Impact of Self Management on NHS services

A new report shows correlation between people’s ability to manage their health condition and use of NHS services.

“We found that patients who were most able to manage their health conditions had 38% fewer emergency admissions than the patients who were least able to. They also had 32% fewer attendances at A&E, were 32% less likely to attend A&E with a minor condition that could be better treated elsewhere and had 18% fewer general practice appointments.” (Barker I, Steventon A, Williamson R, et al.)

Self-management capability in patients with long-term conditions is associated with reduced healthcare utilisation across a whole health economy: cross-sectional analysis of electronic health records. ( BMJ Qual Saf Published Online First: 23 August 2018. doi: 10.1136/bmjqs-2017-007635).

Reflections from CEMPaC  

In many ways the report raises a number of significant questions and issues, especially around individual responsibility for health.

One needs to ask the question:

Why do so many people have low, confidence knowledge and skills in managing their health?

It would be easy to blame the patient. However if we reflect on current health care systems they are very poor at providing support for people. In addition we need to consider peoples capability, opportunity and motivation to engage in managing their health. (COM-B model of behaviour change Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science : IS. 2011;6:42. doi:10.1186/1748-5908-6-42.).

Let us reflect on the typical scenario in most health care systems: We have tests, receive a diagnosis, are given  complex and sometime conflicting information and often asked to make significant changes in lifestyle. All of this happens in the context of often hurried and short consultations.

Let us contrast this with how people learn new skills best: Through small steps, manageable amounts of information, being coached over time, being shown by people with existing experience etc- all over a extended and flexible time period. This is very different from how patients are expected to act on health information and deal with highly complex systems.

There is, fortunately, a growing body of evidence that shows that interventions such as self-management education, health coaching and peer support can all help improve people’s sense of control and ability to manage. In addition clinician skills such as shared decision making, and understanding what outcomes are important to patients (through care and support planning), all help.

However, many interventions will only achieve a change in one level of activation. This is a long way from moving everyone from the lowest levels to the highest level of activation. We also must not forget the issues of opportunity, capability and motivation.

For many people the ability to follow a healthy lifestyle may be difficult because of poverty. Social isolation can significantly effect peoples motivation to change and peer pressure can also significantly impact on this.

Surveys such as this and the EU- Health literacy survey, show that the current education and health systems are systematically failing in enabling people to feel empowered in managing their health and wellbeing.

They show that if we don’t give the psychosocial elements of health and wellbeing the same attention and importance that we do the bio-medical markers,  health care systems will not be able to cope.

Both medicine and the patient’s medical and social care needs are becoming more complex, and  without effective strategies and investment in improving health literacy and creating health literate organisations, pressure on services will only increase.

What is required now is a radical rethinking of the medical model for health care systems means for the future, a model that has to face rising numbers of people with lifestyle related conditions, especially as many of the outcomes are dependent on people being supported to change their behaviour, and not on drugs.

Instead of always trying to train patients to deal with complex systems and information we need to make the systems easier to navigate and information easier to understand.