In health service contexts, self-management usually refers to what people with health condition(s) do for themselves, perhaps with the help of family and friends, but in contrast to what health professionals do for them . Yet policy ambitions for support for self-management go beyond shifting work from health systems and professionals to patients and their families, and efforts are usually made to reassure patients that self-management does not mean doing without professional input altogether . Once it is recognized that people with long-term conditions have to manage them somehow, the purpose of support seems to be to enable them to manage better. This then begs the question of what counts as managing better. The possible answers have significant practical (and ethical) implications.
We have noted previously an important distinction between helping people to manage their health conditions well and helping people to manage well with their health conditions . When the focus is on the better management of health conditions, support is usually biomedically framed and relatively narrowly oriented to symptom and disease control. It aims typically to help people to slow the progression of disease, reduce the risk of complications and maximize length of life with as little disease as possible. There is often a strong emphasis on encouraging people to monitor symptoms and biomedical markers (e.g. blood pressure and blood glucose levels) and to adopt behaviours recommended to regulate these. In contrast, when the purpose of support is understood in terms of helping people to manage better with their long-term conditions, disease control can still be of interest, but services work with more expansive and more flexible aspirations for health, wellbeing and quality—not just length of life.
Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system. Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge. Nor is value measured by the process of care used; process measurement and improvement are important tactics but are no substitutes for measuring outcomes and costs.
Health care delivery involves numerous organizational units, ranging from hospitals to physicians' practices to units providing single services, but none of these reflect the boundaries within which value is truly created. The proper unit for measuring value should encompass all services or activities that jointly determine success in meeting a set of patient needs. These needs are determined by the patient's medical condition, defined as an interrelated set of medical circumstances that are best addressed in an integrated way. The definition of a medical condition includes the most common associated conditions — meaning that care for diabetes, for example, must integrate care for conditions such as hypertension, renal disease, retinal disease, and vascular disease and that value should be measured for everything included in that care.
It is important to have a clear understanding of the meaning of the term health, healthcare and systems that are put in place to facilitate healthcare.
The current organizational structure and information systems of health care delivery make it challenging to measure (and deliver) value. Thus, most providers fail to do so. Providers tend to measure only what they directly control in a particular intervention and what is easily measured, rather than what matters for outcomes. For example, current measures cover a single department (too narrow to be relevant to patients) or outcomes for a whole hospital, such as infection rates (too broad to be relevant to patients). Or they measure what is billed, even though current reimbursement practices are misaligned with value. Similarly, costs are measured for departments or billing units rather than for the full care cycle over which value is determined. Faulty organizational structure also helps explain why physicians fail to accept joint responsibility for outcomes, blaming lack of control over “outside” actors involved in care (even those in the same hospital) and patients' compliance.
Because care activities are interdependent, value for patients is often revealed only over time and is manifested in longer-term outcomes such as sustainable recovery, need for ongoing interventions, or occurrences of treatment-induced illnesses. The only way to accurately measure value, then, is to track patient outcomes and costs longitudinally.
The subject of issues regarding the United States health care is something I have followed passionately and studied extracurricular, and in this paper I will outline many of the identifiable sources contributing to our health care crisis, provide insight towards social and structural...
Determining the group of relevant outcomes to measure for any medical condition (or patient population in the context of primary care) should follow several principles. Outcomes should include the health circumstances most relevant to patients. They should cover both near-term and longer-term health, addressing a period long enough to encompass the ultimate results of care. And outcome measurement should include sufficient measurement of risk factors or initial conditions to allow for risk adjustment.
UK: NHS health care is accessible to most people and therefore this system gives the possibility to improve health of the whole population; US: access to health care is only for those who are paying the insurance and/or the taxes, and therefore there are people that can’t receive necessary treatment; UK: people who can’t afford paying for medical treatment can still receive it and there is no need to take special measures to provide this; US: government has to take special measures for people that are uninsured or can’t pay for their medical treatment; UK: the general psychological effect of being cared of by the society exists; US: people are worried because there can be cases of not receiving medical care when needed; UK: it takes a long time and bureaucratic formalities to get access to a proper specialist; US: people can go directly to the specialist; UK: waiting lists and queues make the medical treatment worse and the resources are not spend effectively in this case; US: the market mechanism working in the health care sphere as well allows avoiding delays in receiving the treatment and allows using resources in an optimal way; UK: budget spending on health care is fixed on a certain level; US: budget financing the health care system is growing more and more with each year. In general, the specific treatments and professional health care services in the USA are much better than in the UK, but the probability of receiving medical care in emergent cases is much lower; and in general health insurance and health of the nation are more protected in the UK and in general, in countries where the public spending and governmental control over the health care system dominate over the private financing of this branch. The recent evidence shows us that such countries (UK, Italy etc.) have higher health rate indexes despite the growing distrust of citizens to the national health care systems. In my opinion, the introducing of the market forces into the relation between public and private sectors is the key solution to this problem: but the dominance of public regulation and financing over the private one has to remain in order to ensure the health of the whole nation.
Broader ideas about the purpose of support for self-management can signal more directly that support should contribute towards patients’: experiences of being respected and enabled as moral agents; scope to function as value-determining partners in their care, and; overall health, wellbeing and quality of life.
The idea of couching the purpose of support for self-management in terms of enabling people to live (and die) well with their long-term conditions [, ] seems particularly promising as a broad statement of purpose. It brings the person with long-term conditions more fully into view as an active moral agent, and one whose view of what counts as living well matters. It can incorporate aspects of healthcare experience, health, wellbeing and quality of life that go beyond those impacted in a knock-on kind of way by disease control.