By Patrick Slevin, Ethnographer, Care Team, ARCH

I’ve been troubled for a long time now with the concept of self-management. I mean, I know what it is: traditionally, it’s about patients learning and practicing the skills necessary to be proactive and purposeful in their care so that they can live a healthy and emotionally satisfying life in the face of a chronic condition. Yes, that does sound wonderful – empowering patients to be central to their own care.

However, I really don’t think Irish healthcare is configured in a way that is all that accepting to this model of care. Yes, there is a shift in mindset occurring in Western society that holds the thought that the provision of care should move from been acute, episodic, and paternalistic in nature to been built around the patient in an integrated and collaborative manner where the patient aids in the decision making process. In theory, self-management fits so nicely into this vision for care that no one seems to be concerned about the reality of what has actually occurred! In Ireland, it seems that the discourse surrounding self-management, especially in relation to chronic conditions, has sprinted past and thus, long forgotten it’s much needed friend, chronic disease management…

Self management

Over the past few years, I have spoken to an array of Primary care workers including GPs, pharmacists, public health nurses and wound specialists, and all of them expressed the need for a chronic disease management strategy – interestingly, when they speak about self-management they accentuate the fact that patients require strong support structures allowing them to do so in the most effective manner possible. In reality, however, Ireland has put the cart before the horse. Patients with chronic diseases are expected to self-manage with, for example, the use of inhalers (COPD and asthma), glucometers (diabetes), medications, blood pressure monitor (hypertension) and the list goes on – but unfortunately, patients are given these interventions and in most cases, are – both literally and figuratively – left to their own devices.

You only have listen to pharmacists talk about the medication adherence crisis they see unfolding; listen to the breadth of cohorts and diseases PHNs are expected to cater for; see the caseloads that GPs face daily; and you will soon realise that people are not empowered to self-manage properly -they are still heavily utilizing the healthcare system – one of the very reasons for the shift to self-management in first place. The issue is this, chronic disease patients fit into the self-management bracket seamlessly due to the intimate relationship the two concepts have recently forged but the healthcare system does not seem to be aware that practicing and becoming habituated to this new found responsibility is a completely different challenge for patients.

Self-management strategies would be fine if patients had clear and defined chronic disease treatment plans but they don’t – patients are too often left to negotiate complex care pathways with little or no direction. It would even be fine if they had standardised follow-up care that meant they saw their GP or consultant every three/six months – especially if they have multi-morbidities but in general they don’t – GMS patients face long waiting lists to see consultants and chronically ill elderly patients may not be physically well enough to visit their GP in the clinic. It would also be somewhat acceptable if Ireland had a population with excellent levels of health literacy but we don’t – only 21% of the population meet this criterion.

In my opinion, Irish healthcare is not configured in such a way that allows patients with chronic disease to self-manage properly. There seems to be paradox at play here where patients are expected to stay at home longer due to self-management but in the same breadth receive no appropriate platform to support help them to do so. Ultimately, there seems to be too much emphasis put on the “self” and not enough on the “management”.

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