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.
Mike O'Brien (Minister of State (Health Services), Department of Health; North Warwickshire, Labour)
I certainly agree with my hon. Friend Dr. Stoate that those proposals need to be given serious consideration. Let me begin by congratulating him on holding this debate, on a subject that is important to him as chairman of both the all-party pharmacy group and the all-party primary care and public health group. Self-care is a cause that he has championed. He has made a strong case that some people turn to their GP when they do not need to, for minor ailments such as coughs and colds, and indigestion, rather than using simple and basic methods of care themselves. That is partly about knowledge and partly about self-confidence, as well as about people being willing to make a judgment about when they really need to see their GP and when they are going just for a bit of reassurance.
Last November, the Proprietary Association of Great Britain and the Royal College of General Practitioners launched their "Declaration of Self Care". They put the total cost of GPs treating minor ailments at around £2 billion, of which £1.5 billion is in GP time. The potential benefits of some element of self-care are considerable, if we can begin to change the attitudes of some patients, some GPs and others. With proper support from health professionals such as pharmacists, people can take the appropriate level of responsibility for their own health. GPs could then focus on treating more complex conditions, which make better use of their expertise and time.
We need to get the balance right. We do not want people with difficult long-term conditions not going to see their GPs. That is not what this debate is about, nor is it about saving money. The NHS budget has increased massively in recent years. It will increase by 5.5 per cent. this year and 5.5 per cent. next year, and we will lock in that further increase for front-line services over the following two years.
Self-care, which comes in many forms, is about people better looking after themselves and their families, where that is the right thing to do. Many people do it, whereas some do not. Self-care can range from taking paracetamol when someone gets a cold, to disinfecting their child's grazed knee when they fall, and from eating healthily and exercising more to stay fit, to getting out for a walk if they are feeling low; or it can mean someone deciding actively to manage their long-term condition with the help of health care professionals.
Society has changed in recent decades. People want more choice. They want to remain independent and stay healthy. They want safe, effective services, tailored to their needs and delivered as near to their homes as possible. A survey in 2005 showed that more than 80 per cent. of people with long-term conditions already play an active part in their own care, that more than 90 per cent. want to do more, and that more than three quarters would feel far more confident about taking care of their own health if they had the right support.
The NHS has also changed. The Government have long been committed to making medicines available over the counter by switching their legal status when it is safe to do so. For example, azithromycin, for people with chlamydia, has moved from being available only on prescription to being available over the counter in pharmacies. Similarly, many nicotine replacement therapies that were previously only available on prescription in pharmacies are now widely available on the high street. We have now made them available without a prescription.
The Government have gone to great lengths to give people more and more accessible information on health. In the late 1990s, we launched NHS Direct, providing national, 24/7 access to information, advice and support over the phone and on the internet. NHS Direct has a number of online tools to help people to care for themselves at home, such as symptom checkers and a "click to call back" function, whereby patients can request a phone call from NHS Direct. In 2008-09, 52 per cent. of all calls to NHS Direct were completed without the need for further medical attention-for example, from a GP.
In 2007, we introduced the NHS Choices website, which now receives more than 8 million visits a month. It provides convenient, comprehensive and clinically accredited information about treatments and local services on health, health improvement and social care. There, people can find "Your health, your way", a guide to long-term conditions and self-care. It also tells people about the range of self-care support available to them locally, including healthy living advice, information about their condition, training to help people feel more in control, and access to self-help groups and to new technology to help people remain independent and in control. As a consequence, people are increasingly using NHS Choices rather than calling NHS Direct or visiting a GP.
Self-care is about more than just providing information, however. It is also about improving the partnership between professionals and the general public. General practitioners have a crucial role to play in engaging people in their own care and helping them to manage their condition, and many GPs already do this brilliantly. But we need to support new GPs and those who want to improve, and we have worked with the Academy of Medical Royal Colleges to produce an e-learning module called "Supporting Self-Care", which is now part of the Royal College of General Practitioners' e-GP training materials.
Of course, not everyone has access to the internet. Those who are not on the web can visit their local community pharmacy for information and support. Pharmacies already support self-care, providing advice and selling over-the-counter medicines, when appropriate. Since the 2005 community pharmacy contractual framework was introduced, support for self-care has been one of the essential services delivered by all community pharmacies in England.
The aim was to increase access and choice for people, including their carers, who wish to look after themselves or their families, helping them to self-manage minor illnesses, injuries or long-term conditions. Every day, pharmacies advise millions of people on how to treat or manage minor conditions, and on the appropriate use of over-the-counter medicines. When a pharmacy cannot help, it can provide information on health and social care providers or support organisations that can offer that help. The contractual framework represented a major change in the role of community pharmacies, from the place where medicines were dispensed, to somewhere that can offer more clinical services, such as chlamydia screening, health checks and support for people with long-term conditions. Some PCTs have even commissioned pharmacies to provide minor ailment services for those who do not pay prescription charges. By 2008-09, more than 3,200 pharmacies provided this service, an increase of 5 per cent. on the previous year.
If these measures are to make a real impact, however, people must first understand that pharmacists are highly trained clinical professionals in their own right who can help them with their self-care. So this year, we will raise public awareness of the skills, expertise and services offered by pharmacies. We are also funding some PCTs specifically to promote services commissioned through and delivered by community pharmacies.
Pharmacy has an important contribution to make to improving public health and reducing health inequalities. One of the themes in our 2008 White Paper "Pharmacy in England: building on strengths-delivering the future" was to help people to self-care-to improve their health and well-being and to take better care of themselves. Work is progressing on a framework to transform into healthy living pharmacies, focusing on prevention as well as cure. We have also published a number of educational resources to help pharmacy staff deliver advice to members of the public on subjects including stopping smoking, weight management and physical activity.
The Government therefore recognise the importance of having reliable, convenient advice readily available-whether it be on the phone, on the NHS Choices website, in GP surgeries or in local pharmacies. I think that the proposals set out at the end of my hon. Friend's contribution are an important contribution to the debate on how we should drive this agenda forward. There are enormous benefits to be made from encouraging people to take more responsibility for their own well-being, where it is right to do so. We will continue to support people to make their own informed choices.
Question put and agreed to.