Within the general population some people actively focus on reaching and maintaining good health, while others are more passive about the whole thing. So what makes the difference?
Is learning to manage your health like learning a country's geography – where all you probably need are a list of facts and a good reference guide? Or, is it more like learning to swim – where facts and a reference guide would be of limited value? In this instance you need to acquire basic skills – like putting your face in the water and learning to float – but you must also practise to gain confidence before advancing to the next step.
Not surprisingly, as our new paper, Supporting people to manage their own health, reports, becoming a good manager of one's health is more like learning to swim: here too you must learn some basic skills, and gain confidence before you can start to take on all of the challenges. However, many health care providers currently treat the process more like a geography lesson; giving patients some key facts and a reference guide, rather than starting from the skills the individual has and helping them to gain further skills and confidence to progress.
More innovative health care systems are beginning to take into account how engaged people are in managing their own health and to help them move forward from this point. It is now possible to accurately assess 'where patients are' in terms of their knowledge, skill, and confidence for managing their health using the patient activation measure (PAM). This is a simple 10- or 13-item survey that people can answer themselves. It has a 0–100 score, indicating how engaged – or activated – an individual is – from being passive about their health to being very proactive.
The PAM is being used in clinical settings to: assess where patients are so that health care teams are better able to tailor care plans for that individual patient; enable clinicians and providers to evaluate progress; and help them measure when patients or whole patient populations are improving their ability to manage their health. This last point is important to help us assess the quality of care. If patients are getting high-quality health care, they should be getting better at managing their own health too. We can now measure this, and in doing so we will shine a light on this critical area of care, enabling us to know what is working, and which delivery systems and clinicians are effective in helping patients gain the skills and confidence for self-management.
Research shows that patients can make gains in their activation level, and these gains translate into more positive health behaviours and improved outcomes. More activated patients also have lower health care costs, largely because they are hospitalised less often and are less frequent users of the accident and emergency departments.
In health care we measure what matters. What the patient brings to the care process may be the most important element of all. By measuring patient activation, and using the information in the design of care, we can finally bring this missing element in the health care equation.
Self-management (or "patient activation") is not a new phenomenon and it does indeed work very well for those individuals who choose to engage with such an approach. I am sure that, with some encouragment, many more people could find this helpful.
However, I am less sure about the claim that such an approach may lead to a reduction in health inequalities. Such a claim suggests a lack of appreciation of the determinants of health and the complexity of inequalities.
People who engage with patient activation are already motivated, interested and have an "internal locus of control". These are people who are likely to have better economic circumstances and who are already more likely to experience better health outcomes. Those who already have poorer health, lack in confidence and a belief in their own self-efficacy or mastery are those who are less likely to engage in such a programme. This is generally the group of people who alreday experience a range of inequalities, including poorer health outcomes. I suggest that such programmes create a risk of increasing health inequalities as those who are more able to take up the opportunities for self-management do so, resulting in an increasing gap.
This sounds like the sort of programme that requires an inequalities impact assessment, followed by consideration of the application of proportionate universalism.
We shouldn't get confused between self-management and patient activation - they are not the same. Patient activation is the underlying concept an individual has of their skills, knowledge and confidence to manage their own health. Measuring patient activation helps to identify where people are and their capabilities. While Anne is right in highlighting that patients who are highly activated have improved self-management skills and often benefit from programmes to support this approach, self management is by no means out of reach of those who are low activated. Numerous studies (as outlined in the report) have shown that tailoring interventions according to patient activation scores and providing appropriate support such as breaking down patient identified self-management goals into managable bites raises levels of activation, improves health behaviours and health outcomes. It is true that many self-management programmes at present may meet the needs of a particular groups who are moreoften more capable, but using patient activation can identify where people may need different approaches and ensure that those who face the greatest health inequalities are supported to manage their health. When patients with the lowest levels of activation are engaged, research shows that they improve the most. With socio-demographic indicators being only weakly correlated with patient activation, the offers a unique way of capturing a different level of health inequality, so much so that US health systems are adopting patient activation as a core mechanism for addressing the health of those who are most disadvantaged. The report underlines the case for similar approaches to understanding health inequalities using patient activation and using this to tailor interventions such as self-management strategies to improve outcomes.
The evidence on inequalities is primarily US-based, where differences in income, deprivation and other markers/drivers of inequalities were only weakly linked to activation - challenging the belief that "they can't look after themselves". In my view, there is much potential for patient activation to tackle inequalities here, but we need to test its distribution in our populations (this is starting to happen). There is clear read across to how well people are supported in their families and communities, the role of "community activation" and social capital and networks, and how these map to, support and maintain the activation of the patient, in a social context, not just in a patient-clincian one. But what this (and soon to be published) work does show us, is that change is possible for everyone, and change improves health outcomes. I look forward to future tests of how well patient activation maps to lower income groups in the UK, and how we can tailor services to their level of activation, and help people become more activated. If we can demonstrate that then this could be a major step forward.
It is true when you say that people in poor health are less likely to follow a regime to improve their health. For one thing they have less energy and less concentration to follow things through, plus the fact that these people are often depressed and suffer from anxiety (like me), because of their frailty.
