With the ongoing increase in long-term conditions threatening to overwhelm already stretched services, there is much talk of self management: all those things people do to manage long-term conditions for themselves, from taking tablets or keeping active to solving daily problems.
There is also a growing interest in self management support: what our health and social care system can do to help people with long-term conditions do all these things as effectively and confidently as possible.
Self management support involves enabling people with long-term conditions to play a more proactive role in their health and healthcare. It does this by providing them with information and practical tools to help them develop skills, such as goal-setting and problem solving, and by signposting them to relevant support or activities in the wider community.
Consensus is building on the need to offer self management support, with strong evidence from pilots across the UK. So what should health and social care be doing to embed this approach into the heart of our system and spread it more widely?
We asked two advisers on the government’s QIPP (Quality, Innovation, Productivity, Prevention) long-term conditions programme for England: Dr Alf Collins, Clinical Lead for Pain Management Services for Somerset, and Sue Roberts, chair of the Year of Care Partnerships and former National Clinical Director for Diabetes.
Tell us a bit about ‘self management support’
Sue: Self management support focuses on two areas of experience for people with long-term conditions: their consultations with the NHS, and the things they do in between these consultations. For the NHS, this involves encouraging professionals to develop new skills, preparing patients to be more actively involved in their health and healthcare, and building organisational, systemic and commissioning capacity.
Alf: Part of it involves inviting frontline health and social care workers to develop new communication skills. For example, if a patient asks for their usual tablets, a doctor might learn to say: ‘We can think about tablets, I am also interested to hear how you already stay healthy' – gently turning the conversation around.
What is the health professional’s role in all this?
Alf: It becomes one of guide or navigator – working in partnership with people with long-term conditions and supporting them to understand the various options available to them, both within the NHS and beyond ‘usual’ NHS provision. To do this, health professionals need to adopt a different mindset, acquire new skills and tools, and have a co-production philosophy. This means supporting patients to recognise and engage with their own resourcefulness and build on that, rather than necessarily just giving them a treatment.
What are the benefits of involving people in their health and healthcare?
Alf: The evidence is that it works. We can measure self management capability by looking at people’s knowledge, skills and confidence. It’s called ‘activation’. Various programmes of work, including the Health Foundation’s Co-Creating Health programme, have shown that the higher people’s levels of activation, the better their health outcomes. So, if we can help people to move along their activation journey from, say, level 1 to level 4, then we know we’ve done a good job.
How does self management support work in the first area you defined: the consultation?
Sue: It ensures that when people meet health services they understand how the system works, how to make use of it, and that health professionals and people with long-term conditions understand their roles and how to work better together. A big part of this is about recognising that people already have experience and ability to bring to the table, and helping to maximise them.
How does it help with the second area: managing health in between consultations?
Sue: If we want to empower people to manage their own health, there needs to be a spread of activities, ranging from peer support groups to physical groups, such as classical Indian dancing, guided walks, fishing clubs or community gardens. These activities are often seen as charming add-ons, but for people with long-term conditions they may be just as much part of therapy as drug treatment or specialist care. Commissioning plays a crucial role in self management support, and we need to be advising commissioners on what activities are needed locally.
What are the key ingredients for bringing these two areas of support together?
Sue: Engaged, informed patients, professional commitment to partnership working and appropriate organisational processes. These are the elements that enable each person to be involved in individual care planning, during which they can identify the right support for them, based on their own goals for living their life with the condition.
Alf: Consistency across the various players and coordination, to ensure that the work is actually taking place. This is partly achievable by embedding skills and tools in the frontline health and social care workforce and partly by introducing appropriate metrics to help staff understand how to continue to improve.
What challenges still need to be overcome?
Alf: We’re still a little way from engaging the majority of frontline clinicians on this issue, partly because this way of working can initially take more time – and time is a big deal. Ultimately over time, GPs will need to see people who live with long-term conditions less frequently. We have to think about long-term conditions in a very different way, working in the biopsychosocial model (which sees health in terms of a combination of biological, psychological, and social factors rather than only biological). We’ve got to get into medical schools and help doctors understand that medicine isn’t always a ‘fix’ – it’s often not curative.
But we’re making progress all the time. In 2011, to promote the QIPP long-term conditions programme, Sue and I took part in roadshows around the country and saw enormous enthusiasm from people working across health and social care who were keen to get started.
What does the future hold for self management support?
Sue: We’re beginning to see a feed through, but with the changes in the NHS, organisations aren’t in a position to systematically think through what’s needed. The great thing is that thanks to Year of Care and Co-Creating Health, there’s a huge amount of learning. And once CCG authorisation is out of the way we can use what we know constructively, to support much more rapid change. We know what to do. Now, we need to get on with some practical delivery.