Optimising systems and processes

To optimise its effectiveness, self-management support needs to be embedded within the systems and processes all services use, both within individual consultations and across the whole care pathway. 

Current systems used by health services are generally designed to focus on the consultation, and episodic treatment of people’s disease(s), rather than on providing the support that people need on an on-going basis and between appointments to manage their own health.  Changes which enable people to self-manage can be made at every level and at every stage of the care pathway, from how services are planned and provided, to support before, during, after and between appointments. 

As self-management support is about enabling people to live well with their condition(s), they have the best understanding of the changes to how services are provided that are most likely to support them.  Working with people with long term conditions to understand the challenges and to co-design the changes ensures that you are able to target and make changes where they will be most effective.

The key areas in which changes can be made are:

  • Developing care pathways to create better links and referrals between statutory, voluntary and community sectors. For example, the ALISS project is a co-produced library that can be added to by anyone and is designed to make information about local sources of support easier to access.  Working together with people with long term conditions to co-design care pathways is the most effective way to develop services that support and enable people to self-manage. 
    Read more about developing care pathways
  • Providing services in different ways, through support groups, emails, text messages, and telehealth, to provide on-going support between face-to-face appointments.  For example, the telehealth service in Newham combines different levels of support for people with a range of conditions via virtual education and symptom monitoring. 
    Read more about different ways of providing care
  • Improving processes to enable people to play a more active role.  This could involve providing agenda setting sheets, that help people to think through what they want to get from an appointment; and providing people with test results in advance of the consultation, so that they prepare questions in advance.   
    Read more on ways systems and processes can can support health professionals
  • Refining IT systems and developing processes to support healthcare professionals. For example, in Ayrshire & Arran many GPs use the same system, so they have developed a ‘tag’ for the records of people with COPD to prompt the GP to check if they have been offered a self-management programme.
    Read more on ways systems and processes can support healthcare professionals

Through the Health Foundation’s Co-Creating Health programme, we also learnt a lot about how teams can work together to plan and implement changes that support people to self-manage. 
Read more

All resource on self-management support