Make self-management education work for you

Implementing and embedding a structured education programme in patient self-management can have major benefits. These include avoiding admissions, reductions in medication costs, better controlled biomedical outcomes, treatment concordance and improved quality of life through changed health beliefs.

However, triggering the full range of benefits and maximising cost effectiveness of structured education relies on organisations working to a robustly planned and executed strategy.  

Before developing a plan for self-management education, you and your organisation must first understand the needs of the local population. Is there a completed needs assessment? What are the characteristics of the population? Are there groups within that population you need to target?

‘Without a solid marketing and promotion strategy you run the risk of low buy-in from healthcare professionals’

For example, if implementing a patient education programme for those newly diagnosed with type 2 diabetes, you and your organisation would need to know incidence rates to calculate the number of patients eligible to be referred to the service each year, and prevalence rates to know the number of those with established diabetes.

If such a programme was offered as group sessions with a maximum of 10 patients attending, you could reliably estimate the number of patient courses needed each year.

This data would then inform the number of educators needed for the service, and the number of educator hours required to meet the needs of your population.

Marketing and communications

Public awareness, internal and external marketing, public relations and advertising − all of these will play an important role in spreading the word about the existence and benefits of your self-management programme among the health community, prospective participants and the public. 

Without a solid marketing and promotion strategy you run the risk of low buy-in from healthcare professionals and poor attendance rates from prospective participants, both of which will impact on the cost effectiveness of providing this essential component of your self-management strategy. Marketing is an area that needs considering well in advance of the introduction of your new service, and needs time to bear fruit. Make it a priority in your plan.

Patient attendance is highly influenced by marketing and promotion. First, you will need to think carefully about engaging with primary care; the referral pathways you set up and awareness-raising strategies with your potential referrers. How staff convey interest and enthusiasm to patients when referring them will be crucial.

You may wish to involve your local communications team in promoting the benefits of your new intervention to primary and secondary care. They may also, for example, be able to advise on how best to encourage participant self-referral.

Stakeholder groups

With clinical commissioning groups now holding the reins for clinical commissioning, GPs are ideally placed to influence the embedding of structured education initiatives. The support of GP clinical champions has been shown to greatly improve the success of new patient interventions in organisations across the UK. 

As well as champions providing continuing support in raising awareness and promoting referrals from healthcare professionals, they also act as role models for their peers.

‘Think carefully about engaging with primary care, referral pathways you set up and awareness-raising strategies’

Enlisting the support of patient user groups is an invaluable strategy in the initial stages of embedding structured education. They are best placed to advise on access issues likely to affect participants, such as the appropriateness or otherwise of venues, the best times on which to run courses and transport and parking issues.

They also have a role to play in directly promoting the new service to communities, helping to achieve maximum attendance.

Paramount to the successful implementation and embedding of all new patient interventions is a skilled and dedicated administration team.

At first glance this may appear a luxury, but ultimately good administration will release clinical time, prevent clinical staff from being directed away from clinical duties, and coordinate the implementation and embedding of the new service, eg: booking venues, inviting course participants, liaising with GPs and sorting arrangements with educators.

The administration team should also lead on supporting audit of the new service, and providing data on a range of audit metrics, such as: referral patterns, attendance and non-attendance.  

You and your organisation will find it easier to implement a new cost-effective patient intervention if you consider all of these elements when developing your plan. Together, these will help to ensure maximum success and sustainability.

Evidence into practice

What might be the outcome of such planning in practice? Take the fictional organisation Barchester City, whose figures are based on national averages. It is a prime example of an organisation that has successfully implemented and embedded a new patient education programme for those with type 2 diabetes.

Barchester City has an overall population of 280,000, with 18,000 people with established diabetes, of whom 85 per cent are eligible for education. Recent quality and outcomes framework data shows that Barchester City has a higher than average number of patients with HbA1c at over 9 per cent (approximately 25 per cent of those with established diabetes) and has decided that this group needs targeting alongside those who are newly diagnosed.

Incidence of type 2 diabetes produces 1,200 cases of those newly diagnosed each year, of which 80 per cent are estimated to take up structured education. This will lead to 5,000 people requiring structured education each year.

‘At first glance it may appear a luxury, but ultimately good administration will release clinical time’

Barchester City has decided that programmes for those newly diagnosed and those with established diabetes will run in parallel. They have chosen a programme that is deliverable by two trained educators.

In their plan Barchester City calculated that it would need 16 educators, practising in eight teams of two people, to meet the needs of the local population. This would allow each of the eight pairs the capacity to deliver 1.5 courses per week (based on 42 working weeks per year), in order to reach the 5,000-patient target.

Armed with this information Barchester City has contacted its local patient user group for help to identify suitable venues spread across its locality. A GP clinical champion has been assigned to lead a key local healthcare professional awareness event, where the benefits of the new programme will be raised, and referral pathways discussed, along with strategies to ensure maximum patient attendance.

Barchester City has also appointed two full-time coordinators to manage the admin support for the programme − contacting patients on receipt of referrals, assigning educators to courses and liaising with the local IT department to ensure that the intervention will be auditable to the local commissioners’ specification.

Programme costs

Consider the DESMOND programme, for example, which has been shown to improve a range of health outcomes, including weight loss, physical activity, reduced reported smoking and depression, and better quality of life and health beliefs. All of which can be significantly sustained 12 months after patients first attend education.

‘Embedding is a cost-effective way of providing effective self-management support’

For Barchester City these patient benefits can be obtained for a cost per patient of as little as £10.50 per person. This becomes extremely cost effective when considering that the cost of those with an HbA1c of over 9 per cent is approximately £35 a month (£420 per year) when prescribed dual therapy and blood glucose monitoring strips.

Looking ahead to the second year of the new service and beyond, when training costs are no longer part of the calculations, the expense of providing structured education falls to £4.84 per patient. Embedding is a cost-effective way of providing effective self-management support.

An added benefit to Barchester will shortly occur when the new health and wellbeing boards, which have identified pre-diabetes as a key target area for the future, initiate a structured education pilot using the DESMOND Walking Away from Diabetes education programme. 

Training two health trainers to target 500 patients as part of a strategy to reduce prevalence of diabetes will build on the initial investment in the DESMOND family of programmes (in terms of training and programme licence fees), with the new intervention costing only £7.80 per patient.

In future, and with this level of costs, Barchester is planning a move towards greater investment in structured education by targeted specific groups in its local population such as people with learning disabilities and diabetes, women with polycystic ovary syndrome, and those with diabetes moving on to injectable therapies.

By embracing structured education in a systematic way, and embedding an intervention which leads to successful self-management alongside traditional clinical management, people with diabetes, healthcare professionals and the community are all winners in the healthcare stakes. 

Alison Harding is project manager at University Hospitals of Leicester Trust, writing on behalf of the Leicestershire Diabetes Centre and Education Writing Group