Helping patients to help themselves

If people want to live for as long a time as their genes allow and be as healthy as possible then they have to take responsibility for their own health and wellbeing. There’s only so much the NHS can do for people with long-term health conditions: nagging and motivating them to better their lifestyle; sharing the ‘power’ of medication in jointly agreed management plans. An all-round integrated approach means consistent advice, and person-friendly local lifestyle services with high ratings for everything that will help conventional treatments, alternative therapies and personal support.

Self-care is the individual responsibility people take in making daily choices about their lifestyle and risk taking. This may be in relation to their work, travel and hobbies, and other aspects of their everyday lives.

Self-care can only work in the healthcare setting if health professionals enable people with longterm conditions to help themselves. Health professionals can only help such patients to help themselves if the local primary care organisation (PCO) has commissioned hospital and community services to support and promote self-care. And information about the availability and reliability of alternative therapies is easily accessed and well known.

The often shown slide at self-care workshops describes a typical person with diabetes receiving up to three hours of care a year from health professionals, the rest being self-care. That diabetic patient needs GPs and practice nurses who encourage their self-management with a jointly agreed plan. The patient should be able to understand how to achieve good blood sugar control – through regular monitoring and probably adjustment of their prescribed treatment. They may bring home blood pressure readings to their clinical reviews at their GP’s surgery. They may actively review their weight and cut down on their food intake accordingly. There needs to be local lifestyle services that aid weight management, good nutrition, physical activity and support people with mental health problems – maybe via one-to-one sessions with lifestyle coaches. The community or secondary services they are referred to should endeavour to encourage self-care.

Tips for practices

Patient choice is only possible if people know what is available and have an understanding of how likely it is that the various treatments are applicable to them, might reasonably be expected to work, are safe and could suit them as individuals. So good patient literature, recommended websites and other sources of information are all vital, presented in a way and language that fit the person’s needs and preferences.

Information is all well and good but patients often need a way of navigating patient choice, as well as the advice and guidance they receive from their health professionals. The recently established network of locally based health trainers in the NHS are one group of guides who can help individuals choose to practise self-care and opt for local lifestyle services available to them. One of the positive attributes of such health trainers is that many originate from the local community so that they have a cultural understanding of their clients.

It can be confusing if health professionals in a practice team give different messages to the same patient about what works, what treatments might be considered for their situation, or how and if people can practise self-care. So consistent advice and guidance should be a watchword in every practice.

Health professionals should be aiming at agreeing self-management plan templates for every long-term condition. The extent of self-management agreed will vary between individuals depending on their ability, personal drive and preferences but should not depend on the health professional’s knowledge, skills or attitudes as it often does at present.

Soon independent providers will be required to register their services with the Care Quality Commission. The practice will have to show that it meets a generic set of registration requirements, based on essential safety and quality standards that include ‘respecting and involving service users’ and ‘monitoring the quality of provision’ and ‘care and welfare of service users’. Promoting and supporting self-care is central to these standards – and practices will need to consider how they demonstrate that they meet these standards from April 2010.

Tips for primary care organisations

PCOs need to actively commission self-care services. Clinical pathway development needs to extend from selfcare in the local community for the majority of people with long-term conditions to secondary or tertiary care for the small minority. Figure 1 reminds us of the high proportion of care for any long-term condition that is down to self-care, whatever the setting. Self-care is a continuum with shared care, carried out by health professionals together with their patients, as individuals cope with acute and long-term health conditions. At the tip of the pyramid there is pure medical care with little or no opportunity for self-care in the immediate episode, until the start of recovery when shared care and self-care can emerge again.

So PCOs need to ensure that they commission services along the continuum of the self-care pathway, valuing business cases that focus on providing support for a range of self-care for all population groups – where the ‘savings’ may be assumed from prevention of long-term conditions rather than immediate gains from reductions in use of secondary care services.

There is a great deal of evidence for what has been traditionally regarded as complementary medicine, such as acupuncture or acupressure for the treatment of back pain, neck pain or dysmenorrhoea. Acupuncture is within the range of self-care in that people can organise it themselves without going through the NHS. But PCOs are agreeing successful business cases for acupuncture clinics where savings come from fewer outpatient referrals for orthopaedics or rheumatology and less surgery for, for example, osteoarthritis of the knee.

PCOs need to work with partners to provide resources for self-care, taking advantage of what the local council or voluntary groups may be able to provide. For instance tele-healthcare is a growth area where patients are empowered, as well as the more common resources that support healthy lifestyles.

PART

The aims of promoting and supporting self-care to patients or the local population at large are to encourage individual people to:

P

Prevent the condition developing

A

Await resolution of the symptoms

R

Use self-care skills for Relief of symptoms

T

Learn to Tolerate symptoms that do not resolve or cannot be reasonably alleviated.

This model involves everyone – individuals themselves, practices and PCOs, and others in the community – in advocating and supporting people’s self-care. The approach is based on the European definition of general practice. 3 This describes the core competences that health professionals in primary care share, including community orientation and holistic modelling, which include the psychosocial and cultural dimensions of an individual’s life. All of these competences are needed for health professionals to support patients’ self-care in effective and integrated ways.Practitioners who practise alternative therapies can model themselves on these competences too.

So what we need is integrated healthcare that values self-care, with health professionals and the PCO commissioners putting people first – the central theme of the first annual conference of The Prince’s Foundation for Integrated Health earlier this year.

Written by Ruth Chambers

GP & clinical champion for the Lifestyle Support Programme, NHS Stoke on Trent, Honorary Professor Staffordshire University

Being a GP for 30 years and honorary professor at Staffordshire University makes me sound old and wise. But I’m still learning how to get people motivated to change their adverse lifestyle habits long-term (don’t they want to be healthy and well? We in the NHS want that for them!) as a clinical champion for the Lifestyle Support Programme of NHS Stoke on Trent. Of course we need good quality and effective services too which is where my other jobs come in – clinical champion for the PCT’s Quality Improvement Framework and clinical lead for Practice Based Commissioning.