I have been offered medication which I should not take, even when in hospital with pneumonia. I don't think that some medics inspect our medical records when being assessed. In hospital patients requests are forgotten. I have observed and heard that some doctors are not listening, which disturbs patients.
In my case, I have quite a few medical conditions, and everyone tells me how amazing I am, but I disagree with them. It is a case of mind over matter. Most of the time I get head tremors, severe head pains, which affect my balance, but I will still force myself to go out. I have had 9 full strokes and get regular TIA's, sometimes collapsing and finding myself in hospital 2 hours later. I have collapsed 8 times with strokes so when I get symptoms I do worry a little. Even so I carried on with my 5 different dance classes until after my 5th stroke, when I was physically incapable, and how I grieve over that!
It is really the age old case of taking each day as it comes and look for something to smile about, to try to be content. Life is as it comes...
The bit that is missing is how to get patient activation taking hold in areas where people do not look after their health. We believe the best way to do this is by putting patients in touch with their local community organisations. We have a website http://www.useyourcommunity.com which is a directory of local community organisations that has a postcode search facility. People can type in their postcode and it will tell them which organisations are available locally and what services and support they can offer. For example we have put people in touch with volunteering agencies and later found they are more motivated. This must have a positive effect on their health. People feel more valued and good about themselves when they engage with local organisations because it makes people feel they belong somewhere, perhaps that is necessary for patient activation.
There is a need to focus more on Mental Health in the management of long term physical conditions. Too many people are chronically depressed and therefore not motivated to respond to health improvement messages.
Hello
Perhaps we shouldn't confuse patient activation with self-management,however as I am a believer in utilising what is already out there in real life and is evidenced to use, I would like to draw the King's Fund attention to a NHS owned resource for cardiac patients in use in many areas (throughout the UK) since 1992.
The Heart Manual www.theheartmanual.com
Built on a CBT model and using an individual based tailored approach,the resource meets the needs of 16,000+ patients per annum.This is a supported self management programme,facilitated by specially trained health professionals,That is the key. Whatever the resource, be it on patient activation or/and self managment the tool is only as good as the person who is skilled up/competent to deliver, introduce and support this type of journey with the patient.
(I would be happy to fw a copy to a named person within the Kings Fund-if provide me some details please).
'Many health care providers currently treat the process more like a geography lesson; giving patients some key facts and a reference guide.'
Why is this? Lack of time with the patient, lack of training in the skills needed to be alongside someone rather than imparting information? As so much research shows that even small steps can have beneficial health effects in conditions like obesity and Type 2 diabetes, it makes sense to equip health professionals to 'start from the skills the individual has and help them to gain further skills and confidence to progress.'
Comments
However, I am less sure about the claim that such an approach may lead to a reduction in health inequalities. Such a claim suggests a lack of appreciation of the determinants of health and the complexity of inequalities.
People who engage with patient activation are already motivated, interested and have an "internal locus of control". These are people who are likely to have better economic circumstances and who are already more likely to experience better health outcomes. Those who already have poorer health, lack in confidence and a belief in their own self-efficacy or mastery are those who are less likely to engage in such a programme. This is generally the group of people who alreday experience a range of inequalities, including poorer health outcomes. I suggest that such programmes create a risk of increasing health inequalities as those who are more able to take up the opportunities for self-management do so, resulting in an increasing gap.
This sounds like the sort of programme that requires an inequalities impact assessment, followed by consideration of the application of proportionate universalism.
I have been offered medication which I should not take, even when in hospital with pneumonia. I don't think that some medics inspect our medical records when being assessed. In hospital patients requests are forgotten. I have observed and heard that some doctors are not listening, which disturbs patients.
In my case, I have quite a few medical conditions, and everyone tells me how amazing I am, but I disagree with them. It is a case of mind over matter. Most of the time I get head tremors, severe head pains, which affect my balance, but I will still force myself to go out. I have had 9 full strokes and get regular TIA's, sometimes collapsing and finding myself in hospital 2 hours later. I have collapsed 8 times with strokes so when I get symptoms I do worry a little. Even so I carried on with my 5 different dance classes until after my 5th stroke, when I was physically incapable, and how I grieve over that!
It is really the age old case of taking each day as it comes and look for something to smile about, to try to be content. Life is as it comes...
Perhaps we shouldn't confuse patient activation with self-management,however as I am a believer in utilising what is already out there in real life and is evidenced to use, I would like to draw the King's Fund attention to a NHS owned resource for cardiac patients in use in many areas (throughout the UK) since 1992.
The Heart Manual www.theheartmanual.com
Built on a CBT model and using an individual based tailored approach,the resource meets the needs of 16,000+ patients per annum.This is a supported self management programme,facilitated by specially trained health professionals,That is the key. Whatever the resource, be it on patient activation or/and self managment the tool is only as good as the person who is skilled up/competent to deliver, introduce and support this type of journey with the patient.
(I would be happy to fw a copy to a named person within the Kings Fund-if provide me some details please).
With best wishes
Louise
Why is this? Lack of time with the patient, lack of training in the skills needed to be alongside someone rather than imparting information? As so much research shows that even small steps can have beneficial health effects in conditions like obesity and Type 2 diabetes, it makes sense to equip health professionals to 'start from the skills the individual has and help them to gain further skills and confidence to progress.'
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