In recent years there has been growing momentum behind the agenda for person-centred care. Supporting people with long-term conditions to manage their own health is now increasingly seen as the right thing to do, and is backed up by evidence showing the benefits to individuals of such support. Despite this evidence, alongside important initiatives such as 'What Matters to You Day' and a commitment to person-centred care in the NHS Five Year Forward View, there is still a long way to go to ensure everyone receives the support they need to manage their condition and the social and emotional impact it has on their life.
In the latest national GP survey results, for example, around one in six people with a long-term condition said they were not confident to manage it. Of those who said they needed self-management support from local organisations and services, one in five said they did not receive enough support in the last year. This equates to large numbers of patients potentially feeling overwhelmed and unable to take an active role in their own care.
There are many reasons self-management support is not more widespread, but one barrier has been our inability to demonstrate the impact it can have on how people use health care services. At a time of rising demand and huge financial pressure in the NHS, policymakers and commissioners are understandably looking for approaches they can have confidence will help address these challenges.
Building the evidence base
Recent research from the data analytics team at the Health Foundation has begun to fill this evidence gap. It shows that patients most able to manage their health conditions had 38% fewer emergency admissions and 32% fewer A&E attendances than those least able. They also had 18% fewer GP appointments. It is the first study in the NHS to demonstrate an association between patients’ ability to self-manage and the use of services across both primary and secondary care.
The research used the Patient Activation Measure (PAM), a questionnaire-based measure of the knowledge, skills and confidence that someone with a long-term condition has, to manage their health and care. The measure gives patients an individual ‘activation’ score and divides them into four levels, from least to most ‘activated’.
Significantly, analysis based on PAM scores for over 9,000 patients found a substantial difference between those at the least activated level and the next level up. The latter had 29% fewer emergency admissions than the former. This is important, as it suggests that improving the knowledge and skills for self-management of patients at the lowest activation level has the potential to make a real difference.
What this research indicates is that the investment in supporting people to manage their own health and care could be substantial. It estimates that if people who are currently least able to manage their health conditions were supported to manage their conditions as well as those most able, it could prevent 436,000 emergency admissions in England each year.
Investing in self-management
The study examined an association between self-management ability and health service usage; the next step is to identify approaches that have the potential to improve this and robustly evaluate their impact. There are a range of promising approaches such as group self-management courses, peer support and health coaching, which include the use of health-related apps and online tools. Many of these have been explored in programmes that the Health Foundation has supported over the last decade, such as Co-creating Health, Closing the Gap through Changing Relationships, and Spreading self-management support.
One way in which understanding patients’ ability and confidence to self-manage can help is by allowing services to tailor the support they offer. This approach is currently being tested in a Health Foundation funded project in South Tyneside, where the First Contact Clinical team are using the PAM to tailor different interventions for people with COPD. Patients with the lowest activation are offered the most intensive support, including sessions with a trained health psychologist, while more confident self-managers are offered social prescribing or community-based peer support.
Many of the programmes mentioned have helped to embed self-management into routine clinical practice. Aside from focusing on developing patients’ capabilities, we need to support health care professionals to understand the importance of self-management and to develop their own knowledge, skills and confidence to build collaborative relationships with patients. We need systems and processes that make this new way of working easier, not harder.
While PAM is important, our earlier work on measuring person-centred care showed that we need a wide range of measures to understand whether services are person-centred. We are still some way from achieving this.
The results of this study show that empowering people to be more active partners in their health and care is not only morally right but could also help stem the growth in demand for NHS care. Significantly, it found that only 13% of patients in the sample felt highly engaged and confident to manage their long-term health conditions and around a quarter were at the lowest level of activation, based on their PAM score.
There is still a long way to go in making person-centred care a reality for all, but being able to demonstrate a clear link between self-management ability and the demand for formal care can only help build the case for further progress.
Suzanne Wood is an Improvement Fellow at the Health Foundation.