12 minute read
Self-care, self-care, selfcare…: have we been missing something?
Complementary approaches may be ideally suited to supporting self-care rather than extending prescriptive medicine, and practitioners may rediscover their role as mentors. The Department of Health may be ahead of the professions in understanding the importance of this.
Healthcare or self-care?
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Health practitioners generally consider that their role is to treat their patients. Professionals may even measure their status by their relative autonomy to prescribe or intervene, and even complementary practitioners may share this aspiration. So consider this: graduates of the only MSc course in herbal medicine in the USA 1 are not permitted in most states to diagnose or treat illnesses, nor to prescribe or dispense herbal medicines. They are indeed well educated to understand pathologies and other medical and phyto-therapeutic disciplines. However they are trained to keep these insights to themselves and to use their expertise instead to provide the best individual advice for ‘clients’ who have made a personal choice to use herbs to manage their own health. Instead of saying ‘I will treat your [ulcerative colitis]’ they say ‘If I were you I would choose these herbs to help you improve your [digestive and immune] health: you can take this list anywhere you like to find them; however we also have them available if you choose… ’ The client is being supported in a self-care choice: the practitioner serves that client, as counsellor, guide, mentor, coach or trainer. They may adopt interviewing techniques to help their clients identify their health needs more effectively: more open-ended questions, less instructions perhaps. This approach seems well suited to the role of guide (particularly in herbal medicine, so many of whose remedies are traditionally seen as supporting physiological and recuperative functions). But it also stimulates wider thoughts about self-care and practitioners’ influence on their clients’ choice-making.
All healthcare systems are struggling to meet growing demands for services, so the prospect of making more effective use of professional time and facilities is a crucial strategy, particularly in chronic illnesses. It has become more widely understood that approaches that motivate patients to make long-term behaviour change are likely to be more effective than those that only patch up immediate needs. The Department of Health puts it this way:
It clearly makes sense to look for ways to encourage the public to manage their non-critical problems themselves, particularly where these are long term and where ongoing professional treatments are not cost-effective. In many areas of medicine for example the direct help a physician can provide a patient is limited, perhaps increasingly so, with the recognition that antibiotics, anti-depressants, anti-inflammatories and other prescription medicines should be constrained for wider community benefit. In many areas, for example persistent viral infections, emotional and mental distress and fatigue conditions, musculoskeletal pain and headache, functional digestive disorders and chronic inflammatory disease, and even family childcare, there are few rational prescription medicines available.
There are new visions for a patient-centred NHS that reflect the fact that the predominant pattern of disease in this country is of chronic rather than acute disease. For example the expert patient programme (EPP) is an NHSbased training programme that provides opportunities to people who live with long-term chronic conditions to develop new skills to manage their condition better. Set up in April 2002, it is based on research from the US and UK over the last two decades which shows that people living with chronic illnesses are often in the best position to know what they need in managing their own condition. Provided with the necessary ‘self-management’ skills, they can make a tangible impact on their disease and quality of life more generally. Such initiatives are taking place to empower patients. They recognise that patients and professionals each have their own area of knowledge and expertise and need to work together.
Who decides what self-care to support?
The Department of Health has also provided a useful working definition of self-care. 3
There is something fundamental here. Self-care by definition is not something that others can determine. Evidence so far is that the public has its own views as to what it wishes to do for itself. For example public health policy over many years in many countries has been to encourage self-medication, in part to shift the cost of treatments from the public purse. Nevertheless in spite of this industry sources suggest that the conventional over the-counter (OTC) consumer health industry has over 10 years not grown as expected or even as much as the prescription drug bill it was intended to replace. OTC market reports in 2009 still talk of potential growth rather than past performance. Apart from new ‘prescription-toOTC switches’, non-orthodox products like health supplements and complementary products seem better prospects in attracting more people to pay for their own medicines.
