Guest Editorial - (2006) Volume 14, Issue 3
Professor of Primary Care, Faculty of Health and Sciences, Staffordshire University, Stoke-on-Trent, and Director of Postgraduate General Practice Education, West Midlands Deanery, Birmingham, UK
It is widely believed that patients who adopt self care practices, will reduce demand on general practitioners (GPs) and other providers of healthcare as a whole. The evidence base that justifies self care is wideranging,but robust evidence of the cost-effectiveness of increased self care by patients is awaited, in terms of better health outcomes for patients, more appropriateconsultations with the healthcare team, and savings on providing healthcare.
It is widely believed that patients who adopt self care practices, will reduce demand on general practitioners (GPs) and other providers of healthcare as a whole.[1] The evidence base that justifies self care is wideranging, but robust evidence of the cost-effectiveness of increased self care by patients is awaited, in terms of better health outcomes for patients, more appropriate consultations with the healthcare team, and savings on providing healthcare.[1,2] There may be displaced costs. For example, more appropriate consultation behaviour by patients with doctors could lead to increased consultation rates with other primary care professionals such as pharmacists, or with primary care nurses. Evidence for the cost-effectiveness of nurses substituting for doctors is in doubt because doctors’ workload may remain unchanged either because nurses are deployed to meet previously unmet patient need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors.[3]
It is not just potential savings in staff costs we need to consider in gauging the cost-effectiveness of a future situation where a greater number of the general population adopt self care more readily or more extensively than is the case now.
The NHS costs of purchasing equipment for patients to enable their self care, for example for self monitoring of hypertension, might be recouped by reducing over-prescribing of antihypertensive drugs and improving patient concordance.[4] But it may be that self monitoring reveals under-treatment of hypertension and goes on to generate increased expenditure on prescribing – although the costs of the additional expenditure on drugs could be more than offset by improved health outcomes and the person’s increased ability to work, and reduced healthcare costs from avoiding the complications of hypertension.
Safety concerns tend not to feature in research reports or policies of those advocating or trialling patients’ self care;[2,5,6] yet there are potential adverse events for most health conditions if medical care is not sought or obtained appropriately.[7–10] So, inappropriate self care could be costly for the individual person if they suffer harm from waiting too long before seeking medical help, or pursue self care with an ineffectual or harmful treatment. It could rebound on theNHSif the result of self care is increased utilisation of healthcare services – for example to treat quinsy or epiglottitis (if a patient significantly delays seeking help for sore throat symptoms), [7] a dissecting aneurysm (back pain symptom),8 hospital admission for asthma (ignored shortness of breath),[9] or an inhaled foreign body (cough symptom). [10] Safe self care is about a person managing risk satisfactorily and seeking medical help for that episode when necessary.
Self care is the basic level of healthcare in any society.[11] It is the reality of most people’s lives. The challenge is to integrate support for self care by patients and the general population as a whole, throughout the provision of normal healthcare services.
In the UK, self care comprises an estimated 80% of all care episodes in primary, secondary and tertiary care. Self care is a continuum, starting from 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 as well as health and wellbeing and other aspects of their everyday lives. Next along the continuum, is the self management of ailments without, and with, assistance from health professionals such as pharmacists, GPs or nurses.[1] Shared care follows on – by health professionals together with their patients, as individuals cope with acute and long-term health conditions. Ultimately there is pure medical care with little or no opportunity for self care in the immediate episode, e.g. compulsory psychiatric care or major trauma or illness – until the start of recovery when self care is possible again.
Promoting self care by patients and people in general is central to the government’s White Paper on care outside hospitals in England.[5,6] This policy envisages supporting patients’ self care as a driver for better co-ordinated multi-professional working within healthcare teams, and across the interfaces of primary, secondary and community care settings.
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.[1,2,11]
This model moves away from the typical medical model, and involves others in the community from local government, non-government organisations, the media, leisure and sports settings in advocating and supporting people’s self care.
The model is based on the European definition of general practice1 that describes similar core competencies which GPs and other health professionals working in primary care share: primary care management, person-centred care, specific problem-solving skills, comprehensive approach, community orientation and holistic modelling which includes the psychosocial and cultural dimensions of a person’s life.[11] These six competencies are rooted in: the attitudes of health professionals and patients; the evidence base or science of medical management and treatment; the context of the primary care setting and the person. All of these competences and practice are needed for doctors and other health professionals to support patients’ self care in effective and integrated ways.[12]
Health professionals need resources and skills to support self care that it is matched to the circumstances and characteristics of the individual (age, ethnicity, language, specific acute/chronic condition etc). Clinical protocols and patient pathways of acute and long-term conditions and minor ailments need to be adapted so that self care is central and applied within primary care and across the interfaces with secondary care and community care, pharmacy, dentistry and public health within a local area. Supporting self care is integral to effective practice-based commissioning; patients’ self management plans are increasingly accepted as improving clinical outcomes and helping to manage demand.
The Expert Patients’ Programme is being mainstreamed, and is another resource for enhancing patients’ self care skills and reversing the medicalisation of the patient perspective of their care and life events.[13]
Training health professionals about supporting self care is not just about their gaining new or updated knowledge and skills, but also about changing attitudes to the relevance and safety of empowering patients to increase the likelihood that, and extend the manner by which, they may care for themselves. Health professionals need to motivate patients to change their dependent behaviour and gain confidence in adopting self care. Empowering the patient means using enabling language consistently, rather than disabling remarks that keep both health professionals and patients chained to a medical model.
