Supported self-care is integral to lifestyle medicine: Can virtual group consultations promote them both?

Abstract

There is a rising burden of lifestyle-related non-communicable disease across all age groups around the world that is reaching epidemic proportions. Over half (58%) of the UK population over 60 is living with one or more long-term conditions,¹ and this prevalence is expected to increase significantly in the next decade. By their very nature, lifestyle-related conditions have an insidious onset and a protracted period of morbidity that negatively impacts quality of life. This places significant pressure on individuals, health systems, economies and society.

The current pandemic has highlighted how significantly more vulnerable people with long-term conditions are to other health challenges. Those living with diabetes and obesity have a higher risk of attending hospital and an increased case-fatality rate for COVID-19 when compared to non-diabetic and non-obese individuals of the same age.² Self-care and personal lifestyle behaviours that improve metabolic health could lead to better health outcomes from infectious disease and, as previously highlighted in this journal, at a population level are an important aspect of pandemic preparedness.³

A key question for healthcare practitioners and healthcare systems today is how to turn the tide on lifestyle-related conditions in a way that is person-centred. This challenge is even more prescient now in the context of the post-COVID era, as virtual care has quickly become the new normal.

There are more than 139 definitions of self-care in the academic literature.⁴ The Self Care Forum UK describes self-care as ‘the actions that individuals take for themselves, on behalf of and with others in order to develop, protect, maintain and improve their health, well-being or wellness.’⁵

The World Health Organisation (WHO) and the International Self-Care Foundation (ISF) have varying definitions of self-care. Perhaps more helpful is to conceptualise self-care as a series of activities, which can be conveniently grouped into the seven pillars of self-care⁶ as follows: (1) knowledge and health literacy, (2) mental well-being, (3) physical activity, (4) healthy eating, (5) risk avoidance, (6) good hygiene practices and (7) the rational service use of products and services.⁷ These bear very clear resemblance and overlap to the six pillars of lifestyle medicine such that the antecedents and interventions are closely related: (1) healthy eating, (2) physical activity, (3) avoiding toxins, (4) managing stress, (5) sleep and (6) nurturing relationships.⁸

Until recently, self-care was not much talked about in the context of healthcare. It was often implied that self-caring was tantamount to ‘no care’ due to an abdication of responsibility by health professionals, leaving patients to ‘fend for themselves’ without support. However, brief reflection makes clear that self-care is not only an unavoidable aspect of modern medicine, but highly desirable from the perspective of individuals (the self-carer), the health system and society at large.

For example, the average person living with type-2 diabetes spends 3 hours per year in total with a healthcare professional.⁹ This diabetic patient therefore spends the remaining 8757 hours of the year outside of the clinical setting. Their actions during this time will impact their health. With the right support, this individual will have the potential to modify a number of daily lifestyle or environmental factors that can have a direct or indirect effect on their diabetes control.

Self-care is therefore not something we can ignore as healthcare professionals, but rather something we should embrace as a key tool to promote the mental and physical health and well-being of our patients, particularly those with lifestyle-related conditions. The onus is on healthcare professionals and the healthcare system to support good self-care, but this is not easily achieved when we operate in a style which has evolved from a long history of paternalistic medicine.

The formal study of self-care is in its early stages, but rapidly gathering momentum. The Self-Care Academic Research Unit (SCARU) was established at Imperial College London in 2017. In 2019, the WHO Guideline on Self-Care Interventions was published, and the International Centre for Self-Care Research was inaugurated later that same year in Rome. The WHO and various other actors including the Self-Care Trailblazer Group are currently supporting the development of self-care communities of practice.

The publication the Self-Care Matrix, which is a pragmatic and accessible framework that conceptualises the totality of self-care, also signalled a new departure for self-care thinking. In this conception, self-care has four cardinal dimensions: (1) self-care activities, (2) self-care behaviours, (3) self-care as a function of resource utilisation and (4) the prevailing self-care environment.⁶ This conception highlights the importance of ‘coaching’, motivational interviewing and lifestyle medicine approaches to support the sustained adoption of health-seeking self-care behaviours in individual by enhancing self-care capability, patient activation, health literacy and a sense of personal empowerment. Promoting self-care capability in patients can be supported by healthcare professionals through health literacy interventions including microlearning¹⁰ (defined as ‘small bite-sized nuggets of information that build up knowledge over time’), peer support or virtual group consultations.

