Ben Wanless, Consultant Physiotherapist at St Georges University Hospitals NHS Trust and Digital Pioneer Fellow, shares his thoughts on the challenges of self-management and his experience of implementing Accelerator digital solution getUBetter.
Four years ago in a meeting with our local commissioners, one commissioner who had just read the newly published NICE back pain guidelines, asked the following question: “What can we do to support people to self-manage their back pain, so they don’t have to wait to see a clinician?”. The answer to this is not straight forward, so I took a breath and said something along the lines of “There are several options but they need looking at thoroughly before we commit to anything”.
The complexity of self-management is often not discussed. We hear that many health conditions can be managed without seeing a clinician but in truth the science is shaky. Guidelines are based on ‘best-evidence’ across populations but often do not acknowledge the complex science of human behaviour when we are injured or in pain and the even more complex science of human behaviour change needed to self-manage our health problems.
The pitfalls of healthcare guidelines
Healthcare guidelines are based on large trials and systematic reviews that look at evidence across populations. As an example, a review of back pain treatment by Artus et al 2010 showed that people get better when they have an acute musculoskeletal (MSK) problem like back pain, irrespective of what treatment they have. This clearly questions the utility of medical treatment and seemingly supports the notion of people self-managing their back pain as opposed to seeing a clinician. Most studies like this have tight inclusion criteria and often leave out the people who have low motivation to get better on their own. We therefore make assumptions based on a small cross-section of society, that everyone, irrespective of their problem, unique situation, cultural, social and economic background, can be given the same basic advice and information about their health condition and they will effectively self-manage.
Simple interventions for complex problems
In MSK, ‘self-management’ is often delivered via a patient information leaflet and sometimes by a phone call from a clinician to sign post them to this information. We then don’t follow up with the patients but instead ask them to get back in touch if they need more support. Who knows if they actually get better? And do we care? Not if they don’t bother us again! A few people have tried to evaluate this properly but no one so far has showed there is an effective way to ensure people effectively self manage. (This is why I needed to take that breath after the question from the commissioners!)
Evidence-based care meets personalised care
The solution we implemented, after much deliberation, and multiple meetings with various companies and expert clinicians, was a digital solution called getUBetter. It was set-up by an NHS clinician working in a busy emergency department, who wasn’t happy with the support he was giving to people with acute back pain. It had thoughtful, evidence-based content but could be tailored to people’s unique situation and pain or injury. For example, the advice given to someone who has just strained their back doing gardening is very different to the advice you give someone who has had back pain for several years. The best thing is that you never lose contact with these people and they can always access clinical care should they need it. No longer are they lost in the system. We truly know if they do or do not get better.
Since we began implementing getUBetter we have had much success. It is now being prescribed across all GP practices in our patch and within our local physiotherapy dept. We have worked closely with behaviour change experts and patients to ensure the use of the app is as good as it can be and clinician and patient feedback has been positive. We have seen a reduction in GP appointments and hospital referrals.
As part of my project on the DigitalHealth.London Digital Pioneer Fellowship programme we are evaluating how to plug all the gaps along the pathway so that wherever someone accesses healthcare they get the app, whether they turn up in the emergency department or attend an orthopaedic or rheumatology appointment. If we achieve this, we believe this is a UK and possibly a world first – we will be delivering a standardised yet personalised approach to support everyone with a MSK problem across the whole healthcare pathway.
We still don’t truly know the best way to support self-management but the evaluations we are doing, along with the holistic approach the clinicians and the company are taking, should start to answer this question in a rounded way. The next stage is to test its efficacy in a real-world evaluation, within a robust research project.
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