Aiming for good mental health over the long-term is an ambition we all aspire to. The title will seem odd, however, if you are aware that since 2005 chronic disease and chronic illness have been rebranded as long-term conditions (LTC) in UK health policy.
With ageing populations and contemporary lifestyles linked to increased risk of developing chronic disease, finding a sustainable solution for providing good quality healthcare is a global priority. Chronic disease is the world’s largest killer, causing more deaths than any other causes combined (WHO, 2011). By definition they are progressive and incurable, and having one chronic disease raises the risk of developing co-morbidities. It is estimated that between 25-30 percent of people with a chronic disease also suffer from depression, increasing the complexity of treatment options.
The change in terms comes with a change in attitude to chronic disease. It may be treatable but because it’s not yet curable, it is a lifelong condition to be managed. The question of who manages it has also undergone some change, and these days the aim is to get people to take ownership of their illness and to accept responsibility for managing it. Policy guidelines advocating self-management of chronic disease may seem counter-intuitive, unrealistic, even irresponsible, as it seems likely to compromise health if access to formal healthcare services is reduced.
Transitioning to a self-management approach will not be easy. Judging by a recent House of Commons Health Committee on the Management of Long-Term Conditions the current priority is to gain clarity about proposed methods for increasing self-management support. Examples include:
- Integrated health and social care
- Joined up services
- Patient-centred care
- The House of Care
The last bullet-point refers to the ‘house of care’ model (McShane, 2013), which uses a familiar object to communicate the unfamiliar.
At the heart of the house ‘lives’ personalised care planning, with commissioning of services at the base, the coordinated services as the roof, and the opposing walls are made up of engaged, self-managing patients, and supportive healthcare practitioners (Coulter, 2013). The overriding message is that these pieces hang together, but I’m not sure if the metaphor brings us any closer to understanding patient-centred care or how to achieve it.
Undoubtedly the administrative purpose of the Health Committee meeting is to agree on a way forward: once we know what ‘it’ is, we can decide whether we want ‘it’, and whether we can afford to support ‘it’. One of the problems with the current search for clarity is the way it is meant to apply to decisions about programme affordability. Baroness Young, of Diabetes UK, described the difficulty of measuring long-term returns from diabetes patient education.
‘[Patient] education [has] a much longer-term set of payoffs. The barriers of both when and where the payoffs come were to us quite substantial. There were very few that could be realised quite quickly in the same part of the system – that is investors getting the benefit out quickly in the same budget. That, for us, drives very clearly the need for a pooled budget of some sort in order to be able to realise those benefits.’ (Oral Evidence, p 3)
Baroness Young lays blame for the barriers to adopting evidence-based patient education on commissioners’ obsession with neat financial traceability — cash flowing out of one account to pay for patient education and cash flowing in to the same account from savings due to reduced healthcare utilisation.
She suggests a pooled budget may be the solution. Would such a change improve the current decision-making model’s myopia? Would it be better at measuring longer-term benefits, or attributing positive spillover effects to the relevant programmes? An example of spillover is improvements in the quality of care provided by healthcare practitioners as a result of patient education provision.
This was one of the findings from an ESRC-funded study (Go Jefferies, 2012) that explored the extent that healthcare practitioners accepted the self-management approach to diabetes care. The study found that healthcare practitioners delivering the 6-week X-PERT Programme to patients had unexpected benefits.
Healthcare practitioners who are also qualified self-management Educators (n=11) suggest that the training to become a qualified X-PERT Educator surprised them by how little they knew about diabetes care, and provided them with important new knowledge and skills outside of their normal specialism. The X-PERT based knowledge and skills were also perceived to improve their support of diabetes patients in their regular clinical roles through adoption of the X-PERT approach and educational materials to regular clinical practice. This increased access to X-PERT principles to those patients who did not attend the full programme.
The Educators expressed satisfaction not only in being more effective at communicating complex diabetes information to patients in a logical way, and which allowed patients the time they needed for the ‘mists [to clear]’ about what diabetes is. Participants also expressed relief from professional anxiety about shifting responsibility for diabetes care onto patients because they were able to have more sophisticated conversations with post-X-PERT patients, as they believed patients were more able to make informed decisions about personal care plans.
Furthermore, the study showed that because delivering X-PERT to Type 2 diabetes patients at diagnosis is a deviation from standard diabetes care pathways, the delivery of up-to-date knowledge and advice before the onset of complications was seen as reducing patients’ exposure to potentially harmful poor advice that participants assumed came from non-diabetes specialists in patients’ regular primary care teams. Recognition of improvements to their own diabetes understanding had positive effects on Educators’ perceived professional effectiveness to help patients according to best practice.
Employee satisfaction has spillover effects on customer interactions (Bowen et al., 1999). Such spillover effects are evident as positive mental health effects perceived by healthcare practitioners who deliver self-management training programmes to patients. Therefore the good mental health of healthcare practitioners is likely to have positive effects on patient interactions.
Josephine Go Jefferies (firstname.lastname@example.org) is an ESRC Doctoral Researcher at Nottingham University Business School (Marketing Division) at the University of Nottingham. She is currently studying patient experiences of telehealth for the self-management of chronic disease.