Promoting self care in the community: the evidence and why it is important
Amisha Patel and Hemant Patel explain the concept of self care and look at how community pharmacy teams can help support patients to manage their own chronic conditions
Self care has become increasingly important to the NHS as it undergoes its most fundamental restructuring for many years. Budgets are becoming more difficult to manage in light of the increasing health burden caused by long-term conditions, an ageing population and conditions related to lifestyle choices such as smoking. Prevention of disease and increasing efforts to educate and support patients in managing their own health should be prioritised by all healthcare specialists.
What is self care?
Self care has been defined by the Department of Health as “the care taken by individuals towards their own health and well-being — including the care extended to the family and the community”.1 The definition is broad and encompasses the actions required for people to maintain good physical and mental health, to meet their social and psychological needs and prevent illness or accidents. It extends beyond traditional concepts of self-management, which focus specifically on learning techniques to manage a health condition.
According to the Proprietary Association of Great Britain, 90 per cent of people use over-the-counter medicines to manage minor conditions without going to their GP.2 In 2010, 973 million OTC medicine packs were sold — this compares with 1,028 million prescription items dispensed. GPs currently spend an hour a day (57 million consultations a year) seeing patients with minor conditions that could be self treated at an estimated annual cost to the NHS of £2bn (including GP consultation time and prescriptions).3 According to the Department of Health, 39 per cent of GP consultation time is spent treating patients who present with self-treatable minor ailments.
Self care programmes have already begun for several long-term conditions (see Panel). According to research conducted by the DH in 2007, over 90 per cent of people were interested in developing self care skills and over 75 per cent believed they would be more confident if they had support from a professional or peer. In conclusion to its research, the DH suggests that the potential implications of improved self care for the NHS are far reaching, and include:
- Improved quality of consultations
- Reduced number of GP visits and outpatient visits
- Reduction of up to 50 per cent in the number of hospital admissions
- Improved medicines use
Systematic reviews have examined the impact of self care programmes on several long-term conditions.
A recent Cochrane review studied the effect of self-management by patients with chronic obstructive pulmonary disease.7 Several outcomes showed positive results with:
- Improved health-related quality of life
- Fewer respiratory-related hospital admissions
- Reductions in dyspnoea (as measured using the modified Medical Research Council scale)
However, the variety of interventions used, the differences in populations and follow-up and the different outcome measures used make it difficult to draw conclusions regarding the most effective form of self-management in COPD.
The benefits of self care apply to children as highlighted in another Cochrane review. The self-care skills were taught to children or their parents with focus on asthma attack prevention, self care during attacks, social skills and problem solving.8 The benefits included a moderate
improvement in airflow and reductions in:
- School absences
- Days of restricted activity
- Nights disturbed by asthma
- Number of accident and emergency visits
These results were greater for children with moderate-to-severe asthma.
Coronary heart disease outcomes can be improved with self care and the development of disease management programmes as seen in a recent systematic review of secondary prevention programmes.9 Patients reported enhanced quality of life or functional status; objective measures were also positive with reductions in the number of admissions to hospital and the cardiovascular risk profiles of the patient group. Interventions included patient education, rehabilitation and exercise, psychosocial support, appropriate consultations and co-ordination of home and community care. Five out of seven trials reported significant reduction in risk factors. In addition, five out of seven trials reported a significant increase in the prescribing of at least one effective medicine (ie, beta blockers, antiplatelet agents or statins). Further research is needed to determine effects on survival and recurrent infarction rates, as well as cost-effectiveness.
A review of 1,322 patients with, or at risk of developing, diabetes concluded that self care produced:10
- A significant reduction in weight
- Reductions in one or more measures of blood glucose in the short and long term
- Positive changes in dietary patterns, physical activity and psychosocial outcomes
Self care interventions typically involved teaching patients about blood glucose monitoring, glycaemic control, dietary habits and exercise.
A randomised controlled trial involving patients with rheumatoid arthritis or osteoarthritis showed that an individualised self care support programme and training course led to improvements in functioning, exercise and pain, with a reduction in the number of GP visits and in the number of days taken off work.11
Self care is likely to factor in the future management of mental health conditions. A systematic review of studies into bipolar disorder found significant benefits from treatments, including group therapies, cognitive behavioural therapy, psychosocial education and family psychotherapy. There was a 15 to 60 per cent reduction in hospital admissions, increased adherence to medicines and a decrease in the duration of hospital admissions, as well as improved social functioning.12
Patients should be able to manage minor ailments and long-term conditions at home or in the community with resources available to ensure that health and well-being is maintained after an acute illness or discharge from hospital.
The DH has carried out several studies investigating public perception and practice of self care. It found that 82 per cent of those who have a long-term health condition state they play an active role in caring for the condition themselves and 87 per cent often treat minor illnesses themselves.
