Chapter 3 - part 2
Getting organised for supporting
self care as a primary care organisation

Building teamwork

Ateam may be clinical – in your PCT or in a general practice; health professionals have to work together and with patients. It may be organisational – as with your working group on the self care support strategy and implementation. Team members need to respect the skills and contributions of other team members. All should be clear about their roles and responsibilities.

You will depend on the teams in your PCT and out on the frontline in composing and implementing your self care support strategy. Try out Tool 11 on your immediate teams to check how well they are functioning. If there are any crises or complaints, undertake a significant event audit as in Tool 12.

Choosing interventions

The interventions you select will depend on your priorities and target groups. Tool 13 may be more pertinent to general practice action planning. It assesses the clinical and organisational workload generated by a variety of example health conditions, then considers what can be done in respect of prevention, awaiting resolution, relieving symptoms and toleration for those conditions (see p. 16 and Chapters 10–13). As a PCT you might work with several practices and support them using Tool 13. Then you could collate what help and support practice teams need, and apply that resource on a PCT-wide basis, addressing your whole patient population. Examples include:

those responsible for public health and health promotion in your PCT might work with other partners on aspects of prevention
a minor ailment scheme with pharmacists (see p. 84)
enhanced services with general practices that cover self-monitoring of anticoagulant therapy (see p. 23)
extending the EPP initiative (see p. 106)
creating more local smoking cessation or exercise on prescription schemes11
appointing and supporting health trainers to support people in the local community with greatest needs12
marketing better health to the community with social services and educational bodies as in the Slough project13
focusing on people with long term conditions with the highest risks of health care usage in primary care, or of admission to hospital14,15
focusing on more organisational interventions, helping practice teams to gain new skills or move through change (see Tool 14).

Go back to Tool 3 to carry out a SWOT analysis or Tool 5 to undertake a gap analysis if that helps you to select priority interventions. Read through documents that encapsulate the learning of other PCTs who are already supporting self care and are actively promoting it.16,17 Consider resource implications of your chosen interventions using Tool 8.

Lastly

Many a health service strategy gathers dust on the bookshelf for the reasons listed in Box 3.4. Include actions to ensure that your self care support strategy and implementation plan is widely welcomed and gains general ownership.

Box 3.4:

When a strategy goes wrong . . . it may be because:

It is not read or understood

Once a strategy has been produced it needs to be seen, read and understood by
the target audience. Careful thought needs to be given as to how the message
should be communicated to key movers and shakers.

It is too vague and woolly

An implementation plan with targets and milestones is essential.
It is too prescriptive

A strategy which is too detailed and lacks flexibility may not meet local needs
and then fails.

It lacks ownership

An essential element of strategy development should be to engage key players;
this includes patients, carers and the wider public.

There are unexpected events

Unexpected events, such as a new government initiative, can blow a strategy off
course. The strategy should be flexible to enable it to adapt to new circumstances.

It is launched at the wrong time

The timing can be wrong for an otherwise perfect strategy – it may be ahead of its
time or too late. You can develop a strategy and wait for the right time for its
implementation.

Of the financial implications

With many competing priorities for scarce health service resources, a strategy
should assess the financial implications and see that appropriate resources are
secured.

Stage 2: keeping going

Look back at Figure 3.1 for where you are on your route to establishing a self care culture across your PCT with effective self care resources and interventions applied by a willing workforce. Adopting a developmental approach should encourage staff, rather than issuing ‘top down’ directives that are resented by staff and difficult to implement. Otherwise, frontline staff will view self care as just adding to their workload, and not part of demand management.

Everyone working on, or associated with, the self care strategy should be clear about the goals, individuals’ roles and responsibilities, timetabled programmes for improvements, and standards of performance required.

Overcoming barriers and facilitating change

The most commonly perceived barriers to supporting self care initially in the Joining Up Self Care initiative are described in Box 3.5.

Box 3.5:

Barriers to extending self care

The most frequently mentioned barriers were time and resources.
Patients’ lack of knowledge about possible services and sources of advice was frequently mentioned. There were some sceptical or negative views from health professionals about patients’ ability and/or willingness to take up self care.
Negative attitudes and lack of knowledge and skills of health professionals in relation to self care were recognised. Awareness of opportunities to support self care during consultations was lacking across all the professional groups. (Holmes J. Joining Up Self Care – baseline health professional research. Personal communication, 2005)

Encourage health professionals who have attended initial training on self care aware consultation techniques, or are considering supporting self care, to keep a learning log during their everyday practice, as in Tool 15. Or suggest they undertake a significant event audit relating to their promotion of self care support succeeding or failing as in Tool 12. Encourage practice teams to think about what worked out well, or what got in the way using Tools 12 and 14 or any other Tools. They should come up with solutions they can sustain to overcome barriers and move towards supporting self care as part of their everyday practice.