The NHS Long-Term Plan includes a commitment to deliver personalised care; treating people as individuals and ensuring their personal needs are met within the context of the healthcare they receive.¹¹ The proactive care agenda and personalised care emphasise the importance of forging a new relationship between individuals and professionals; one that is based on mutual trust and a shared responsibility for health.

Personalised care can be seen as a complex challenge, and it may feel difficult to understand and deliver within the confines of short interactions between the clinician and the patient. These limited touchpoints constrain our ability to know enough about a person to be able to develop a truly personalised care plan.

This is where personalised care and self-care come together, since there is wide agreement that the greatest expert in an individual is themselves and those who care for them.¹² The best care plan is one written and endorsed by the individual. By recognising the different ‘experts in the room’, it is possible to build a new relationship based on partnership working between the person and the professionals involved in their care. This creates a starting point for discussing options and looking for solutions that work for the individual via shared decision making.

The Personalised Care Institute, launched in September 2020, highlights that people want to be involved in decisions about their care and supported to manage their own health, with the intention that this leads to improved population and individual health outcomes.¹³

Many people do not like the term ‘patient empowerment’ or ‘activation’ as it implies a passive process which is done ‘to’ a person. True empowerment is about ensuring people have the understanding and confidence to be active participants in their health. This will necessarily look different for different people.

The benefits of patient empowerment are well documented.¹⁴ Confident patients make better use of healthcare resources and are more likely to ask for help at an optimal time.¹⁵ The patient activation measure (PAM) is a validated tool that measures the knowledge, skills and confidence of individuals. It has been widely adopted as a method for scoring and monitoring an individual's empowerment. Improving PAM score relates directly to individual health behaviours, corresponding clinical outcomes and healthcare costs.¹⁶ However, PAM is primarily directed at individuals who may already have a prevailing condition and does not measure self-care capability directly.

The delivery of healthcare in the 21st century is based around the biomedical model of health. There is a tradition of one-to-one, face-to-face consulting in an increasingly medicalised setting. This is often an environment which is familiar and comfortable for the health professional but can leave patients feeling vulnerable. Rarely does it foster true dialogue or equal partnership in discussion.

Anyone entering a medical environment will be familiar with the pressure of time and pace of activity. An emphasis on ‘fixing’ problems, whether by prescription of drugs or surgical intervention, is the hallmark of the biomedical model of medicine. This fosters a culture of dependency and contributes to the rising epidemic of long-term conditions and lifestyle-related disease where solutions are never going to be quick.¹⁷ It also places more focus on downstream measures of intervention as opposed to upstream measures of prevention.

The past year has seen a very significant move to virtual consulting in response to the COVID-19 pandemic. In many cases this change is likely to become permanent. While virtual consulting has many advantages, patients report it often does not meet their needs.¹⁸ Yet, even if unlimited healthcare professionals and funding were to be available the current methods of healthcare delivery cannot adequately address the challenges of delivering modern personalised care which truly supports patient empowerment and self-care. What is needed is to change the environment of healthcare, and in doing so influence the outcome.

The quadruple aim of healthcare delivery is to (1) improve individual's experience of healthcare, (2) improve population health, (3) reduce per capita cost of healthcare delivery and (4) improve professional experience of delivering care.¹⁹ The WHO and sustainable development goals emphasise the importance of promoting healthier populations. Afocus on supported self-care could contribute to realising these ambitions.

People who have the capacity, autonomy and confidence to self-care feel more in control of their health and have better healthcare experiences. They are more likely to make good lifestyle decisions and ask for help at the right time when things are not going well.²⁰ Because empowered patients are more likely to access the right services for themselves and be in a better position to advocate for their needs, they can achieve significantly improve their clinical outcomes and quality of life.²¹

Discussions with patient groups highlight the need for people to be supported to take more responsibility for their own health and well-being. This has been particularly highlighted during lockdown when access to routine services became more difficult for many, emphasising the need for supported self-care across various settings.²² There is also growing recognition amongst practitioners that supporting individuals to self-care also has benefits for healthcare staff. For example, clinicians involved in delivering group consultations report developing better relationships with patients and colleagues²³ and feel more satisfied with their work.²⁴ This may in turn reduce healthcare professional's risk of burnout whilst improving their experience and the quality of their interaction with patients.

