Promoting self care for minor illnessBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2913 (Published 10 June 2010) Cite this as: BMJ 2010;340:c2913
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Nazareth and Murray correctly state that enhancing people's ability
to self-manage minor illness should be a priority for the NHS but may I
ask how we define "Minor Ailments / Illness"(1).
The main problem we are finding it hard to discourage patients is
because symptoms like runny noses, snuffles, or rhinitis have been
diagnosed as common colds and coughs as chest infections. We also labelled
asthma as wheezy bronchitis, wheezy tendency, viral infections, and flu,
and often treated with antibiotics and cough mixtures.
Similarly, we also encouraged patients with high fever, sore throat,
or earache to access healthcare professionals.
Symptoms provide the most important process in deriving at a
diagnosis. We must remember patients describe symptoms for which they are
seeking professional attention they are also reporting the story of an
illness as they have lived and remember it (3). Diagnosing infections and
offering treatment based on protocols and guidelines (most are based on
studies conducted in 1980 & 90s) is now not only dangerous but I would
say this practice is un-ethical.
WHO has declared Oct 1 & 2 as "World MRSA Day" to remind us about
the impending danger of playing with fire "The Antibiotics". So it is
mandatory not to prescribe antibiotics for "minor ailments" but unless we
have a simple method to help patients differentiate minor from serious
symptoms, this publicity is likely to fail.
Views on common diseases as seen in primary and secondary medical
care vary and depend on the primary care physician's or nurse's experience
of interpreting symptoms.
I feel we must now take control of prescribing antibiotics (As Prof
Fleming expected doctors to be the custodians) and allow only physicians
who have in-depth knowledge of pharmacological, pathology and differential
diagnosis of diseases and helped by microbiologist.
Treating infections based on protocol and guidelines is now unsafe
and unethical and is not only in the interest of patients but also our
1. The Self Care Campaign launched in March 2009. Royal College of
General Practitioners, NHS Alliance, National Association of Primary Care
and the PAGB. Its key objective is to bring an end to the culture of
dependency on the NHS for self limiting illnesses.
2.Banks I. Self care of minor ailments: a survey of consumer and
healthcare professional beliefs and behaviour. Self-Care 2010; 1:1-13.
3.Srivatsa KM; Pre-printed assessment sheet; Quality in Healthcare; June
1996, Volume 5; No:2.
Competing interests: I have worked on this simple problem for six years and now developed a simple tool that could help reduce patients visiting hospitals and surgeries
Nazareth and Murray correctly state that enhancing people’s ability
to self-manage minor illness should be a priority for the NHS.–The
economic benefit they state is important. We suggest that empowering
patients and their families to manage their own health and avoid
unnecessary interventions is very important too. Although they refer to
NHS Direct’s website as an example of support for such an approach they do
not reference the actual work we do or the success it has had and
continues to have in achieving the objectives for the NHS they recommend.
While we agree that further research on effectiveness of
interventions to promote self care is needed we have data and information
from our internal sources and from external reviews that telephone-based
support from health advisers and nurses is effective. It helps patients,
their families and carers manage a wide range of minor and not so minor
conditions themselves or with further advice from local services such as
their local pharmacy.
NHS Direct receives 5 million phone calls each year ( around 14500
every day).Patients ask for advice about specific symptoms, They also
call for general health advice or for medicines information. NHS Direct
deals with about 60% of all calls without the need for any onward referral
to another healthcare professional or agency. We know from follow up
surveys that had our patients not had access to NHS Direct they would have
sought advice or care from other healthcare sources including their GP,
from A&E departments or by calling 999.
In 2009/10, our core services saved 2.4 million appointments with
GPs and other primary care services. They also prevented 1.6 million
unnecessary ambulance journeys and visits to accident and emergency
departments. By applying the usual NHS tariffs we estimate that NHS Direct
saved the NHS £213m in 2009/10*.
Our patients report a high level of satisfaction with our services –
complaints are less than one call per ten thousand. That is in keeping
with an increasing enthusiasm for many other remotely provided services
that take advantage of telephone and internet technologies that are
available when and where the user wishes and will prove a key support in
helping patients manage their illness minor or more serious.
Brian Gaffney. Medical Director NHS Direct
Tim Heymann. Reader in Health Management, Imperial College Business School
and non-executive board member NHS Direct.
*How we calculate Value
NHS Direct has agreed with its Commissioner, East of England SHA, a model
for calculating the value of its core telephone and online service.
The model identifies benefits created for the health economy through NHS
Direct's role in directing patients to more appropriate points of care
than they would have gone to if NHS Direct was not available. The model
uses a combination of IFF independent survey data, which identifies where
patients would have gone if NHS Direct was not available (together with
their compliance with advice), 5m patient call records, and web usage
information. Any costs used in the calculation are taken from the 09/10
contract tariffs where available, and 09/10 PSSRU unit costs where no
tariff is available (e.g. GP consultation costs).
BG employee of NHS Direct
TH Board member of NHS Direct
Competing interests: No competing interests
Educating doctors and nurses does not feature in the editorial about promoting self care for minor illness (1) despite their prominent role. Misinformed health professionals keep failing parents when giving advice to "treat a fever" rather than educating parents on how to support a childhood fever.
