Clinical support for patient self-management is rhetoric rather than reality

Self-management support aims to increase the patient’s ability to take ownership over their condition and in some cases, to self-treat. It is widely seen as critical to ensure the sustainability of health services in terms of costs. Although potentially effective, patient based interventions can be limited as not all patients engage with them. However, embedding self-management support discussions and decisions into everyday clinical practices is thought to encourage patients to become more actively involved.

The study, led by Senior Research Fellow, Anne Kennedy at the University of Southampton, was carried out in the North West of England by the Universities of Southampton, Manchester, York and Keele and published in the BMJ. It assessed a whole system intervention, which attempted to implement self-management support, led by the health service, for patients with diabetes, chronic obstructive pulmonary disease or irritable bowel syndrome.

All staff, including clinical, management and administrative staff, at 44 practices were trained in a new self-management approach, designed by the universities involved, which helped them to put the patient at the centre of their care and use a range of self-management support resources.

More than 5,500 patients took part in the trial – one of the largest randomised controlled trials of self-management support in primary care ever completed. Practices were randomised to either receive the training intervention and deliver the new self-management approach or provide routine care (the control practices were trained after the trial was completed).

However feedback and assessments showed that while practices engaged with and enjoyed the training, they did not use the approach to improve shared decision-making with patients or encourage the take-up of self-management support. There was no difference in results for any patient outcomes or on service use between the group that had the self-management approach and the group which received usual care.

Southampton’s Dr Anne Kennedy comments: “We are disappointed by these results, as self-management support options do have the ability to help a lot of people, but the findings were very clear. There were a small number of patients who did benefit from the self-management process during the study but overall the feedback showed that the self-management model does not fit with the reality and demands of primary care practice and it is just paid lip service to. The active components required for effective self-management support need to be better understood, both within primary care and in patients’ everyday lives Furthermore a separate process evaluation will explore why practitioners were not able to implement the intervention.”

Co-author Professor Peter Bower, from the University of Manchester, says “[the study] used an intervention that could be delivered widely in routine primary care settings to maximise the applicability of the research.” He added that the results suggest that self-management support may require considerable additional incentives to encourage practices to more actively engage with a self-management agenda.

Dr Kennedy adds: “One possibility is that most forms of intervention, whether provider based or patient based, are outside patients’ workaday and social activities, so fail to embed themselves into their everyday lives. It may be that greater efforts to integrate support for self-management into patients’ personal social networks or by using means that are more pervasive in people’s lives, such as mobile technology, would prove a more effective approach to engaging patients with self-management.”

The study was funded by National Institute for Health Research (NIHR) Programme Grants for Applied Research (PGfAR) Programme and The National Primary Care Research and Development Centre.