Knowing how is not equal to doing

There have been several attempts to develop a standardised approach to self management – one of the most popular in New Zealand is the Flinders Program (TM). This is a programme developed in Australia from the 1990 Australian Coordinated Care Trials. It’s based on cognitive behavioural therapy, includes problem solving and motivational interviewing techniques, and provides a set of tools and processes that clinicians can use to help people assess and then develop self management plans. The aim, as for any self management programme, is to shift the ‘balance of power’ so to speak from clinician-centred to patient or client-centred partnership, so that shared decision-making about health occurs.

It has been used in New Zealand for some years: the Arthritis New Zealand organisation conducts group programmes for members, and there has been widespread training of mainly primary health care nurses in the programme – about 500 health professionals have attended a two-day training workshop carried out by a Flinders trainer, and there are  assignments to be completed before a Certificate of Competence in Chronic Condition Self-Management is issued from Flinders University.

All very well then.  Training is available, people have completed the training – so we should be sweet? Maybe not.  This paper by a group of New Zealand researchers interested in chronic condition self-management identifies that while primary care clinicians may know what to do – in practice, they don’t actually do it.  Or at least, they weren’t at the time of this study in 2007-2008.  Thankfully, this paper identifies some of the problems – and some of the enablers too.

So what gets in the way of helping people in the community develop self management?

The main response was – lack of time.

It takes about 60 – 90 minutes to conduct an assessment and start the process of generating goals.  Follow-up appointments are estimated to take around 30 minutes.

Other problems are possibly more telling – lack of funding for providing this service, no electronic versions of the material, clients can’t/don’t want to pay for this, clients don’t want to have the long appointments, no space to do the work, resistance from GP’s (what?!!), resistance from other nurses (!), resistance from management (!), lack of mentoring.  And a few others such as not being in a Maori framework, or people not speaking the language.

Wow – 14% of respondents suggested that GP’s and 12% suggested that nurses resisted the use of this approach. I wonder what that’s about?  Resistance to a tool that has good evidence, helps patients, encourages people to get involved in their own health – but, admittedly, does take time and isn’t directly funded.  And there is that possibility that it’s a huge shift from a clinician-centred to a patient-centred approach.

Systems issues are incredibly powerful.  I’ve often pondered the fact that the greatest agent of change in health practice is not ‘evidence’, it’s not the latest workshop or the best clinical approach – it’s what is funded and how it’s funded.

Take a quick look at the impact of funding options on the delivery of physiotherapy in New Zealand.  In the early 1990’s there were physiotherapy practices all over New Zealand treating people with chronic pain using passive therapy for – well one patient proudly told me she had been to physiotherapy three times a week for hands-on therapy for the last five years.  All funded by our accident insurer.  And she also admitted that she only got short-term relief, maybe an hour or so.

In mid-2002 this all changed.  Treatments for people with persistent pain now needed to be delivered by interdisciplinary teams – rapidly a whole new set of private providers responded: occupational therapists and physiotherapists started to work together, and even the occasional clinical psychologist got in on the act.  Now, in 2010, the same programme must be staffed by clinical psychologists, while occupational therapists and physiotherapists are lumped together under the heading ‘functional’.  All changes initiated, and maintained by the way treatments are funded.

What enabled the use of the Flinders Program in New Zealand?

Strong leadership, ongoing contact with a trainer, funding for the programme, support from nurses, support from GP’s, and far behind… conferences and newsletters.

Like the people we work with, simply knowing how to do something is not enough.  We need to develop confidence and skill in a new approach, and we as clinicians certainly need to be supported and have systems that make it easy to carry on with an approach that differs from ‘standard medical practice’.

It seems to me that while there is ready acknowledgement in many circles that chronic health conditions such as chronic pain need to be self-managed, our current service delivery systems don’t support it.

Self management is not just a case of telling someone what to do – that’s the old  ‘Trust me, I’m the doctor’ approach.  Self-management requires time, engagement from both parties to see it through, and mutual trust.

The patients I work with say again and again that they just wished their doctors, specialists and other clinicians would only stop and listen to them, then give them information and options so they can choose.

This is such a different way of working from our traditional healthcare training that I’m not a bit surprised that so few of the respondents in this survey actually used all the Flinders Program tools in the way these tools were intended.  It’s not enough to know how – clinicians really do need mentoring (we could call it supervision), help to know they have time and collegial support as well as funding to change practice.

Finally, this study argues that there is limited evidence that a self-management approach is able to be adopted in New Zealand in the way it has been elsewhere in the world.  I’d say the authors need just to take a look at the three main pain management centres in New Zealand – two of whom have been operating since at least the early 1990’s – to see a group of clinicians who have been able to deliver and support self management to people who have chronic pain.  While the approaches are not the Flinders Program (TM), they are solid self-management strategies and are very effective in a patient group that can be challenging.

Maybe transplanting a ready-made programme isn’t the only way to begin a revolution in New Zealand.  Maybe it’s time to take a look at a home-grown approach.  And maybe it’s time for health systems to start with the successes we already have and learn from them.

M Horsburgh, J Bycroft, F Goodyear-Smith, D Roy, F Mahony, E Donnell, D Miller (2010). The Flinders Program of Chronic Condition Self-Management in New Zealand: Survey findings Journal of Primary Health Care, 2 (4), 288-293