Putting self care into practice

Integrating self care into everyday practice ensures consistent messages for patients - but requires the involvement of the whole practice team

Recognising the important role self care can play in the battle for NHS survival is an important step for practice nurses. A far harder step is ensuring self care becomes an essential component of everyday practice. And the burden should not only fall upon the nursing team. Promoting self care at every patient interaction - from the receptionist and the healthcare assistant through to the nurse practitioner, the practice nurse and the GP - ensures the patient receives a consistent message.

With the changes underway from the Health and Social Care Act 2012 (England),1 there may not be a better opportunity to enshrine the principles of self care into daily practice, but what changes are needed to deliver this within your practice ?

SUPPORTING SELF CARE

In 2009, the Department of Health outlined different categories of self care support and also the expectations and knowledge needed for healthcare professionals to support self care for patients.²

The four categories are:²

Information - particularly for those with long-term conditions. This should not simply focus on health but take a whole systems approach, providing information on social care and voluntary services, housing and education. Have information available within the practice that patients can to access, or can be signposted to

Skills and training - encouraging patients to take control of their health is essential. While they are the person who knows the most about their condition, albeit minor or long-term, they often do not realise that they can self care most of the time. It is as though they need permission from a clinician to do so. Providing training and awareness sessions within the practice, referring to the Expert Patient Programme or involving the practice's Patient Participation Group can give patients the right skills and knowledge to be able to self care.

Tools and devices - awareness of the resources and technology available that can be used to self care for minor ailments and long term conditions is important. For example, highlight the role of the pharmacist to patients; not only can they offer advice on minor ailments but many pharmacies offer medicine use reviews or are involved in support for those with long-term conditions. There is also a role for new technologies. Currently there over 1,000 small trials underway globally to determine the impact of telehealth in helping patients manage their long-term conditions,³ often with nurses involved in providing support and advice. The use of mobile phone apps to help patients monitor long-term conditions will become increasingly important, with free apps being available to 'prescribe' from the surgery in the future, said the DH earlier this year.⁴ Patients can be directed to apps available through NHS Choices and NHS Direct that offer symptom checking and trackers for smoking, drinking, BMI and exercise.

Support networks - involving patients in their needs assessment can place them in the centre of their care package, can improve quality of life, services and patient satisfaction. Recommending a support group can also help.

Being able to provide these categories of self care support places additional demands on the healthcare care team, which the DH acknowledges. According to the DH, healthcare professionals need to have right skills and knowledge to be able to:²

• communicate effectively
• identify people's strengths and abilities
• provide advice on support networks
• promote choice and independence
• enable people to manage identified risks
• provide relevant and evidence-based information.

WISE words

Crucially, effective self care is not about a one-way dialogue where the healthcare professional gives one-size-fits-all information, recommendation and support, but requires the ability to frame this support within the context of the patient's own experiences, desires and concerns. How patients are equipped to manage their conditions varies by background, socio-economics, living arrangements, locality and their own personal experience.⁵ To facilitate this change in behaviour requires deep understanding and repeated interventions to nudge the patient along the path to effective self care. If we are honest, as healthcare professionals we also need nudging along this route too.

Teaching patients self care skills is not enough, change is needed to the way we think about self care with an approach that engages both the patient, the healthcare professional and the NHS.⁵ The National Primary Care Research and Development Centre, Manchester University, advocates a whole systems perspective to self care, the WISE model (the Whole System Informing Self management Engagement model).⁵

The WISE approach envisages providing opportunities for patients to receive and utilise information through support and guidance from healthcare professionals trained to be more responsive to their needs.⁶ This has to take into consideration the different ways patients self care and the current healthcare system.⁵ For example, training for healthcare professionals in self care often focuses on certain healthcare groups or conditions, therefore training should encompass the whole team and can be applied to any long-term condition and many minor ailments.⁶ In addition, the needs of the patient have to be considered, so the patient feels in partnership with the healthcare professional.⁶

MANAGING MINOR AILMENTS

With minor ailments accounting for one in five GP and nurse consultations in the UK,⁷ encouraging patients to self care can also enhance patients' ability to manage long-term conditions when these arise. Adopting a self care for minor ailments strategy within the practice can save substantial time and resource in the surgery - as outlined in the previous article (Practice Nurse, 20 July 2012) minor ailments consultations cost the NHS around £2 billion per annum.⁷

