Chapter 1 - part 2
Making self care happen

Health inequalities and self care

Self care support for patients and the public is one ingredient in improving the health of the community and reducing health inequalities. Other health inequalities are unavoidable, being due to genetic and biological differences between people. Some inequalities arise from differences in opportunity, in access to services (health and social care, education, leisure etc), in their environment and material resources, as well as in lifestyle behaviour such as diet, exercise and smoking. Poor living and working conditions resulting from poverty, little education and inadequate housing also contribute to health inequalities.
People who have these disadvantages may potentially benefit most from strategies to encourage and support them to practise more self care. But they are often the most challenging groups of people to help. They may be more difficult to access, and more resistant to change. Someone who is aware of the benefits of change, trusts the health professionals advising them and is used to making autonomous decisions, is more likely to be helped to change, than someone who is instinctively mistrustful of authority figures, has low self confidence and had limited benefits from the education system in the past. Any general practice team or PCT has to come up with a very wide- based strategy that caters for all types of people in a way that redresses these inequalities to promote self care effectively. They will need well-designed resources matched to a person’s needs and way of life.

Health and social services support for self care

Making self care effective will require increasing the capacity, confidence and efficacy of patients and the public for self care. There is also need to build on social capital in the community. The ideas in Box 1.3 describe actions that health and social care services can take to boost the chances that individuals in their community will practise self care for themselves or those they care for.17 Most of these ideas can be incorporated into everyday general practice with good planning and resources.

Box 1.3: Methods of health and social services support for self care

Appropriate and accessible advice, information and campaigns on lifestyle issues to change behaviours (such as physical activity, healthy eating, other behaviours to sustain wellbeing and prevent ill health) and to change the care of minor, acute and long term conditions
Health education (such as adult health skills and health literacy programme)
Self care skills training, for example through the Expert Patients Programme
First aid training in schools for children
Health promotion in schools: exercise, diet, learning to say ‘no’ to smoking, drugs, alcohol and other unhealthy practices
Self-diagnostic tools, self-monitoring devices and self care equipment
Multi-media, multi-lingual self care information and skills training materials
Individualised care plans
Support networks of people with experience and memory of healthy living and of caring for minor, acute or long term conditions
Active participation of the public locally and nationally in the formation and implementation of relevant local and national government policies and programmes
Education of the public and practitioners to change their attitudes and behaviours towards self care
Training of practitioners inwhenandhowtouse approaches tosupport self care
Work to develop partnerships between care professionals and the public to enhance shared care and for patients and the public to become co-producers of their care

Moving from medical care to self care in the future

A review of the long term future of the NHS highlighted the potential of self care as a key factor in the change of demand for care services.8 Wanless predicted a switch of 2% of GP activity to pharmacists, and a reduction of 17% in outpatient attendances among people practising self care. In his scenario the general public become fully engaged in improving their health, for example through better lifestyles and more self care. Some research highlighted in the report suggested that visits to GPs could decline
by over 40%.

Many people with long term conditions are already involved in self care actions. Chronic disease currently costs the UK government £12 billion per year in disease management and lost earnings.18 In one national telephone survey, 79% of people with diabetes were self-monitoring their diabetes, though far fewer of those with hypertension or lung disease were self-monitoring their condition. Education is a key component in empowering patients to take care of their own chronic disease, but the capacity to self manage health and health care is least evident among people with poor health.19

Promoting health and wellbeing through self care support

You can target health education at whole populations, e.g. giving advice on the prevention of depression to everyone you see. Alternatively, you can target high-risk groups, e.g. giving advice on the prevention of depression to elderly people with precipitating causes such as bereavement.
The Health Development Agency evolved a resource for improving the health and wellbeing of people in mid-life (aged 50–65 years; see Box 1.4).20 This age range is recognised as a period of mid-life transition when people address various issues including their health; there are opportunities to increase life expectancy and preparing for a healthier older age.

Box 1.4: Taking action at local level: a resource for improving health and
wellbeing in mid-life

The resource provides information and suggestions about:

relating to regional and national policy initiatives
identifying mid-life needs within a locality
identifying partners
building a case for action
identifying which models to use and the evidence available
developing ways to evaluate initiatives.

When undertaking health promotion, GPs and other health professionals need strategies to encourage people’s individual action (empowerment) rather than use coercion or blame, as the essential nature of health education is that it is voluntary.

People do try self care before engaging with the NHS. But they may abandon this too soon believing that their ‘symptoms are persisting’, not necessarily because their home remedy is no longer relieving their symptoms, but being unsure whether their symptoms are due to something more serious. Their presentation to the doctor or triage nurse offers the opportunity to have a self care aware consultation; their own home remedy, herbal or over-the-counter medicine, complementary therapy or remedy can continue to provide relief.

