Although supported self-management has been recommended in asthma guidelines for the past three decades, implementation has been patchy. Professor Hilary Pinnock, of the Asthma UK Centre for Applied Research at the University of Edinburgh, shares with WPR why clinicians and healthcare organisations should prioritise making sure that every person with asthma has access to support to help them control their illness.
WHAT EXACTLY DOES SUPPORTED SELF-MANAGEMENT ENTAIL?
It entails supporting people to ‘live’ with their asthma (incorporating the medical and emotional aspects). We tend to focus on the medical (which is where the evidence base is), but it’s important to remember the broader context.
Asthma is a variable condition, so it’s about recognising deterioration, knowing the action to take (self-treatment, calling for medical help), and being able to carry out maintenance, such as adjusting treatment and avoiding triggers.
HOW CONCERNED SHOULD WE BE ABOUT THE LACK OF SELF-MANAGEMENT SUPPORT FOR ASTHMA PATIENTS?
We should be concerned. We published a paper which was a systematic overview – to give you some idea of the size, we looked at 27 systematic reviews which encompassed about 270 randomised control trials, so it was a huge body of evidence.
The overarching message is that supported self-management reduces unscheduled care, such as acute attacks; improves patients’ overall day-to-day control, so they have less symptoms; and it improves the overall quality of their life.
Because all people with asthma are already self-managing their condition; it behoves us to support them to do it better.
WHY HAS ENCOURAGING IT ACROSS THE HEALTH SERVICE PROVEN TO BE SO DIFFICULT?
It’s a complex intervention – a new way of (partnership) working – which involves developing consultation skills.
It may also be perceived as time-consuming, but it doesn’t all occur at once. The support occurs over time – each increment does not have to be long. It can be a challenge to change routines when you feel that you are sinking under the weight of demand, so we need teamwork.
Implementation requires attention to the needs / resources of the patient, the motivation and skills of the professionals, and the priorities and routines of the organisation.
WHAT ELSE CAN YOU TELL US ABOUT THE THE HEALTHCARE PROFESSIONAL’S ROLE HERE?
They should support the patient in any way possible in managing their condition. A lot of self-management education is formally for nurses in the UK system, but that doesn’t mean that they should be the only people involved.
We can reinforce patients’ management of their condition or suggest improvements. This applies to pharmacists, casualty officers etc – everybody in the context in which they’re working.
WHAT ARE THE MOST FATAL ERRORS WHICH ASTHMA PATIENTS CAN MAKE?
It’s not ‘errors’, it’s a question of people working out for themselves what they want to do and for it not necessarily being ideal. Probably the biggest area is that people will get a cold, or get into the hay fever season, and they’ll use their blue inhaler a couple of times but they won’t do anymore about it because they hope they will get better.
They don’t act promptly, but most attacks develop over days – giving them time to take action.
According to the National Review of Asthma Deaths, 45 per cent had not received medical attention (due to issues of delay and access).
WHAT IMPACT WILL THE MODE OF SELF-MANAGEMENT HAVE ON OUR WIDER HEALTH SYSTEM?
It will be a way of working in partnership with patients – recognising that the ultimate responsibility for how people manage their condition is theirs. Our responsibility is to ensure that they have the necessary information and skills needed, and to be accessible to answer questions and support.
Self-management also reduces unscheduled care, including our out-of-hours services and A&E departments, by enabling people to take action promptly which will abort an attack, or enable it to be managed much more efficiently and quickly.
DO YOU HAVE ANY ADVICE FOR THOSE HEALTHCARE PROFESSIONALS WHO ARE STRUGGLING WITH PATIENTS’ ADHERENCE?
Adherence is a complex problem – everybody is self-managing, just not necessarily in the way that is best, but that’s for us to nudge people in the right direction.
Non-adherence is normal so we must be completely non-judgemental about it. We must also understand the difference between the two forms and their causes and management Adherence broadly divides into intentional non-adherence, which could be based on their previous experiences, fears, or preconceptions. Unintentional adherence is when a person has decided to take the treatment but may not practically be able to. We can also have a mixture of both.
Read the Necessity / Concerns framework which is really helpful in understanding how people think about things:
• Think (non-judgementally) about adherence every time you see the patient
• Listen: Help patients balance necessity / concerns
• Remedy any practical barriers (cost / taste / appearance / noise)
• Recognise and respect patients’ perspectives
• Keep communication open