NICE has been perfectly clear in 2007 that raised temperatures do not need treatment but that parents need to know how to check for dangerous underlying infections.
However, health professionals are still ignorant about the bullet points made on page 14 of the NICE quick reference guide. (2) That is perhaps because doctors (and nurses) might not be aware of the difference in symptoms between septicaemia (the ‘rash’) and meningitis (‘headache or neck ache, photophobia’) and still calibrate seriousness of infectious disease by the height of the temperature. (3 ) It is my ongoing experience as a GP that paediatric departments and emergency departments still seem oblivious of the NICE guidelines as feverish children are still spoon fed with paracetamol in the departments and parents are still given advice to lower the temperature – and are not given explicit and written advice on how to CONTINUE at home to regularly check for meningitis (sitting upright and looking down) and septicaemia (check for non-blanching rash ANYWHERE on the body) and to come for review if longer than 3-5 days or urine sample if consistently over 39 Celsius.
With reference to research, I would wish for academics to stop churning out comparisons of paracetamol and NSAIDs on the "treatment" of fever and instead focus on non-commercial research that promotes self care, for example, into normal circadian fever processes as described http://www.bmj.com/cgi/eletters/338/apr20_1/b1187#212534 here (4) and the concerns around ubiquitous analgesic use and http://www.bmj.com/cgi/eletters/337/sep02_2/a1409#202312 numerous other areas for research outlined here (5). But that probably takes a paradigm shift in health professionals of "Semmelweis proportions" as health professionals by their actions with reference to childhood fever, maintain that colluding with parents' and other doctors' traditional opinions is easier than applying common sense and do research and
educate peers and parents on how to support the fever process in children.
7 Clinch J, Dale S. Managing childhood fever and pain – the comfort loop. Child and Adolescent Psychiatry and Mental Health 2007, 1:7doi:10.1186/1753-2000-1-7
Competing interests: http://www.everyday medicine.com/fever.htm
Competing interests: No competing interests
Proper use of CAM in minimally debilitating health conditions.
I appreciate Nazareth and Murray's view, while I also would like to
discuss the role of CAM (Complementary and alternative medicine) in this
Humans are still struggling to cope with ill health either somatic
or psychological. Medical science does not give the solution
to all questions. Use of CAM is very common in both developed and
developing countries, maybe due to belief that they are
beneficial, free from side effects, and economical. CAM fulfils about
80% of the needs of the Indian population where more than 70% of population reside in
rural areas. In the world CAM users may stand between 9% and 65%. CAM includes
mainly ayurveda, siddha, yoga and unani in India. The increase in number
of CAM users may be due to the lifestyle changes and advances in
Use of CAM is most common nowadays, for instance, for Ophthalmic
manifestations in Brazil, in rural Egyptian and Malawi almost always begun
at home1, for the endemic like chickengunya and joint manifestations in India,
As we know, Medicine is an 'evidence-based’ Science. But Goldman and Dennis2 clearly say that the scientific basis of medicine is
remarkably recent. As Hegde3 says, scientific truths are not true
for all times and gave the reference in his article Science and the art of
medicine ,i. e survey research conducted in Thailand proved that all
kinds of healers from the quacks to the best trained contemporary doctors
have been equally effective in society if they had humanitarian qualities
to guide the patients in a proper way.
The main issues pertaining to CAM are analysis of market structure,
conducting research, evidence based health care strategies, services and
teaching, issues related to standardization of the products, etc.
As Einstein, says “The most beautiful thing we can experience is
the mysterious”. It holds good with CAM. WHO reports during the
period of 1997 to 2002 that financial assistance to improve health status in
developing countries increased by about 26%, i.e. $6.4bn to $8.1bn.4 But
Hypocrisy is developing countries share 90% of the disease and 84% of
the world's population; if suppose a country like India dropped CAM and
relied only on conventional medicine like the Americans($5,277/yr) then the total
expenditure of India for health should be Rs 7,52,67,514 Crore more than
her GDP. In India the National sociodemographic goals are 14 in number. Goal
number 12 expects us to integrate indigenous medicine. As the health minister of India Thakur CP was very keen to bring in CAM as a part
of teaching and training programme in AIIMS, Delhi.
Mashelkar RA, former Director General of the CSIR, India, rightly
said we should create the golden triangle of traditional medicine, modern
medicine and modern science’.
01. Bisika et al., Self treatment of eye diseases in Malawi, Afr. J.
Trad. CAM (2009) 6 (1): 23 – 29.
02. Goldman L., Dennis A. (eds.) (2004), Cecil's Text Book of
Medicine, Approach to medicine, the patient, and the medical profession:
medicine as learned and humane profession, 22ndsub Edition, Vol. 1,
03. Hegde B.M. (1999), Science and the art of medicine, Journal of
Indian Academy of Clinical Medicine, 4:1-3.