Indeed the evidence base for professional direction of ‘patient-centred’ interventions is mixed. 4, 5 Rather than plan self-care strategies it may be more productive to see where the public is already going. If the purchase of healthcare approaches outside the NHS is increasing, the implications are that these are usually also outside the knowledge base and skills set of NHS personnel. They often arise from self-directed research of the internet and other media and occur in spite of the lack of support for such choices. They include well-established home remedies from different cultural traditions in the UK, media-promoted dietary and lifestyle advice and increasingly complementary and alternative treatments. The evidence base for these approaches is variable: some have plausible rationales but undoubtedly there are cases in an unregulated sector where marketing promotion and hype can mislead. It will be necessary to engage this sector in a more collaborative fashion.
Collaborative self-care?
Where the public are consulted, they confirm their interest and potential confidence in self-care, at least in the more socio-economically developed sectors of the population, but also demonstrate that their behaviour does not always meet intention and that more encouragement from healthcare professionals would be important. 6 It is still the case that the doctor wields unparalleled authority in healthcare decisions. 7, 8
However studies have consistently shown that doctorpatient communication about autonomous patient choices is poor, 9 with non-disclosure about unconventional approaches as high as 77% in some studies. 10 If doctors were to be more engaged in encouraging a wider range of patient self-care, then the potential benefit for personal and family health, for doctor-patient relationships, for doctors’ job satisfaction and for the public purse could be appreciable.
There appears to be an opportunity for negotiating with people’s self-care choices. Constructive engagement with personal choice may appeal to many patients who
might otherwise not comply with healthcare direction. With improved navigation aids they may be helped to choose more wisely. Patients who are supported in their instincts may be more likely to feel well tended by their practitioner and less likely to adhere to the wilder claimmongers.
The Culm Valley initiative
The Culm Valley Integrated Centre for Health is a new family practice and primary care trust centre serving a mixed rural and urban population in Devon. It is committed to providing an integrated health service to its community, including a range of complementary treatments. Handing back healthcare autonomy is an important part of this vision and with Department of Health support the practice has embarked on a self-care project, with Bromley-by-Bow family practice in East London, the University of Westminster and Peninsula Medical School.
This project focuses on developing effective self-care in the context of family practice, for a range of conditions that are particularly demanding of NHS resources and GP time, are long-term, ill-defined and difficult to treat, with symptoms such as:
* Back and neck pain
* Tiredness
* Stress and anxiety
* Mild to moderate depression
* Difficulty in sleeping
* Headache
*Irritable bowel syndrome
* Recurrent infections (respiratory, urinary, thrush, herpes)
* Osteoarthritis
* Hayfever and allergies
* Eczema and skin problems
* Menopausal and menstrual problems
* Non-specific muscle and joint pains.
These are also problems likely to engender frustration between patient and clinician because standard treatments are often ineffective or have side effects. They are thus doubly suitable as areas where patients could be enabled and empowered to find their own chosen therapeutic approach.
The project will concentrate pragmatically on what market data and surveys show that people already choose: home remedies, OTC medicines, supplements and ‘natural’ products, ethnic medicines, and complementary and alternative treatments. There are two parallel tracks:
1 A survey conducted by a team at the Peninsula Medical School to understand the range of patient’s self-care strategies.
2 A review by researchers at the University of Westminster of the available evidence base on a wide range of treatments and advice on diet, exercise and lifestyle.
There will follow a collaborative and formal review of drafts among groups of patients and health professionals at Culm Valley and Bromley-by-Bow. Final documents in user-friendly English and other languages will be available for wider distribution, for website delivery and as presentation materials to patient groups and other educational outlets. These materials will include:
• simple self-help measures that can be applied at home including diet, exercises, lifestyle changes, and the use of home remedies, cooking recipes, herbal teas, herbal medicines and supplements
• the potential benefits and limitations of various hands-on therapies with clear guidance as to likely costs involved
• appropriate use of prescription and OTC medication
• appropriate use of family doctors, therapists and other health professionals.
Community care?