The NHS needs to identify and streamline the widespread adoption of evidence-based solutions that promote the delivery of high-quality integrated care in a way that is sustainable whilst remaining person-centred. This could be done by supporting individuals in developing the skills and confidence to manage their own physical and mental health and well-being. Group consultations have shown promise as a new model of care which has been well received by patients and supports personalised care. Group consultation patients spend more time with their clinician in a relaxed environment that promotes self-empowerment.²⁵ In the hospital setting, group consultations have been shown to have five key enabling themes which support the delivery of high-quality clinical care – efficiency, empathy, education, engagement and empowerment.²⁶ The Personalised Care Institute highlights the need to use a range of different consultation models, including group consultations, to provide the different aspects of personalised care.

As society and health system reposition to tackle the COVID-19 pandemic, the delivery of group consultations via virtual means will likely be necessary and instrumental in delivering healthcare in the new setting. The World Lifestyle Medicine Council, which represents a lifestyle medicine global alliance, highlights the feasibility of virtual group consultations from an international perspective.²⁷ Virtual group consultations appear to provide many of the same benefits as face-to-face group consultations, including greater autonomy and improved self-care.²⁸ An initial review of the adoption of virtual group consultations in UK general practice during the COVID-19 pandemic suggests many benefits of face-to-face groups are maintained in the virtual space.²⁹ Virtual group consultations can improve access and continuity of care, provide peer support and better health outcomes at a time when all of these are difficult to achieve while maintaining safe social distancing and infection control. There is evidence that virtual group consultations also enhance access for those who may find attending healthcare settings difficult due to geographical or practical limitations.¹⁶ Providing benefits which go beyond the immediate safety need and moving towards a healthcare offer which fits with the lives of patients.

There is also an indication that groups who traditionally struggle to access care may find the group consultation model less intimidating,³⁰ meaning it may provide a means to support improved access for marginalised groups. This resonates because the very first group consultation model – Joseph Pratt's ‘Class Method’ – was for TB patients too poor to get sanatorium treatment and included elements we would now call social prescribing.³¹ Provided digital exclusion is explicitly addressed, virtual group consultations are likely to do the same. However, this is not the only change needed to support self-care. There are many structural population factors limiting individual health choices: a more personalised, supportive and equitable healthcare system needs to address these too,³² but that is not the focus of this editorial.

In the face of unprecedented pressure and risk at the start of the COVID-19 pandemic, the delivery of healthcare changed almost overnight. A major part of this change involved a greater emphasis on virtual clinical contact. Where this was largely a pragmatic response to a difficult situation more research is now needed to develop a coherent strategy to ensure new models of care are embedded appropriately. There is an opportunity for health systems worldwide to envisage a model of healthcare suited to the social and medical needs of individuals in the 21st century, supporting self-care and personalisation.

Long before the COVID-19 pandemic, the potential for the group consultation model within the NHS setting had been recognised, but comprehensive evaluation is lacking.³³ NHS England/Improvement has championed a sentinel programme to support and investigate the implementation of virtual group consultations in general practice which has scaled from 70 to over 500 practices. Ethical approval has now been secured and National Institute of Health Research (NIHR) Clincal Research Network (CRN) adoption agreed for a National Evaluation of Group Consultation Models, creating the opportunity for sharing better process and outcome data for those delivering virtual group consultations (and in time, in-person groups) who wish to contribute (email [email protected] or [email protected]). More research is needed to explore the best method for implementing the group model and the context in which group consultations offer the most benefits for patients and the healthcare system.³⁴

Supported self-care is a key aspect of delivering effective healthcare to meet the realities of our modern-day health and lifestyle challenges. Increasingly, self-care is being recognised as the only sustainable means to tackle the rising challenge of non-communicable diseases of the lifestyle, and since recently as the critical answer to tackle virus transmission and the COVID-19 pandemic. Whereas virtual group consultations could offer an effective and efficient means of supporting self-care more research is needed to understand how they can be used to support empowerment and build individual self-care capability in a way that is person-centred.

We have read and understood Lifestyle Medicine policy on declaration of interests and have the following interests to declare: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; FB has received research grants for spread and evaluation of group consultations from Sir Jules Thorn Trust, National Institute for Health Research, Medical Research Council and is Editor-in-Chief for the Wiley open access journal Lifestyle Medicine.

AEO is partly supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) North West London. The views expressed are those of the authors and not necessarily those of the NHS or the NIHR or the Department of Health and Social Care.