Table 1 outlines the top 10 minor ailments by consultation volume.⁷ A significant proportion of these consultations are suitable for self care, leading to a substantial cost saving and freeing up valuable resources that can be allocated for the care of more complex conditions.⁷

Changing behaviour in the management of minor ailments takes commitment and time, both within and outside of the surgery. The Royal College of General Practitioners has launched an e-learning module on self care for minor ailments that is available for all healthcare professionals. This outlines how to develop a self care consultation approach that is responsive to patients' needs and acknowledges their previous experiences.

UNDERTAKING A MINOR AILMENTS CONSULTATION

Begin every minor ailments consulation with two aims in mind: to exclude potential 'red flag' symptoms and encourage a self care solution. In the case of the latter this may not always be possible. To understand the patient's openness towards self care, take a history that includes the following questions:

• What have you already tried? Bear in mind that this can include non-pharmacological options, such as rest, a hot bath, etc.
• How long have you tried this?
• What were you trying to achieve by doing/taking this?
• Has it worked and how?
• Have you stopped doing what you tried and why?
• What would you do next time?

These questions can help you determine the patient's willingness to think about their health options, their potential for change (both now and in the future), the reasons for the consultation (is any one symptom of concern, is it duration of disease, is it the need for a sick note and time off work?), the patient's reasons for consulting and the potential for suggesting self care at the end of the consultation.⁸

If self care is an option for a patient, embark on a process of shared decision-making. A patient who feels 'fobbed off' with a self care option will be back in the surgery soon, whereas a patient who feels involved is more likely to try self care and to be successful. The following can help explain the benefits to the patient and foster a shared approach:

• Acknowledge and praise any self care measures undertaken, whether non-pharmacological or pharmacological
• Share information about why you do not believe a problem is serious - this can help the patient recognise symptoms in the future and realise they can self care
• Encourage a follow-up if symptoms persist beyond the expected duration or deviate from normal - however, this need not be in person in the surgery but could be via telephone or a visit to the community pharmacy
• Promote the services of the community pharmacy
• Support any verbal advice with further information, e.g. a patient leaflet, or advice on where to access credible information, such as NHS Choices
• Clarify a patient's use of over-the-counter medicines including dosages, frequency and duration to ensure they are appropriate and safe. For example, in considering pain relievers, paracetamol is present not only in analgesics but also in cold and flu remedies, and patients need to be reminded that ibuprofen should not be taken by those with aspirin-sensitive asthma.

SUMMARY

Encouraging self care requires a whole practice approach, but change begins with one champion. As practice nurses, it makes sense for us to be that champion and become the surgery self care expert.

The next features in this series will give practical advice on self care for the most common minor ailments.

REFERENCES

1. The Health and Social Care Act 2012. Available at: http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted

2. Department of Health Self Care Support for the Workforce. May 2009. Available at: UK:http://www.dh.gov.uk/en/Healthcare/Longtermconditions/supportingselfcare/DH_084350.

3. Sunday Telegraph Business Technology Supplement, April 2011. Available at: http://www.scribd.com/doc/61360105/Sunday-Telegraph-UK-Business-technology-supplement-April-2011.

4. Department of Health Press release. GPs to 'prescribe' apps for patients. February 22, 2012. Available at: http://www.dh.gov.uk/health/2012/02/apps/.

5. Kennedy A, et al. Support for self care for patients with chronic disease. BMJ, 2007;335:968-970.

6. Kennedy A, et al. Delivering the WISE (Whole Systems Informing Self-Management Engagement) training package in primary care: learning from formative evaluation. Implementation Science. 2010:5:7.

7. Pillay N, et al. The economic burden of minor ailments on the national health service (NHS) in the UK. SelfCare 2010;1:105-116.

8. Blenkinsopp A, et al. Joining up self-care: evaluation of a PCT wide programme of support for self-care. Primary Health Care Research & Development. 2009:1-15. doi:10.1017/S1463423608000984.