The NHS in England faces a huge challenge over the next decade. The tighter public spending settlement for the NHS means the NHS will have to increase productivity in the order of four per cent per annum. The health sector is a labour intensive industry; it will only be possible to deliver productivity improvements by using human as well as financial resources differently.
Christensen et al have previously argued “Managers and technologies need to focus on enabling less expensive professionals to do progressively more sophisticated things in less expensive settings.” At a recent Salzburg Global Seminar, supported by the Dartmouth centre for healthcare delivery science, the message was clear: healthcare teams need to transfer responsibility for delivering care to those that have the skills they need and no more. According to Al Mulley, director of the Dartmouth centre, healthcare delivery systems where staff “function at a lower level is inefficient, at a higher level unsafe.”
There is potential for significant productivity gains from challenging the accepted wisdom about the professional roles and responsibilities in the care team. Wherever possible, staff need to be given the opportunity to work consistently at the level of their knowledge and capabilities. This is not about undermining or devaluing clinical skill and judgment, but about ensuring that the right care is given by the right person with the right skills. But this transfer of responsibility must not stop at healthcare professionals. It needs to extend to us as patients and citizens too. Patients are also members of the clinical team. Real benefits can also come from conferring agency on the patient in self management, self care, and in maintaining health.
The chronic care model clearly identifies the important role that patients play in self management and self care. But not all patients feel equally confident to take on this role. The patient activation measure was developed to measure patients’ knowledge skills and confidence to self manage. For people at any level of activation having the necessary information and knowledge is a basic prerequisite to self management. Research shows that higher levels of activation are associated with better self management activities. Furthermore those with low activation see self management primarily as about compliance, i.e. following the advice of doctors or taking medication as directed. Those with higher levels of activation talked about self management as taking control. They see themselves playing a much more proactive role in their own health and health care.
If the NHS is to deliver productivity improvements on the scale needed, it will need to radically change the skill mix involved in the delivery of care within teams. It will also need to radically change the balance of professionally delivered care, and self care. Empowering patients to be more active participants in their care is not a nice-to-do, it is imperative if we are to deliver on higher value care.
Anna Dixon is director of policy at the King’s Fund
1. Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations cure healthcare? Harvard Business Review 2000; 102-12.
2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288(14):1775-9.
3. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the patient activation measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Services Research 2004;39(4):1005-26.
4. Hibbard JH, Mahoney ER, Stock R, Tusler M. Do increases in patient activation result in improved self-management behaviors? Health Services Research 2007;42(4):1443-63.
5. Dixon A, Hibbard J, Tusler M. How do people with different levels of activation self-manage their chronic conditions. Patient-centered outcomes research. Patient 2009; 2(4): 257-68