Self-Care (Minor Ailments)
Howard Stoate (Dartford, Labour)
It gives me great pleasure to introduce this debate. I should say at the outset that self-care is not about no care, but about ensuring that patients have far more control over their own health; not about saving money, but about ensuring that NHS resources are spent in the most cost-effective way to give the best possible outcomes; and not about simply passing people from professional to professional, but about many professionals being involved in ensuring that people can have control over decisions on their care.
The importance of self-care has long been recognised by the Government and their advisers. The Wanless review, published in 2004, concluded that the promotion of self-care is one of the most effective ways of reducing pressure on NHS front-line resources and improving overall health outcomes. That is very important. The review also said that for life expectancy and health outcomes to improve across the social gradient, patients need to become fully engaged in their health care and to take an active role in the diagnosis and treatment of conditions. Sir Derek Wanless called for the adoption of a comprehensive strategy on self-care that would give people the support and confidence they need to take greater responsibility for their health.
Lord Ara Darzi's vision of the future of the NHS, "High Quality Care For All", built on that vision, calling for more care to be transferred from hospitals into the community. More recently still, my right hon. Friend the current Health Secretary made it clear that the NHS needs to become
"a more preventative and people-centred service"
with patients getting more choice, more convenience and more control over their care.
We are still a long way short of the vision originally set out by Sir Derek Wanless. Research by IMS Health, for example, has found that every year 20 per cent. of all GP consultations involve minor ailments that patients could treat themselves. That is a grossly inefficient use of NHS resources. In most cases, minor ailments can be dealt with effectively and far more appropriately by patients opting to self-care.
It is worth listing the minor ailments that I mean. They are generally part of everyday life and include backaches, coughs and colds, headaches, toothache, indigestion, skin problems, allergies and some respiratory problems. In many cases people manage these minor ailments already through self-care using an over-the-counter, or OTC, product, but research conducted by the Proprietary Association of Great Britain indicates there is often a significant level of dependency on the doctor.
The research shows that people often abandon self-care in favour of a trip to the doctor. Typically, this switch is made between four to seven days after the onset of symptoms. According to GPs, this is earlier than needed, generating unnecessary consultations. Furthermore, in most of these cases, a prescription is issued that would not have been issued if patients took their own decisions.
Little research has been done to measure the amount of NHS resources dedicated to ailments that could be treated by self-care. The first major study was commissioned by PAGB and undertaken by IMS in 2007. The study considered GP work loads for minor ailments and the associated costs. It showed high volumes of GP consultations for minor ailments, with some 57 million consultations per year. Some 6 million of those consultations were for a minor ailment in association with another condition that necessitated a trip to the doctor, but 51 million were only for the minor ailment that could have been treated differently. That included 5.3 million consultations for nasal congestion; 6.8 million for heartburn and indigestion; and 2.7 million for migraines. It has been estimated that 18 per cent. of GPs' work loads were for minor ailments alone. Nearly half the consultations are generated by 16 to 59-year-olds. Overall, minor ailments account for £2 billion of NHS funding a year or some £250,000 for every general practice in the country.
Why is this happening? The problem seems to be that a culture of dependency has built up, whereby patients lack the confidence to address minor ailments themselves through self-care. This must be addressed if we are to maximise the efficiency of NHS spend in these times of tightening budgets. There are three main reasons why this culture of dependency must be addressed. First, it would help to alleviate current demands on the NHS, and in particular GPs, for the treatment of minor ailments. The pharmacy White Paper makes several welcome recommendations to relieve pressure on GPs by utilising the resource of community pharmacies. That is to be encouraged, although I want to ensure that this debate is not simply about passing patients from one professional to another, but about enabling people to take care of themselves, when appropriate, and using the expertise of pharmacists and others to help them do so.
Secondly, we need to help people to strengthen their ability to self-care, empowering them to be more confident and independent in their attitudes and behaviour. Thirdly, we need to free up resources in the NHS, which could enable us to continue to develop NHS resources even in times of constrained budgets. We have to free up money to use in the most cost-effective and appropriate way, thereby continuing the development of front-line patient services.
These calls originate from the London declaration for self-care, which was signed up by both the PAGB and the Royal College of General Practitioners, and emerged from a joint conference last year that I attended.
Why do patients fail to choose self-care? They are usually looking for reassurance on diagnosis from a medical professional, or confirmation that no serious disease is present. Asking patients to make a risk assessment of their symptoms, then select an appropriate medication and finally monitor their response to the medication demands a degree of confidence and knowledge that many feel they do not have. People are also much less likely to "risk" self-care if it is a question of someone else's health, such as a child or dependent adult.