Despite the potential benefits, there is evidence that healthcare professionals have yet to explore the potential of self care fully. In 2005, a national DH survey found that more than 50 per cent of patients who had seen a healthcare professional in the previous six months had not been encouraged to develop self care skills. Furthermore, one-third of patients said they had never received any advice regarding self care. It is uncertain what the state of play is at the moment but anecdotal evidence seems to suggest that the situation needs to improve significantly to ensure that self care advice is available universally.
Data sharing and continuity of care
To achieve effective patient engagement with self care, healthcare professionals need to be able to share patient data more efficiently than current systems allow. All those involved with a patient’s care, whether community or hospital based, should be able to access relevant information about co-morbidities, allergies, drug history, previous interventions and blood test and imaging results. This will save time during consultations, help all healthcare professionals to follow the same care plan or guidelines (which is particularly difficult for patients with multiple co-morbidities who are under the care of several hospital consultants) and prevent duplication of work.
One of the clinical commissioning groups in North London has begun using data sharing between hospitals and primary care for several long-term conditions (eg, heart failure, respiratory disease and diabetes) to enhance clinical consultations — with admirable results. The “did not attend” rate for appointments has fallen from 26 per cent in 2012 to 10 per cent in 2013. Appointments for elderly patients were arranged for community clinics, rather than at the hospital, to ease transport and access difficulties.
Each member of the multidisciplinary team provides an important service but difficulties in co-ordinating investigations and interventions persist. With a nominated lead clinician or nurse, conflicting opinions regarding management can be resolved without causing confusion and unnecessary medication changes or interventions.
In addition, continuity of care enables the patient to develop a meaningful relationship with their clinical team and are more likely to engage with medication plans and behavioural changes. For example, although GPs may not have time during a consultation for a full discussion about the benefits of smoking cessation, they can initiate the conversation and refer the patient to a local pharmacist for smoking cessation support.
Pharmacists trained in motivational interviewing will be able to encourage patients to review their behaviour and set realistic goals for behavioural change.
Health coaching is a process that facilitates healthy, sustainable behaviour change by challenging clients to listen to their inner wisdom, identify their values and transform their goals into action. Health coaching draws on the principles of positive psychology and the practices of motivational interviewing and goal setting
The evidence available from a recent systematic review in the UK suggests that patient choices are influenced by anecdote and opinion, personal recommendations or previous experience by family and friends.4 Those most likely to engage with self care were affluent or educated. The targeted promotion of self care services, such as smoking cessation, to less affluent groups, ethnic minorities and socially isolated individuals may be necessary to achieve equitable use.
A further study has analysed the methods most likely to achieve success in the promotion of self care.5 A significant concern is that patients often fail to appreciate the complexity of living with long-term conditions. Healthcare professionals need to engage with patients when discussing their conditions, diagnostic testing and management plans. This will help guide patient choices and develop manageable and effective self care plans. Self care can only be achieved with wider engagement of organisations such as charities, voluntary organisations and patient groups. Potential strategies include:
- Online guides for medical conditions that are amenable to self care, such as those in development by North East London Local Pharmaceutical Committee (NELLPC). These contain information about symptoms, management plans and advice on managing new or changing symptoms and becoming more independent
- Trial programmes run by clinical commissioning groups and public health departments aimed at integrating services. For example, in north east London, the self care pharmacy practice programme plans to integrate strategies for the prevention of illness, effective use of medicines and follow-up care. This includes improving mobility for stable patients with long-term conditions
- Increased use and promotion of social prescriptions (eg, exercise and enrolment with local support groups)
- Targeting health inequalities
A meta-analysis of self care in diabetes provides ideas on delivering interventions to minority groups, including ethnic minorities and low-income groups. Measures with supporting evidence include the use of proactive telephone calls, touch-screen computers for information delivery and redesign of GP practices to promote self care resources and peer support by scheduling diabetes patients for visits at the same time.6
NELLPC call to action
The action plan for the NELLPC to embed self care as standard practice is strongly focused on improving patient outcomes. Actions include: creating a “pharmacy first” culture and promoting self care; ensuring patients get the best from their medicines and self care; integrating community pharmacy into patient pathways, including self care; and ensuring that medicines packaging and formulation are not barriers to effective self care.
The plan emphasises the importance of self care in improving the management of chronic conditions to minimise hospital admissions and the benefits of effective multidisciplinary working. Community pharmacies have the potential to influence their local communities by promoting self care resources and providing the support for patients to develop the confidence in their care plans.
Amisha Patel is assistant auditor at the National Audit Office. Hemant Patel, FRPharmS, is secretary at North East London Local Pharmaceutical Committee.
Citation: The Salvadore DOI: 10.1211/PJ.2014.11137908
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