Kallur Suresh: Prevention and self-management—two pillars for a paradigm shift in thinking about our health

Generation Q 12 June 2012We all know that the health service is struggling. GPs are seeing escalating workloads, waiting times are getting longer, emergency care is on its knees with ambulances queueing in front of Accident and Emergency departments, discharges from hospital are delayed leading to longer stays, and community services are unable to cope with the demands placed on them.

The equation is simple. There is a huge gulf between resources and demand—and it is going to get wider. There are a number of factors arrayed against better performance by the health service. Rising demand and patient expectations, increasing life expectancy, increasing numbers of frail older people, higher rates of detection of long term conditions for which there is no “cure,” and rising healthcare costs.

An easy and quick solution is to put in more resources and increase capacity proportionate to the demand. But this will only help in the short term—just as building more roads is unlikely to reduce traffic congestion in the long term. Small increases in capacity are likely to be swallowed up by the disproportionately higher rises in demand. So, supply side solutions are not always the answer. Another logical solution is to enhance efficiency and cut waste. Besides being very hard to do, a small percentage gain in efficiency, albeit welcome, will not be enough.

The answer is simple too. We have to get much better at using patients as a resource. We need to treat them as equal partners in managing their health and illness, and give them the tools to empower them to do it better. In long term conditions–which probably place the greatest burden on healthcare services–patients become more important than the professional, as they live with their conditions 24/7 and professional contact is limited to just a few hours of consultation and crisis management every year.

If the demand on health services has to reduce, prevention is key. Healthy people can do a lot to reduce their likelihood of developing disease or at least, postpone its onset. Further levels of prevention can be facilitated by early diagnosis and treatment, reducing long term complications and good quality rehabilitation.

Once a diagnosis has been made and a treatment plan is in place, supported self-management has the potential to reduce ongoing demand on the service. This potential of self-management has not been tapped fully apart from in a handful of conditions, such as diabetes mellitus, COPD, musculoskeletal disorders, and depression.

Patients present to us with problems but we often forget that they also hold the solutions. They need help in unlocking them and health coaching can help. Health coaching is about having a different conversation with the patient, rather than the one we are used to. The purpose of health coaching is to raise awareness of the problem in the patient and increase their personal responsibility to do something about it, ultimately leading to sustained behaviour change enabling self-management. This approach has its limitations in that it works better for “activated” patients and is much more suitable for chronic, lifestyle related conditions for which there is no “cure” in the traditional sense.

However, both patients and clinicians need support in enabling self-management. This starts with education and a change in mindset. Both parties need to feel confident in the process and trust each other to do it. There are other enablers such as patients having access to their own records so they can take greater control of their health information. Although access to health information has improved dramatically with the internet, we are still far from giving patients access to their own health records and test results.

Health services have been set up mostly to deal with illness and its treatment rather than prevention and enabling patients to self-manage where they can. These require patients to become more active and have a different relationship with the health service, and clinicians to enable that to happen. Without prevention and self-management, increases in capacity and efficiency are likely to be drowned out by the exponential demand.

Kallur Suresh is a consultant psychiatrist in the specialist dementia/frailty service at the North Essex Partnership University NHS Foundation Trust. He is a GenerationQ fellow at the Health Foundation.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I have completed a Masters degree funded by the Health Foundation and my dissertation was on enabling self-management in mental health. I have attended a conference on health coaching for behavior change organized by Health Education East of England and run a workshop on health coaching in mental health settings.