieff adds that for self-management to be successful, commissioners need to:
• measure the ability of patients to manage their own long-term condition
• train clinicians to support patients to manage their long-term condition
• provide training for patients, as an integral part of the care pathway, so they have the confidence and skills to manage their own condition.
Emma Wilkinson is a freelance journalist
For more information, visit health.org.uk/publications/evidence-helping-people-help-themselves and rcgp.org.uk/PDF/CIRC_Care_Planning.pdf