Establishing support and development

As a PCT you need to work closely with practice teams of GPs and other independent contractors to help them build momentum for supporting self care. Look back at Chapter 2 to see the conclusions about successful self care support – i.e. the whole systems approach that is needed.18 You need well-educated health professionals to be able to communicate ideas on self care to individual patients consulting them. Patients themselves need to be offered the information they want and need. The spoken word needs to be reinforced – by guided self management, personal care plans, online resources, etc. The PCT should promote parallel activities at community level and in schools.19

The education and training you provide, signpost or commission should:

match health professionals’ learning needs (see Tool 10)
support good practice teamworking (see Tool 11)
encourage reflection on performance and learning from experience (see Tool 15)
promote efficient working and service provision so that there is time to promote self
care during consultations (see Tool 16)
help practice teams to assess

Mirror this range of encouragement and support you will be extending to practice teams within your PCT employed workforce too.

Supporting self care

Your actions to support self care will be a continuation of the self care interventions you selected earlier. Encourage the application of Tool 13 workload assessment in general practices or discuss the range of self care support initiatives described in Chapter 2 and match themwith your population’s needs. The experience of the Joining Up Self Care initiative described in Box 3.4 shows the importance of encouraging good patient-centred consultation techniques in your health professional community – so advocate Tools 19 and 20 for your workforce to assess their consultation skills and style. You could use Tool 21 as a core component of a workshop on self care skills training for your PCT workforce.

Lastly, remember that promoting self care will be tough. Anything new that requires such significant change in knowledge, skills, attitudes and behaviour, will be difficult and may seem overwhelming to people already working under pressure. Encourage your workforce and health professional community to look after themselves too. Tool 18 is a good start, for individuals to map out the types and extent of support in their own lives, and see which sources of support can be boosted.

Stage 3: monitoring and evaluation

Evaluation is an essential component of any programme or service. Incorporate it into your action plan from the beginning, matched to your vision and aims. Time and effort spent on evaluation should be in proportion to the activity that is being evaluated. Keep it as simple as possible to avoid wasting resources on unnecessarily bureaucratic evaluation. Use Tools 9 and 12 to undertake audits of the self care outputs and
activities being generated by your self care support strategy and its implementation. Look at Chapter 9 for more on evaluation.

Mainstreaming and sustaining a self care culture in your PCT

Your strategy and action plan is directed at establishing a culture of supporting self care, rather than perceiving this as a time-limited project. Activities and milestones should reflect the mainstreaming and sustaining of achievements you expect. Reassess your priorities and resource needs as you gather data evaluating your progress to date. You will be moving in a circular fashion to re-examine barriers to progress and facilitate further change – as in the algorithm of Figure 3.1.

References

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

2 Swanton K. AToolkit for Developing a Local Strategy to Tackle Overweight and Obesity in Adults and Children. London: Faculty of Public Health; 2005.

3 Working in Partnership Programme. Self care in Primary Care – a new way of thinking. London: Department of Health; 2005. www.wipp.nhs.uk

4 Corben S and Rosen R. Self-management for Long-term Conditions. London: King’s Fund; 2005.

5 Cavanagh S and Chadwick K. Health Needs Assessment: a practical guide. London: Health Development Agency; 2005. (HDA functions are now transferred to NICE www.nice.org.uk)

6 Department of Health. Creating Healthier Communities: a resource pack for local partnerships.
London: Department of Health; 2005.

7 Drinkwater C. Commissioning Obesity Services: PCTs’ services and strategies. London: NHS Modernisation Agency and NHS Alliance; 2005.

8 Health Development Agency. Partnerships. Tackling health inequalities. Learning from East and West Midlands. London: Health Development Agency; 2005.

9 Crisp N. The Challenges of Commissioning. Speech made by Sir Nigel Crisp, Chief Executive to the NHS at the NHS Confederation Conference; November 2005.

10 Murphy J. A Review of the Evidence on Organisational Development for Effective Commissioning in the NHS. Cambridge: Norfolk, Suffolk and Cambridgeshire Strategic Health Authority; 2005.

11 Powys and Ceredigion Health Promotion. Programmes – primary health care.
http://healthcare.powys.org.uk/primary.htm

12 Department of Health. Delivering Choosing Health. London: Department of Health; 2005.

13 Levy J. How to Market Better Health. Diabetes. A Dr Foster community health workbook.
London: Dr Foster Ltd; 2005.

14 Ham C, York N, Sutch S et al. Hospital bed utilisation in the NHS. Kaiser Permanente and the US Medicare programme: analysis of routine data. British Medical Journal. 2003; 327:
1257–60.

15 King’s Fund. Predictive Risk Project. Literature review. London: King’s Fund; 2005.

16 Department of Health. Self Care Support: baseline study of activity and development in self care support in PCTs and local areas. London: Department of Health; 2005.

17 Department of Health. Self Care Compendium (Complete). London: Department of Health; 2005.

18 Partridge MR and Hill SR on behalf of the 1998 World Asthma Meeting Education and Delivery of Care Working Group. Enhancing care for people with asthma: the role of communication, education, training and self-management. European Respiratory Journal. 2000; 16: 333–48.

19 Kennedy A and Rogers A. Improving self management skills: a whole systems approach. British Journal of Nursing. 2001; 10: 734–7.

part 1

Chapter 3 - part 2 Getting organised for supporting self care as a primary care organisation