The culture of the NHS also encourages dependency. Speaking at a conference organised by the Royal College of General Practitioners and the PAGB last November, Dr. Laurence Buckman, chair of the British Medical Association's general practitioners committee, suggested that the nature of the relationship between patient and GP, with the GP seen as an uncritical, no-strings-attached provider of free medication, supplements, housing, legal support and advocacy, has encouraged a culture of passive dependency among patients, coupled with an ingrained aversion to risk. He feels that, as a result, many patients feel scared to proceed without permission.
Other factors that might also play a part are the duration of the illness, previous experience of the illness, availability of suitable medicines and social factors, such as family pressures. Confidence, too, is a key factor. Once a patient has successfully self-treated on one occasion, they are much more likely to do so again should the illness recur. Moreover, once a patient is in the habit of self-caring, there is a good chance that their family and friends will follow suit. Cost, too, is an issue. Many patients will make appointments to see a GP simply to get a free prescription for a minor medication or analgesic. In theory, patients should be able to pick these prescriptions up from the pharmacists, many of whom can now prescribe independently, but that is not happening as much as it could. The NHS, as a whole, needs to do more to publicise this option.
Why are professionals failing to promote self-care? The best way of persuading patients to self-care is if their doctors, pharmacists or practice nurses-people whom they know and trust-encourage them to do so. Yet self-care is an option rarely discussed in consultations, and many doctors feel that it is an issue that they do not have much time for in a consultation. Crucially, there are no performance-related financial incentives to promote self-care. Although promoting self-care might help to reduce surgery work load in the long term, it does not appear to be influencing practitioners' behaviour at the moment. Perhaps we need to consider whether the quality and outcomes framework could be used to encourage GPs to include self-care as part of a consultation.
There are good examples from around the country, however, of where that has been working. The Pharmacy First minor ailments scheme, which was introduced in Erewash primary care trust a few years ago, is a good example of a self-care programme in action. Aimed at the mothers and carers of children aged from three months to 12 years, it attempted to increase awareness and take-up of self-care options and reduce the number of GP consultations for minor complaints. Information booklets and leaflets including, "Better Health at Home and at Work", "Caring for Kids" and material relating to seasonal campaigns-on, for example, winter ailments and hay fever-were distributed widely across the community to support the scheme. The scheme was accompanied by a lot of public relations activity supporting the minor ailments promotion.
As well as leading to a slightly higher level of self-care for several childhood ailments, the scheme encouraged mothers and carers to think again about how they used GPs, pharmacists, practice nurses and other health care professionals. The scheme also illustrated how hard it is to encourage patients to become more self-sufficient and confident in their own care. Not only do we need extensive, carefully tailored community publicity, but we need to ensure that key opinion formers, such as GPs, early years child care workers, health visitors and teachers, are fully behind the self-care model. We also need national publicity and high-profile endorsements, which are also important in changing patients' attitudes. In other words, if we want to achieve a lasting cultural shift in perceptions of self-care across the country, we need a coherent, well planned national campaign requiring ministerial support.
How can greater self-care be achieved? The opportunities for self-care are greater than ever before, given the growing number of formerly prescription-only medicines now available over the counter, including for indigestion, pain, thrush, quite a few minor infections, and emergency and hormonal contraception. That is beginning to turn the tide. To increase the level of self-care we also need to address the culture of dependency and give patients the support that they need to feel confident in treating their own minor ailments.
All that could lead to significant cost savings, which, as I have said, could be passported to other parts of the NHS to achieve greater improvement there. According to a list that I have managed to achieve, the 10 minor ailments most commonly seen in consultation, beginning with the most common, are: back pain, dermatitis, heartburn and indigestion, nasal congestion, constipation, migraine, cough, acne, sprains and strains, and headache. That is a long list of minor ailments for which medication is now available over the counter. We need to take action to ensure that that is more widely publicised.
Five clear steps need to be taken if we are to ensure that self-care is increased. First, it is time to recognise the need to change the culture of dependency for minor ailments. Secondly, we need to develop a training package for health care professionals-GPs, pharmacists and nurses-on how to conduct "self-care aware" consultations. Thirdly, we need to initiate communications, nationally and locally, on the efficient use of the health system and taking responsibility for one's own health and that of one's family. We need TV and radio advertising campaigns, together with posters and patient information leaflets, in GP surgeries, pharmacies and citizens advice bureaux, that provide lists of minor ailments that could be treated by over-the-counter medications. All promotional material should include the strapline, "Ask your pharmacist", because many people will approach their pharmacists, as they are often open quite late and on weekends.
We also need to develop a co-ordinated health and social care policy that promotes self-care behaviour, particularly for minor ailments, and introduce a comprehensive health education package in schools, to ensure that future generations use the health service efficiently and understand the principles of healthy living. Pharmacists and expert patients could also be invited into schools to give presentations on self-care. With those proposals in place, there is a good chance that we will begin to change attitudes to self-care among patients across the country. I hope that my right hon. and learned Friend the Minister will give those suggestions good consideration.