Editorials

Self management in asthma care

Professionals must rethink their role if they are to guide patients successfully

Papers p 1507

Equipping people with asthma with the tools they need to manage their condition is as important as writing the correct prescription," according to the United Kingdom's National Asthma campaign. Guided self management has an established place in asthma guidelines and recommendations.^1-2 Yet the reality of everyday asthma care is quite different from that which the guidelines suggest, as shown by Jones et al in this issue (p 1507).³ Even among general practitioners in an academic setting, asthma remains underdiagnosed and poorly treated,⁴ despite increased awareness of the condition. Professionals perceive asthma as a lifelong problem, but patients discontinue treatment after a few years or do not consult health professionals at all.⁵

General practitioners and nurses have an important role in implementing self care programmes. However, Jones et al report that patient self management and transfer of responsibility from professional caregivers received a lukewarm response at best from general practitioners, practice nurses, and patients. This is particularly striking among nurses, who are generally valued for their ability to implement protocols, including encouraging self care. This response could be related to specific characteristics of the programme, but more probably it signals a development in primary care nursing in which nurses are no longer prepared only to follow instructions but wish to act using their professional judgment. There are indications that nurses need specific asthma qualifications to provide the best possible care for patients with asthma. Robertson et al found that nurses with advanced qualifications in asthma provided self management plans significantly more frequently.⁶ Ownership of guidelines is essential to guaranteeing implementation, not only for general practitioners but also for nurses.

The nurses in the study by Jones et al believed strongly that guided self management plans might do more harm than good as these plans would "increase the likelihood of patients falling into bad habits." The nurses believed that self management plans were appropriate for just a few patients: the ones who were already almost fully compliant with their treatment regimens. The nurses' lack of faith in the effectiveness of self management plans and their reluctance to hand over responsibilities to the patient contradict the very basis of self management. The objective of self management is to empower patients with the knowledge and skills they need to treat their own illness. A first step towards this is to have patients share responsibility for their treatment with their caregivers.⁷ But empirical data on asthma care can only serve to indicate the breadth of the differences. For example, a general practice based screening programme in the Netherlands found that about 75% of those with mild asthma and 65% of those with moderately severe asthma who were eligible for treatment were reluctant to visit their general practitioner or to comply with follow up⁸; most of the patients studied did not consider themselves ill.⁹ In the study by Jones et al patients stated that they were not interested in guided self management plans, describing themselves as "already self managing competently" and "behaving responsibly." This reflects self reliance more than competent self management according to guidelines.

It also indicates a failure to integrate the personal and the medical dimensions of medical care¹⁰that is, the integration of the medical agenda with the patient's perspective. Self management schemes have to combine the best of these two elements, but sharing responsibilities implies that patients as well as medical professionals should determine the goals of treatment. Ownership of a management plan is an important precondition to effective treatment for both patients and health professionals. It is not a question of whether guided self management is effective or should be implemented, but rather the challenge is to accept that patients are managing their care one way or another and that we need to create opportunities to clarify how medical input can enhance their personal situation. Cooperation is the key to bridging the gap between the efficacy and effectiveness of asthma care.

Bart Thoonen, general practitioner. 

(B.Thoonen{at}hsv.kun.nl)

Chris van Weel, professor of general practice. 

(C.vanWeel{at}hsv.kun.nl) Department of General Practice, UMC St Radboud, University of Nijmegen, 229-HSV, P O Box 9101, 6500 HB Nijmegen, Netherlands

Acknowledgments

BT has received grants from the Netherlands Organisation for Scientific Research and AstraZeneca for research into self management of asthma. CvW has received financial support for research and education from various pharmaceutical companies that have an interest in the care of asthma.