I attended a workshop today on supported self management for chronic health conditions. It’s something the New Zealand Ministry of Health are keen to support, it’s popular in the US and UK – hopefully will save money, because it’s all about what the person with the health condition does, it’s a bit of a buzz-word.
Some of the other buzz words for the day: biopsychosocial model; health literacy; cognitive behavioural therapy; and patient-centred.
I was pleased to see so many people from a diverse range of practice settings all keen to hear about new ways of delivering health. It was exciting to see people given hard evidence that self management in a condition such as refractory angina actually works. It does cost less to help someone do some daily exercise, eat healthily and learn about their health problem, than it does to simply put in a stent or pop a pill.
I hope that the excitement of the day doesn’t disappear with the reality of some of the obstacles that are most definitely present.
And now for some thoughts on this concept based on experience within the field of chronic pain management. In New Zealand, Burwood Pain Management Centre has been providing self management programmes for chronic pain management since at least 1987, and I’ve been working in this field since 1989, so we have some practical as well as academic experience to draw on!
- Not everyone is suitable for self management. Some people are either not ready for it, have very fixed beliefs about their role in their own health (the main one being ‘but Doctor, you’re supposed to fix me’), or have limited resources to expand their coping. This is OK – health care can be individualised, and levels of support will need to be provided even for self management. It’s about the right approach at the right time for the right person.
- Self management is hard work for the individual. We are talking about making changes to behaviour – this is all about habits, and old habits die hard while new ones need nurturing. We can’t expect people to attend a self management programme and immediately adopt new behaviours without providing them with support. If you’ve ever started an exercise programme, or tried a diet you’ll know what I mean – it takes time to make changes
- Self management means a shift in ‘power’. I had to think for a moment to come up with the right word but I think power is the right one. What I mean is that for some people health is not their priority. They may have other things in their lives that are more important. As health providers, we expect that people will want to prioritise their health – but it ain’t necessarily so. This means we need to allow people to make their own decisions about when, or indeed if, they want to take on changes. This means we may need to watch people ‘do the wrong thing’ for a while. This is not easy when our work is being measured in terms of outcomes. Self management is about choices, even ‘wrong’ ones.
- Self management is not ‘education’. Health providers are not generally trained to meet people where they’re at. Typically, we are taught that people coming to see us are ‘ready’ to be given ‘education’. Education and information are part of self management, but in the end the hardest part of self management is helping people become aware of their beliefs and attitudes, the outcomes of those beliefs and attitudes, and alternative ways of viewing a situation. To help someone self manage their health problem involves ‘us’ understanding where ‘they’ are coming from first.
- Supporting self management takes time and funding and skills. It requires listening, providing, supporting, reminding, prodding, encouraging, planning – and this does not happen just face-to-face. New Zealand’s current funding system doesn’t pay for email contact, telephone contact or even for sending out reminder letters. And it seems to be the ‘personal touch’ that makes a big difference for those people who are slipping up or having trouble maintaining changes. Several things spring to mind here. An effective IT system that will automate some of the activities that we as humans are not good at – review dates, links between secondary/tertiary care facilities and primary care, access to the whole medical record across ‘diseases’ and ‘departments’ – these would be fantastic! And allowing clinicians time to do both planning this type of proactive care and to tie up the details rather than simply tying funding to direct patient contact hours. Training so clinicians can use IT effectively, along with enhancing their clinical listening and CBT skills. This won’t happen overnight, and it will be an up-front expense.
- Self management is patient-centred but not patient-directed. What I mean by this is that not everything a patient thinks would be helpful for their health actually is helpful. Things that don’t have an evidence base like homeopathy, or Reiki. Things that help short-term but have little or no long-term effect like massage or chiropractic for chronic pain. And I especially hope that things that create dependence on being involved in a health care setting are really looked at very closely. In chronic pain at least, these things are often offered because the patient is distressed, their distress reduces quickly once they have a health care encounter – but rapidly rises again because they are not taught how to actively cope with their distress. Patients may like them, but they don’t do a lot for patient autonomy or self efficacy.
- If it’s self management – then people are not patients. At some point I’m guessing we will move from seeing people as patients who ‘need our help’, and we’ll see them as people who have lives to live, goals to achieve, places to go and things to do. We won’t talk about ‘care plans’, we’ll talk about ‘action plans’. We’ll remove the diagnostic labels and we’ll instead ask people about their hopes and dreams, and what they want to do in life and how they want to do it. We’ll be looking at their participation levels rather than disease management. Roll on that day!
Food for thought – if self management is to be a significant part of the ‘new’ health care delivery system, then some clinicians will find it relatively easy to do. I don’t think it’s necessarily about a specific professional group (eg psychologists) or even an area of practice (eg chronic pain). I do think some clinicians think in terms of ‘wellbeing’ and ‘living life well’, while others continue to focus on removing or eliminating the ‘problem’ and hoping this will directly influence health.
For some more information on the New Zealand Ministry of Health’s strategy for chronic health conditions, you can go to here.
For a New Zealand gateway for health information based on a self management model, go to Health Navigator NZ here. I’ve been told it’s about to be revamped visually, so go back in a couple of weeks for the new and improved version!
You can bet I’ll be writing more about this as time goes on. I’m no cynic, but I have worked in pain management long enough to know the initial enthusiasm for self management in chronic health conditions will need to have some robust financial support, some systems change, and really effective training and support for the health providers who will support the people starting to manage their own health. Hopefully a blog like this will do a bit to help the latter. Don’t forget you can drop me a line either through the comments (which will be visible to anyone reading the blog), or via my About page (which will go direct to my email). And I do respond (it reminds me I’m not simply ranting to myself!).