It is important to look closely at how best to provide the information generated in this project. There is much evidence to reinforce the findings from a Department of Health review, that some of the most sustainable outcomes of self-care initiatives involve support networks ‘in which participants form informal or formal associations, continue to stay in touch with each other and receive support from others as well as actively provide support to others…’ 11 There is agreement that the information generated should not be limited to leaflets and booklets and may for example be in the form of teaching materials and guidelines for group facilitators and health trainers, and in other ways support interaction between people with non-specific conditions and others in their community or in mutual support groups.
Inspired by the community foundations of the Bromley-by-Bow centre other ways were sought to bring the community further into the Culm Valley practice and to support the objective of sustained self-care. The main initiative has been to set up a community café in the building, a place where all who visit or work at the health centre may feel comfortable and where ‘informal or formal associations’ may be born.
Self-care and complementary practice
The rise of alternative approaches to healthcare, the professional redefinition of complementary medicine in the 1970s and 1980s, 12 and the current maturation into integrated healthcare, have all been driven by public demand rather than planning by the medical or regulatory establishments. It is arguable that the focus of many in this movement towards stronger professional recognition has shifted attention away from the fundamental needs of that public and the radical opportunities to be real agents of change. So many approaches used by complementary practitioners are well suited to supporting self-care and generally engaging with health improvement rather than disease management. In so many cases complementary approaches accord well with public instincts and personal stories of health and wellness.
Even the NHS has realised that there needs to be a new professional deal and has created the ‘health trainer’ as a person who can facilitate health change rather than instruct. Complementary practitioners could look productively at describing their work as ‘health training’, at encouraging real changes in their patients. They may be pleasantly surprised at how refreshing their work becomes in this context and how they increase their engagement with the wider public.
By Simon Mills - Herbal practitioner
My passion is to help medicine become more meaningful to the people who need it. After my medical sciences degree many years ago I chose to use plants as medicines that have always had both meaning and effect. I have since lived through various complementary medical initiatives, academic, professional and regulatory, and keep returning to the absolute importance of engaging with the story in each of our lives, and as lived in our community. I am also on the hunt for an alternative word for ‘patient’ and ‘client’ (‘valetudinarian’ – one seeking health – is good but does not easily flow!).
References
1 Master of Science Program in Herbal Medicine, Tai Sophia Institute for the Healing Arts, Laurel, Maryland USA (seewww.tai.edu). 2 Department of Health. S upport for self care in general practice and urgent care settings – a baseline study. London: DH, 2006 (available at www.dh.gov.uk/selfcare). 3 Department of Health. Self care – a real choice: self care support –a practical option. London: DH, 2005 (available at www.dh.gov.uk/selfcare). 4 Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2001; 4: CD003267. 5 Nilsen ES, Myrhaug HT, Johansen M, Oliver S, Oxman AD. Methods of consumer involvement in developing healthcare policy and research, clinical practice guidelines and patient information material. Cochrane Database Syst Rev 2006; 3: CD004563. 6 Department of Health. Public attitudes to self care – a baseline survey. London: DH, 2005 (available at www.dh.gov.uk/selfcare). 7 Gorin SS, Heck JE. Meta-analysis of the efficacy of tobacco counseling by health care providers. Cancer Epidemiol Physician-patient communication about over-the-counter medications. Soc Sci Med 2001; 53 (3): 357–69. 10 Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners: a review of qualitative and quantitative studies. Biomarkers Prev 2004; 13 (12): 2012–22. 8 Pinget C, Martin E, Wasserfallen JB, Humair JP, Cornuz J. Costeffectiveness analysis of a European primary-care physician training in smoking cessation counseling. Eur J Cardiovasc Prev Rehabil 2007; 14(3): 451–5. 9 Sleath B, Rubin RH, Campbell W, Gwyther L, Clark T. Complement Ther Med. 2004; 12 (2–3): 90–8. 11 Department of Health. Research evidence on the effectiveness of self care support. London: DH, 2007 (available at http://tinyurl.com/2wgabu). 12 Mills S. The development of the complementary medical professions. Complement Ther Med 1993; 1 (1): 24–9.
