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  • Embedding self-management support through the three strands of the Co-creating Health programme.
  • Phase one ran from September 2007 until August 2010 and focused on chronic pain management.
  • Phase two ran from 2010 until November 2012, rolling out the approach with chronic obstructive pulmonary disease (COPD) patients.
  • Included both primary and secondary care settings.

The overall aim was to ensure that self-management support was offered as soon as a person with a long-term condition made contact with their primary care physician. To achieve this the trust trolled out the three elements of the Co-creating Health programme:

  • Self-management Programme (SMP) for people with long-term conditions
  • Advanced Development Programme (ADP) for clinicians
  • Service Improvement Programme (SIP) to redesign services.

The initial focus was people with chronic musculoskeletal pain, the approach was then rolled out to COPD patients in phase two of the project.


Eight clinical teams were established to test changes to services as part of the SIP. They introduced changes across primary and secondary care settings, which demonstrated a number of improvements.

Consistent use of agenda setting with individuals before clinic consultations led to increased patient confidence to discuss issues important to them. An audit of medical notes also showed consistent evidence of collaborative goal setting and action planning, demonstrating clinicians had become comfortable providing self-management support.

Patient confidence to manage their condition improved, leading to less use of medication and fewer encounters with health professionals.

A large number of individuals successfully achieved personal goals such as losing weight, giving up smoking, becoming more active, and developing their own support networks.

The project wasn’t without challenges. Some of those faced were:

  • Recruiting a large enough group of tutors to undertake the programmes.
  • Clinicians found it particularly difficult to spare time and source cover to participate in the programme. To tackle this an e-learning package was introduced for ADP to minimise time taken out of clinical practice.
  • There is a need to strongly link the three components of Co-creating Health: SMP, ADP and SIP. The team found they needed to focus on this more in phase two.

Further reading

About this programme

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