Briefing: Can we achieve a self-care revolution?

 

EMPOWERING patients is viewed by many as a crucial step to delivering sustainable, personalised healthcare fit for the 21st century.

Much has been made of the need for “patient-centred care” which The Health Foundation describes as supporting people to “develop the knowledge, skills and confidence they need to more effectively manage and make informed decisions about their own health and healthcare.”

Out of this debate has developed a push for greater patient “self care”, which has been heralded by some as a solution to the NHS crisis of increasing demand and dwindling resources. Making patients less dependent on the medical profession could save billions, it is argued, while giving people more confidence and control over their own wellbeing.

This sounds like the perfect solution – but is self care achievable? The Self Care Forum, an online resource for doctors and patients, defines it as: “The actions that individuals take for themselves… to develop, protect, maintain and improve their health, wellbeing or wellness.” (Proponents are clear that patients are not expected to cope on their own without any help from a health professional.)

An estimated 80 per cent of all care in the UK is self care, with the majority of people content to manage minor ailments such as coughs and colds using over-thecounter medicines. Despite this, the Forum says there are still 57 million GP consultations a year for minor ailments at a total cost to the NHS of £2 billion. It cites research suggesting people often abandon self care earlier than they need to, largely due to a lack of confidence in understanding the normal progress of symptoms. They often see their GP for reassurance that nothing more serious is wrong and for a prescription to “cure” their illness, even though the same medicine may be available over the counter.

In a January 2018 column for Pulse, Dr Shaba Nabi argues that time-constrained doctors focus more on compliance with medication than compliance with lifestyle changes. She says: “It is far easier to sign an FP10 than to encourage a patient to adopt a biopsychosocial model for their pain… so our patients adopt the same preference for drugs over anything else. By adopting a narrow medical model, we have created patient dependency.” She adds: “Self-care, if truly embraced by the Government and the medical profession, could save the NHS billions of pounds.”

There was support for her viewpoint from readers, with one locum GP commenting that “self care is vital for both patients and the salvation of the NHS”. But equally there was scepticism, with a GP partner adding that dreams of self care were “pie in the sky” because “the free all-you-can-eat NHS buffet torpedoes any valiant self-help campaign”.

So what can be done to increase levels of self care? Research published in the BMJ in September 2007 notes that, despite “enthusiastic promotion of self care, randomised controlled trials often show modest benefits.” Authors Anne Kennedy, Anne Rogers and Peter Bower argue that teaching patients self-care skills is unlikely to be sufficient for effective self care and that fundamental changes are needed in professional attitudes and the way healthcare is delivered.

Previous attempts to deliver self-care training have faltered, they say, because they do not take sufficient account of patient variability and the different ways in which people self care. They have also found that self care can “raise tensions between patient autonomy and professional responsibility and the delivery of evidence-based care”.

They say two key changes in thinking are required: a whole systems perspective that engages patient, practitioner, and service organisation; and widening the evidence base to acknowledge recent research on the way in which patients and professionals respond to long-term conditions.

An article on the Self Care Forum’s website by Catherine Macadam encourages doctors to “adopt a coaching approach”, using one-to-one discussion to enhance patients’ knowledge and skills. This would in turn restore confidence, reduce dependency and free up more time to deal with serious and complex conditions.

Encouraging children to self-care and to live healthy lives is an important step, says GP and Self Care Forum co-chair Pete Smith. He believes early years education could improve health literacy and give youngsters “the grounding to prepare them for dealing with bigger issues in later life”.

Achieving a self-care revolution will require considerable time and investment from patients, professionals and government. As the Forum says: “Self care is not something to be added once everything else has been put in place. Indeed, the NHS must support people to self care at every appropriate contact.

Joanne Curran is associate editor of Insight

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