Interventions to enhance self management supportBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3949 (Published 19 June 2013) Cite this as: BMJ 2013;346:f3949
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These comments are regarding the editorial ‘interventions to enhance self management support’ BMJ 2013;346:f3949 and associated research article, ‘implementation of self management support for long term conditions in routine primary care settings: cluster randomised controlled trial’ BMJ 2013; 346:f2882.
In the paper Kennedy e.a describe a pragmatic, two arm, cluster randomised controlled trial, to engage patients with self-care by providing special training and paper tools to primary care clinicians who then conducted self-care consultations with patients. Time constraints on practice staff made patient tracking and follow-up impractical. The paper concludes that this approach to enhancing self-care in UK general practice had no significant effects on patient outcomes.
The study provides evidence that this resource intensive way of working to engage patients to self-care does not work significantly better than the current reactive way of care provision in general practice. This conclusion is not surprising since embedding such support into routine primary care practice is difficult to achieve within existing educational structures and requires considerable additional resources combined with incentives to encourage practices to engage with this agenda. Moreover, implementing such an approach across general practice requires a significant ‘culture shift’ and re-engineering of current general practice. This resonates with the point made by Sun and Guyatt in their editorial about how ‘resource intensive effective interventions are likely to fail when introduced into settings with tight resource constraints where doctors are preoccupied with the considerable stresses of everyday practice.’
Positive health and healthcare outcomes have however been shown using care planning - in other countries and in the UK (1-8). This approach, rather than being clinician led, is patient driven and addresses issues selected as important by the patient by setting personalised goals and action plans enabling active improvement in self-caring. There is ample evidence of the benefits of implementing care planning for patients with long term conditions. These include improved quality-of-life, greater knowledge and confidence in being able to cope with condition, better use of medication, reduced emergency attendances and inpatient days, significantly reduced costs and overall improved quality of care. In UK general practice the approach involved proactive multi-morbidity management using personalised care planning consultations, supported by special screens in the clinical system. Patients set their own personally relevant goals and action plans and become active participants instead of being ‘told what to do’. This yielded greater patient satisfaction, better outcomes and health system efficiencies. 995 patients in my practice are treated this way today. To successfully scale up this approach across general practice and avoid the need for significant general practice reorganisation, the care planning method can been designed into an internet and smartphone delivered service to connect patients and clinicians. VitruCare is one such solution used in practice, allowing a growing number of patients to create meaningful self-directed goals and action plans at their convenience in collaboration with their clinician, and track progress in real time as they achieve their actions plans. Patients become empowered because they create their own care plan and are in control, and become more accountable as ‘active players’ with the clinician as ‘coach’ - remaining connected through mobile technology, video and face-to-face consultations as required. In contrast to the process studied by Kennedy e.a., this approach is demonstrating positive results.
Traditional clinical interventions, whether provider based or patient based, often lie outside patients’ work and social activities and fail to embed themselves into their everyday lives. Being smarter about integrating support for self-care into patients’ social networks, including the use of widely available mobile technology, is proving more effective in activating patients to self-care and achieve better outcomes. This approach can transform the NHS from its current transactional delivery of care to patient driven and clinician supported selfcare that is needed to achieve the goals set by the DH in the management of patients with long term conditions.
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Competing interests: Shahid Ali is a GP Principal in Phoenix Medical Practice, Bradford, West Yorkshire and a Director in Dynamic Health Systems which has designed VitruCare.