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  • Embedding self-management support through the three strands of the Co-creating Health programme.
  • Focused on working with chronic obstructive pulmonary disease (COPD) patients.
  • The first phase ran from September 2007 until August 2010. The second phase ran from January 2011 until November 2012, broadening the focus to people with other long-term conditions.
  • The project began with embedding the approach in secondary care, before moving on to involve GP practices.

Overall, the aim was to introduce positive benefits from efficient self management thereby improving people’s quality of life, helping avoid emergency admissions to hospital, and reducing the burden on the NHS. To achieve this they rolled 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.


Evidence gathered during a monthly casenote audit showed that individuals and clinicians were jointly setting an agenda and together agreeing goals and follow-up. Feedback demonstrated that the majority of service users felt they had the information they needed to manage their condition well and were supported by their clinician to manage their condition.

Other evaluations also showed that clinicians had changed their consultation behaviours and were enabling people to be more in control.

The trust also tested a combined COPD and diabetes programme, which was a success with good attendance and retention of participants.

Some of the specific actions the team took to ensure this success were:

  • Promoting SMP as part of the ADP course encouraged clinicians to refer to the programme.
  • Ensuring engagement and commitment from influential people within the organisation enabled CCH to become embedded as an important dimension of several organisational work streams.
  • Integrating self-management support activities into systems and pathways wherever possible ensured sustainability.
  • Collecting evidence to show that supporting self-management had a positive impact (by limiting emergency hospital admissions and reducing length of stay) to secure ongoing investment.
  • Working on making clinician training flexible to suit need, including introducing an e-learning module, enabling time-pressed clinicians to take part.
  • Adapting SMP and ADP, making them locally relevant and sustainable.

This project was twinned with the Co-Creating Health project at Cambridge University Hospitals NHS Foundation Trust.

Further reading

About this programme

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