Self-management support is when health professionals, teams and services (both within and beyond the NHS) work in ways that ensure that people with long term conditions have the knowledge, skills, confidence and support they need to manage their condition(s) effectively and live well in their everyday life.
- Defining health in a more holistic way
Health services have traditionally defined ‘health’ in purely clinical terms and measured it only by clinical indicators, but it is increasingly being understood in a more holistic way. This broader understanding recognises that health and well-being are a combination of biological factors (such as having a long term health condition or conditions), psychological factors (such as stress and depression) and social factors (such as isolation, money, and employment), and that each of these factors impacts on the others. This is often called the ‘biopsychosocial model’.
For people with long term conditions, this wider definition that goes beyond the purely biological is key, as their condition(s) are not something that can be ‘fixed’ but something that they live with on a day-to-day basis. People need different kinds of support to keep these different aspects of their life in balance and to live well with their condition(s).
- Moving beyond clinical outcomes to enabling people to live well
For people with long term conditions living with their symptoms and adjusting their activities around them is part of everyday life. In self-management support, people are given the support and signposted to the resources they need to better manage their own health and wellbeing on a day-to-day basis. Improvements in clinical outcomes are understood as contributing to the outcomes that are important to people – such as being able to walk to school with their children – and as part of enabling people to live well. People are supported to build the skills and resilience to manage the impact of their ongoing symptoms and limitations so that they can live a full and meaningful life whilst having symptoms. Professionals in the mental health sector often describe this way of working as the ‘recovery model’.
The example below from the Personalised Care and Support Planning Handbook demonstrates the shift in thinking from clinical outcomes to outcomes that are important to people:
- Changing roles, responsibilities and relationships between patients and the health professionals who support them
Self-management support involves a cultural shift in how we understand the roles, responsibilities and relationship between patients and the health professionals who support them. Patients and health professionals work together in a collaborative relationship where people with long term conditions are active partners in managing their own health. For health professionals, it means not only providing clinical care, but helping people to think about their strengths and abilities and the changes they can make in their lives to take control, reach their goals and maintain their health and wellbeing. For people with long term conditions it means developing the skills, knowledge and confidence to make decisions and take actions that enable them to live well with their condition. It often also means that the way services work need to adapt to enable people to play a more active role, for example by providing test results in advance of appointments so they can think beforehand about things they might want to ask or talk about.
- Supporting people between clinical appointments
Self-management support recognises that people with long term conditions manage their own health and well-being the majority of the time. They therefore need support between health appointments to develop and maintain their skills and motivation. This support comes in two forms: it may be provided by the NHS, for example through texts, rehabilitation programmes or health coaching between consultations; it may also be provided through the local voluntary and community sector and online. This second type of support includes peer support and there is strong evidence for its value in helping people with long term conditions to maintain their health and wellbeing. Think tank NESTA calls it 'more than medicine'.
How self-management support translates into changes in practice
A system of effective self-management support requires changes at every level from how and what services are commissioned, to how health professionals and people with long term conditions / service users work together in a consultation, to how people are supported in between appointments.
Here is a summary of some of the key changes in thinking and practice that are involved in effective self-management support:
NHS Commissioning objectives
- Traditional practice: The commissioning objective is to achieve a set of specified clinical outcomes and key performance indicators.
- Self-management support: The commissioning objective is to enable people with long term conditions to manage their own health in their everyday life facilitated by improvements in their clinical outcomes.
- Traditional practice: Primarily medical, focusing on clinical interventions.
- Self-management support: Biophychosocial, recognising that clinical, emotional and social support are all essential to supporting someone living with a health condition.
- Traditional practice: People who use services are consulted on any proposed changes to services.
- Self-management support: People who use services are involved in the design of the care pathway and of the service from the outset and throughout the commissioning process.
Who provides services
- Traditional practice: Services are commissioned almost exclusively from NHS organisations to deliver the specified clinical outcomes.
- Self-management support: NHS commissioners commission a combination of NHS services and services from other organisations, often in the voluntary and community sector, to provide both clinical care and wider support.
- Traditional practice: Services focus on the times when patients come into contact with the service through appointments or admissions. There is little focus on how people are supported between appointments or support they may receive from organisations beyond health services
- Self-management support: NHS and other services are commissioned to provide seamless care that both addresses people’s clinical needs and supports people to maintain their own health and wellbeing between clinical appointments.
Objectives of the NHS service
- Traditional practice: Clinical outcomes are the primary objective – e.g. keeping blood glucose levels of people with diabetes within safe parameters.
- Self-management support: Health outcomes that are determined by people and that give them the best opportunity to lead the life they want are the primary objective – e.g. avoiding foot ulcers that prevent walking the children to school
- Traditional practice: Patients perceive the health service as expert in determining the interventions and clinical outcomes that are best for them and ideally adhere to associated treatment regimes, so adopt a passive recipient role towards their healthcare.
- Self-management support: People are active partners in determining the health outcomes that are important to them (such as being able to walk their children to school) and in managing their health in their everyday lives (such as changing their diet and joining a walking group). They are collaborative partners in deciding treatments plans, goals and how they are going to achieve them and translate their intentions into action
- Traditional practice: Health professionals provide clinical care to achieve specified clinical outcomes. They also give advice on condition-management.
Self-management support: Health professionals provide clinical care, and use evidence-based skills and approaches to enable people to set their own goals and action plans and identify what help, support and resources they need and how to access it.
Health professionals move towards facilitating rather than delivering, based on the understanding that people need knowledge but also the skills, confidence and motivation (often called ‘activation’) to change their health-related behaviours.
- Traditional practice: Peer support is often available within the community, but is not seen as part of the care pathway nor are patients systematically encouraged or supported to access it.
- Self-management support: Peer support is understood as a key component to enabling people to develop and maintain health behaviours, and people are systematically encouraged and supported to access it as part of the care pathway.
- Traditional practice: Some patient education, mainly focused on increasing people’s knowledge about their condition(s) from a medical perspective
- Self-management support: Training programmes that increase people’s knowledge about their condition, and also build their skills, confidence and resilience to manage the emotional and practical day to day impact of their condition(s).
- Traditional practice: Training for health professionals focuses on disease management, information giving, treatment planning and approaches to increase concordance.
- Self-management support: Training for health professionals, health coaches and others who support people with long term conditions focuses on the skills they need to work in partnership with people with long term conditions to share responsibility and decision making. It includes the evidence based skills and approaches known to be effective in supporting and enabling people to self-manage.
A couple of examples of service delivery
The health professional develops a treatment and management plan for each patient designed to optimise their clinical outcomes.
Patients are sent a letter with details of their appointment
Health professional shares results and information during the consultation
Health professional provides advice on some lifestyle changes – such as diet and exercise – that the patient can make that will help to maintain or improve their health.
The patient and their health professional work collaboratively together to develop a care and support plan designed to optimise their health and wellbeing.
People are sent a letter with details of their appointment and an agenda-setting sheet to help them think through what they want to get out of their appointment
Person receives results and information at the appropriate time, for example, in advance of their appointment, so they can think about any questions they might want to ask, what’s working, what’s not working and what’s important to them
Person with the long term condition identifies that they would like to lose weight as a way to help maintain their health, and the health professional explores their perspective and refers them to the health navigator, who can link them in with the local walking group and some other activities in the local community that can help them lose weight