Christensen et al (2000) 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 Center for Health Care Delivery Science, the message was clear – health care teams need to transfer responsibility for delivering care to those that have the relevant skills but no more. According to Al Mulley, Director of the Dartmouth Center, health care delivery systems where staff 'function at a lower level are inefficient, at a higher level they are unsafe'.
Challenging the accepted wisdom about professional roles and responsibilities in the care team could have significant productivity gains. 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 judgement, but about ensuring that the right care is given by the right person with the right skills. Furthermore, this transfer of responsibility should not stop at health care professionals. It needs to extend to us as patients and citizens too. Patients are also members of the clinical team and real benefits can come from encouraging the patient to take responsibility for self-management, self-care and for maintaining health.
The chronic care model clearly identifies the important role that patients play in self-management and self-care (Bodenheimer et al 2002). But not all patients feel confident enough to take on this role. The patient activation measure (Hibbard et al 2004) was developed to measure patients' knowledge 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 (Hibbard et al 2007). Furthermore those with low activation see self-management primarily as compliance – ie, following the advice of doctors or taking medication as directed (Dixon et al 2009). 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 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-have' – it is imperative if we are to deliver on higher-value care.
This blog is also available on the British Medical Journal website