04. WHO. Engaging for health. Eleventh General Programme of Work 2006
05. John Zarocostas, World Bank warns of financial crises in
healthcare systems BMJ 2006; 332:1293 (3 June),
Competing interests: No competing interests
I would like to commend Irwin Nazareth and Elizabeth Murray on their well researched
paper. The interventions of education and other resources for promoting
self care for minor illnesses are very important. Although hard to achieve
as they stated I would like to submit that advocating for more patient
education could be the key.
There is a high need for developing a more structured aspect of
patient education, for patient care. Patients who have a strong
understanding of their disease or illness are much more likely to recover
fully and do not have repeated relapses but benefits with the result of
better health and an improved understanding of how they need to live to
continue to have optimal health. However, the medical staff, health care
facilities and insurance companies also benefit by having a reduced number
of unnecessary hospitalizations and ER visits and ultimately impacts and
benefits all taxpayers (state and federal) (Jernigan, 2009). Identifying
those most interested in developing skills in patient teaching, providing
resources, time, expert input and developing an expectation among the
general public for better education and information regarding health and
well-being are essential elements to providing and maintaining optimal
health. This will also improve quality health care delivery, practice and
health care systems. Assuming more responsibility for patient education in
the ambulatory setting keeps patients healthier and keeps medical
conditions from worsening (Anwar, 1996). It can reduce the need for
hospitalization and patients can be taught the importance of prevention,
early treatment and overall health maintenance (Anwar, 1996). Patient
education is therefore extremely critical to ensuring patient adherence to
prescribed regimens for both chronic and non-chronic conditions. It is
even more critical because it helps prevent complications, promote self-
care and independence, and reduce readmissions. Patient education as an
important aspect of treating the patient provides patients with
instruction about their care and provides direction for preventing
complications.These complications can cause unnecessary admissions to the
hospital, an increase in medication costs and financial burden to the
patient, family and insurance company thus educating the patient is a
simple and effective way to prevent these complications and also thwart
any new diseases from occurring (Jernigan, 2009).
Patient education in any health-care setting is significantly more
challenging than in regular educational systems, as patients’ needs and
ability to assimilate information will be overshadowed by their health-
care deficits. However providing information about patient’s condition and
care has proven very beneficial for many patients. One such research study
showed that patients who had been subjected to planned teaching in
preparation for their treatment experienced less anxiety, increased belief
in their control over recovery and higher incidence of health maintenance.
Falvo (1994) concluded that the quantity of health care information and
patients' access to it have grown dramatically in the last several years.
Although patients may be anxious to be informed and play a more active
role in their own care, they aren't always sophisticated enough to be able
to judge which are the more credible sources, so there's potential for
them to be misinformed (Falvo,1994).
Patient education increases patient compliance, it build trust,
reduces anxiety, and minimizes the risk of malpractice lawsuits against
hospital systems and providers. By working to ensure that patients are
well-informed, you'll also be addressing another requirement of the
current health care environment – that reduces malpractice risk, and
consequently by educating the patient and enabling him or her to make some
decisions about treatment options, for example, sharing some of the
responsibility, will if something goes wrong, have the patient less likely
to blame you for the outcome (Falvo, 1994).At the Saint John's Health
Center, California, patient education is an essential building block in
their longstanding mission: to improve the health of the individuals and
communities we serve (Saint John's Health Center, 2008). Not many
hospitals even practice and or maintain the consistency of ensuring that
the patients are educated. Having a mission in this regard would therefore
be futile. A well informed and knowledgeable patient is better able to
play a role in helping to improve his or her own care both before entering
and after leaving the hospital (Saint John's Health Center, 2008). It is
also a means of empowerment for the patients to take control of their
health, thus maintaining optimal health. Certainly, if the patient is
content it will be a result of good health and or optimum health being
Since patient education is an essential element of care that should
involve the multidisciplinary team, patients and their significant others
must therefore have access to patient teaching programs which must be
carefully considered and chosen to meet the needs of the patient and their
significant others. As a result the patient will clearly benefit from well
-organized and appropriately planned patient teaching. Certainly, the
patient’s significant others, such as family members and close friends
should be involved in the teaching session subject to ethical
considerations and patient consent.
To achieve desired outcomes, educational goals must be geared to the needs
of the patient, with an educational plan that accounts for the learning
style of the patient and potential barriers to the educational process.
Careful consideration not only about the patient’s rights of dignity and
respect for privacy, and confidentiality are essential, but the right to
participate in choosing their treatment is also very important. By
continually educating patients about their condition, nurses can help
patients improve their health outcomes, build positive attitudes regarding
their treatment, and become independent. Education provides patients with
a knowledge base that empowers active participation in decisions about
their own care and outcomes. Consequently, a patient cannot successfully
choose his treatment and maintain his rights without patient education
because knowledge is power.
Anwar, R. (1996) Patient education for better managed care.
Physician's News Digest, Inc. Retrieved January, 2010 from
Falvo, D. (1994) Effective Patient Education: A Guide to Increased
Compliance. Gaithersburg: Aspen Publishers, Illinois.
Jernigan, K. (2009). The Importance of Patient Education: Knowledge
Has Many Different Benefits Retrieved January 2010 from
Saint John's Health Center (2008). Patient Education. Retrieved
January 2009, from http://www.stjohns.org/body.cfm?id=222 - 118k
Competing interests: No competing interests