Creating a safe self care culture

Understanding of safety and risk by the NHS in general as well as by those people practising self care is another facet in the creation of a self care culture. Ensuring that the care patients receive is safe and effective is at the heart of everything that the NHS and social services do. The better your systems are at identifying and managing risk, the safer your practice will be. The National Patient Safety Agency (NPSA) has a practical checklist (see Box 1.5) that a PCT or practice team could use to underpin the safety of their self care support strategy and practice.21

Box 1.5:

Seven steps to patient safety – in relation to supporting self care

1 Build a safety culture: so you minimise risks to patients whilst supporting self care.

2 Lead and support your staff: establish a clear and strong focus on patient safety throughout your PCT/practice.

3 Integrate your risk management activity: develop systems and processes to manage your risks and identify and assess things that could go wrong – eliminate inadequate training, or encourage an incompetent person to self care.

4 Promote reporting: ensure staff can easily report incidents relating to self care that have gone wrong, in a central log.

5 Involve and communicate with patients and the public: communicate openly with, and listen to, patients – do not thrust self care at them.

6 Learn and share safety lessons: encourage staff to learn from any incident arising from supporting self care and communicate this to each other.

7 Implement solutions to prevent harm: embed lessons through changes to practice, processes or systems relating to the promotion of self care. Supporting self care

In conclusion

Self care by patients is central to the vision for reform in the NHS. The Department of Health intends that:

the healthcare system will become more proactive in working with patients to enable them to manage and protect their own health in the long term. Local practices will have incentives to provide locally based health improvement and health protection services. They will be able to use their budgets to invest in such services which could be provided by the local PCT or by private or voluntary sector providers, or by a combination of these. Patients for their part, empowered by more and better information and able to choose from a range of services, will be in a stronger position to manage their own health and wellbeing. Tackling inequalities in health will become more important, as it will ensure that more people can benefit from good health.

References

1 Department of Health. Public Attitudes to Self Care Baseline Survey. London: Department of
Health; 2005.

2 Department of Health. Our Health, Our Care, Our Say – a new direction for community services.
White Paper. London: Department of Health; 2006.

3 Department of Health. Supporting People with Long Term Conditions to Self Care. A guide to
developing local strategies and good practice. London: Department of Health; 2006.

4 Hewitt P. The Nation’s Health and Social Change. Discussion Paper. London: The New Health
Network; 2005.

5 Colin-Thome´ D. The Policy Drivers for Self Care. Presentation to 8th annual Self Care
Conference 29 September 2005, London.

6 Department of Health. Towards a DH/NHS Strategy to Support Self Care. Working Paper.
London: Department of Health; 1996.

7 Department of Health. The NHS Plan. A plan for investment, a plan for reform. London:
Department of Health; 2000.

8 Wanless D. Securing our Future Health: taking a long-term view. London: HM Treasury;
2002.

9 Department of Health. The Expert Patient. A new approach to chronic disease management for
the 21st century. London: Department of Health; 2001.

10 Department of Health. Building on the Best. Choice, responsiveness and equity. London:
Department of Health; 2003.

11 Department of Health. NHS Improvement Plan – putting people at the heart of public services.
London: Department of Health; 2004.

12 Department of Health. Delivering Choosing Health: making healthier choices easier. London:
Department of Health; 2005.

13 Department of Health. Better Information, Better Choices, Better Health – putting information
at the centre of health. London: Department of Health; 2004.

14 Department of Health. Self Care – a real choice. Self care support – a practical option. London:
Department of Health; 2005.

15 Pringle M. Managing Everyday Healthcare – implementing an integrated self care strategy at
PCT level. Presentation to 8th annual Self Care Conference 29 September 2005,
London.

16 Department of Health. Tackling Health Inequalities: status report on the programme for action.
London: Department of Health; 2005.

17 Dost A. Further Towards a Self Care Support Strategy. Leeds: Economics and Operational
Research Division, Department of Health; 1998.

18 Alder J. Incidence of Chronic Disease Set to Soar unless we Manage it Better. London: Chronic
Disease Working Party, Cass Business School; 2005. www.cass.city.ac.uk

19 Ellins J and Coulter A. How Engaged are People with their Healthcare? Oxford: Picker Institute
Europe; 2005.

20 National Institute for Health and Clinical Excellence. Taking Action at Local Level: a resource
for improving health and wellbeing in mid-life. Part 1: Developing local strategies. London:
NICE; 2005. www.nice.org.uk

21 www.npsa.nhs.uk

22 Department of Health. Health Reform in England: update and next steps. London: Department
of Health; 2005.

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Chapter 1 - part 2 Making self care happen