Kate Lorig, a professor at Stanford University, conducted the first
randomised controlled trials of self-management by “expert
patients”. She found that when people with arthritis got together
in a community-based group with a customised manual and volunteer
tutors, they became much more knowledgeable, self-confident and
efficient in managing their condition than those in the care of
health professionals. It proved a great deal cheaper and a lot more
effective, reducing the call for visits from a doctor by more than
40 per cent.
So the government’s expert patient programme, which draws
extensively on Lorig’s work, is welcome. Self-management courses
are now being piloted by primary care trusts in the UK.
There are three important ideas behind the programme. The first is
that lay people have valuable knowledge based on direct experience
that cannot be rivalled by professional expertise – although the
two may complement each other. The second is that people fare
better if they are directly involved – and in control of – their
own care. The third is that the more individuals control the
conditions that affect their daily lives, the more likely they are
to enjoy good health.
In his famous Whitehall studies of civil servants’ health,
Professor Michael Marmot of University College London produced
evidence linking low levels of control at work with increased risk
of cardiovascular disease. He found that stress caused by
psychosocial factors helped bring about metabolic changes that made
individuals more vulnerable to heart disease.
This helped explain, for Marmot, why there had been such a dramatic
increase in heart disease and premature death among people in
Russia after the collapse of the Soviet Union. When established
systems of social and economic management disintegrated, many
individuals felt their lives were suddenly out of control. And this
had a dire effect on their health. Marmot is now interested how
these lessons might apply to an ageing population. Would older
people stay healthier longer if they felt they had more control
over their lives? And how could that be achieved?
The implications for health policy in the UK go well beyond the
expert patient programme. If people can manage their own chronic
conditions better than professionals, then surely healthy
individuals are the best managers of their own health.
The idea that the health of the nation depends on individuals
making healthy “choices” has already been well-rehearsed by John
Reid and his ministerial team in the Department of Health. However,
not all individuals have an equal capacity to choose, nor do they
all have equal chances of living healthily.
A recent survey of public attitudes to public health commissioned
by the King’s Fund and the Health Development Agency, showed that a
large majority (88 per cent of all respondents) say individuals are
responsible for their own health. But a significant proportion also
acknowledge there are too many factors beyond individuals’ control
to hold them solely responsible.
There are some telling differences between rich and poor
respondents to the survey. Those in the poorer social groups (D and
E) are less likely to say they are in good health (59 per cent
compared with 90 per cent of the better-off A and B groups). They
have lower expectations of being healthy in future (53 per cent DEs
compared with 72 per cent of ABs). And they are more likely to
regard health as beyond their own control (54 per cent compared
with 31 per cent of ABs).
More than 60 per cent of all respondents agreed that tackling
poverty would be the most effective way of preventing illness. But
here, too, there was a divide. Seventy per cent of DEs and only 51
per cent of ABs agreed with the statement.
If the government is serious about improving the public’s health
and narrowing the health gap between rich and poor, the challenge
is to find ways of giving poor citizens a far greater sense of
control in their daily lives. This could entail a radical shift in
priorities for primary health services, so that they focused on
enabling people who are vulnerable to illness (but not yet ill) to
understand their health and improve it. It would also mean tackling
the reasons why people feel powerless – such as poor education and
housing. It would also require more inclusive decision-making,
including the most disadvantaged, in decisions affecting their
social, economic and environmental circumstances.
Anna Coote is director of public health, the King’s