Why Self Management?

Reasearch Outcomes

Self-management as an intervention is often described as having no significant impact on patient outcomes or health service use.  A recent study indicating such an outcome was published in May 2013:

Implementation of self-management support for long-term conditions in routine primary care settings: cluster randomised controlled trial.  BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2882 (Published 13 May 2013). Cite this as: BMJ 2013;346:f2882 [24].     

Such studies beg the question regarding efficacy as associated with any cognitive / behavioural intervention: Why, as a society, do we continue to invest large sums of money into something that doesn’t work…?  If it doesn’t work, why do policy makers still cling to the goal of great gains in public health as a result of self-management interventions?  Something must be missing.  A closer look at the presumptions underpinning this study holds some answers.

In this study, practice staff were given guidebooks on self-management to give to patients and access to a website that listed local self-management resources, again, to be passed on to patients.  Given that the target population for this intervention experienced the highest levels of deprivation it is not surprising that the intervention demonstrated no significant impact.  Patients experiencing high levels of deprivation will not have the literary and/or social skills necessary to make effective use of guidebooks and web based resources.  Include the additional psychosocial impact of a severe chronic condition and the patients targeted by this study will be the most vulnerable.  It is the most vulnerable that require the most support when accessing help in such circumstances.  This intervention, by definition, was only able to provide minimal support within the clinical environment and it seems, even less support outside the clinical environment.

A third tool, Pictorial Representation of Illness and Self Measure (PRISM), used to establish the support needs of patients, was the least used of any resources given to staff.  It is well established within the theory of androgogy that the degree of learner self-awareness - and pertinent context that such an instrument provides - is the necessary starting point for any self-management intervention. 

The fact that self-management programmes are educational in nature means they require substantial social interaction and nurturing to enable the normalisation process.  Yet only in rare cases during the course of this intervention were patients referred to induce focused social interaction in the form of specialist psychological services.  Handing out guidebooks and web-based resources does not provide the degree of focused social interaction required to support the normalisation process that self-management interventions are designed to instigate.  Again, such an intervention is least likely to succeed with individuals experiencing the highest levels of deprivation.

It is also arguable that clinical settings are not best placed to tackle the inequalities associated with socioeconomic deprivation because they focus on rectifying the outcomes of deprivation that manifest themselves in the form of chronic and/or acute health conditions.  Additionally, clinical environments are mandated to focus on delivering efficient services driven by adherence to funding formulas that translate into pressurised, at times dysfunctional, organisational environments.  The culture of these environments is often a complete antithesis to the objectives and outcomes of self-management interventions. 

Self-management interventions, by definition, are designed to ameliorate as far as possible the causes of a condition, as well as the condition itself, which, in socio economic terms, is what makes them so attractive to administrators and politicians alike.  In other words, self-management interventions have the potential to reduce long-term health costs because of their ability to ameliorate some of the causes of poverty, as well as the chronic conditions that arise out of socio economic deprivation.  Clinical interventions lack this focus on socio economic causality, which is probably the main reason there is often resistance to the Personalisation Agenda from within the medical profession.  Causality in a psychosocial context can be a very grey area that inherently weakens the traditional black and white power of clinical culture and ultimately exposes the clinician to dealing with patient issues for which they traditionally have no clear answers.

Hence, given the anathema that self-management interventions are to many clinical practitioners, adoption of the Whole System Informing Self Management Engagement (WISE) theory by the authors of this study is also perhaps somewhat misplaced.  The concept of total immersion, integral to the normalisation process, is an unspoken essential to the WISE Whole Systems construct.  This study offered no significant opportunities for total immersion as a part of the intervention.

Furthermore, the Whole Systems construct of WISE bears little or no relation to the context of primary care practises under enormous economic strain and the pressure of major reorganisation.  Considering that the study’s sample was drawn from a socio-economically deprived population, the WISE constructs of Health Literacy and Social Science Applied to Health and Healing bear little or no relevance to the sample population.  The constructs of Behavioural Change and a Learning Organisation were not embraced by the practises that participated in the study.  Organisational and funding issues precluded this from happening. 

As a result, although staff approved of the training provided to support the intervention, arguably, insufficient time was given to the implementation of training.  Additionally, it is also clear that insufficient time was available to staff to implement the intervention and only one practise devoted any time to fidelity checks - more on this.

Support for Patient Centred and Health Literacy constructs also fail to be accounted for in the design of this intervention.  Developing these constructs within an organisation requires a significant investment in time.  All individuals that participated in this self-management intervention, which is an educational ‘process’, needed nurturing, as in any other educational/developmental environment, to achieve a significant outcome.  Unfortunately that was not the case with this intervention. 

System based approaches are not necessarily person oriented in focus or outcome.  Clinical settings are not naturalistic environments that focus on real world applicability from a patient perspective.  Such real world applicability comes when a patient has had time to accept their circumstances.  Remember acceptance is the final stage of the rehabilitation process; the first stage is denial.  Socio economically vulnerable individuals will need extensive nurturing to navigate the rehabilitation process and achieve acceptance regarding all aspects of their condition.  Such extensive nurturing was, again, not a part of this intervention, a circumstance supported by outcomes of the study’s Forest plot. 

Energy and Vitality, Social or Role Limitations and Shared Decision Making were all better for patients before being subject to the intervention.  This is consistent with vulnerable individuals being asked to make major changes within their lives when they have neither the necessary self-management skills nor more importantly, the ability to acquire such skills without significant support of a psychosocial/educational nature.  Non-intervention leaves patients happy within their existing comfort zone as opposed to struggling outside their comfort zone without appropriate support.

To be successful, self-management interventions must be viewed as educational in nature and as such, given the time they require for implementation.  These interventions must also be well grounded in the theories of androgogy if they are to have the slightest chance of success. The same is true of anybody delivering such interventions. Afterall, one does not consider taking a motor vehicle to the doctor when it needs repairing.