Quick guide

December 2015
Written by Anya de Iongh, Petrea Fagan,
Julie Fenner and Lisa Kidd.

With thanks to Jim Phillips, Lynne Craven,

Alison Anderson, Alf Collins and Sara Demian.

A practical guide to self-management support

is published by the Health Foundation,
90 Long Acre, London WC2E 9RA

ISBN 978-1-906461-74-4
© 2015 The Health Foundation
Contents

1 Introduction 2

2 What is self-management support and

why is it important? 4

3 Putting it into practice: an overview 10

4 Putting it into practice:

planning and commissioning 16

5 Putting it into practice: building knowledge,

skills and confidence 21

6 Putting it into practice: peer support and

community assets 29

7 Putting it into practice:

workforce development 34

8 Putting it into practice: optimising

systems and processes 40

9 Putting it into practice: measurement

and evaluation 45

References 50

 1
Introduction

1
This guide provides an overview of self-management
support and the key components for effective
implementation.

It is for people with a role where they can implement

self-management support, such as commissioners,
health care professionals, service managers, people in
voluntary or community groups and patient leaders.

The guide will be useful both for those starting

their self-management support journey and those
building on and improving the support that they
already provide.

Introduction 3
What is
self-management
support and why
is it important?

2
Every day, people with long-term health conditions,
their family members and carers will make decisions,
take actions and manage a broad range of factors that
contribute to their health. Self-management support
acknowledges this and supports people to develop
the knowledge, confidence and skills they need to
make the optimal decisions and actions.

Most of the time, people manage their own health

and wellbeing, rather than health professionals
or services taking on this role. Health policy, and
increasing evidence of positive outcomes, highlight
the benefit of supporting people to manage their own
health as effectively as possible. These benefits can
be felt by people with long-term health conditions,
health professionals, providers (both within and
beyond the NHS) and commissioners.

Together with good quality clinical care, self-

management support ensures that people receive
the full range of support they need to manage the
physical, emotional and social impact of their long-
term health conditions at different stages and ages
during their lives.

What is self-management support and why is it important 5

Self-management support is an important component
of person-centred care, which has four principles.

1. Affording people dignity, compassion and respect.

2. Offering coordinated care, support or treatment.

3. Offering personalised care, support or treatment.

4. Supporting people to recognise and develop

their own strengths and abilities to enable them
to live an independent and fulfilling life.

Figure 1: The four principles of person-centred care1

Care is... Care is...

personalised coordinated
re s p e c t
Pe rs o n

Care is...
n,
is

enabling
io
t re

ss

te
pa
a

d
wi
t h .. om
. d i g n it y, c

6 A practical guide to self-management support

For people living with long-term health conditions,
self-management support means:

•• being active partners in determining outcomes

that are important to them and how to achieve
them, working in collaboration with health
care professionals

•• being supported to build knowledge, skills,

confidence and resilience to manage the impact
of their symptoms and limitations so they can
live a full and meaningful life

•• being enabled to access the support they need

within and beyond health services to better
manage their own health and wellbeing on an
ongoing basis.

Effective self-management support requires

changes across the whole system, from how services
are regulated, planned, commissioned and provided,
to how health professionals and people with long-
term health conditions work together, and how
people are supported in between appointments.
It also requires these groups to work in partnership,
with a common understanding of and commitment
to self-management support.

What is self-management support and why is it important 7

Different technologies can support change, such as
online consultations and self-monitoring, and are can
also help people to self-manage and deliver services
to support them.

Self-management support is important for the

following reasons:

•• People with long-term health conditions and

their carers can enjoy a better quality of life,
self-confidence and achieve the outcomes that
are important to them.2

•• People with long-term health conditions

experience better clinical outcomes.2

•• Professionals working in and beyond the NHS

can have more meaningful conversations with
people with long-term health conditions and
greater impact from, and satisfaction with,
their practice.3

•• Services can be delivered in a more ‘joined-up’

and cost effective way.4

•• Nationally, supporting self-management is part

of implementing health and social care policies
across the UK and the transformational change
needed within our health care services.5

8 A practical guide to self-management support

Further reading

Self-management support – The Health Foundation

person-centred care resource centre
A collection of resources on all aspects of
self-management support
[Link]
care/self-management-support

The key policy documents for England,

Scotland, Northern Ireland and Wales that
promote self-management support

• The Five Year Forward View. NHS England

[Link]/ourwork/futurenhs/

• Gaun Yersel. Health and Social Care Alliance

Scotland
[Link]/resources/library/
search/gaun+Yersel/

• Living with Long Term Conditions: a policy

framework. Department of Health, Social
Services and Public Safety, Northern Ireland
[Link]/index/[Link]

• Long Term Conditions: changing for the better.

NHS Wales
[Link]/sitesplus/863/opendoc/219791

What is self-management support and why is it important 9

Putting it into practice:
an overview

3
New models of care draw on the principles of self-
management support, where the key question shifts
from ‘what is the matter with you?’ to ‘what matters
to you?’ This can feel like a significant culture change.

The ‘House of Care’ was originally developed by the

Year of Care partnership6 as a model for providing
care and support for people living with diabetes. It
has since been adapted and applied for all long-term
health conditions.7

As shown in Figure 2 overleaf, the House of Care

depicts the shared responsibility across a health care
system (commissioners, health care professionals,
organisational processes and people with long-term
health conditions) to deliver care and support planning,
which is often seen as the gateway to identifying the
self-management support needs that individuals have.

Putting it into practice: an overview 11

Figure 2: The House of Care, Coalition for Collaborative
Care (C4CC)8)

Organisational and
supporting processes

Health
Engaged, Person-centred and care
informed coordinated care, professionals
individuals through care and committed to
and carers support planning partnership
working

Commissioning including
‘more than medicine’

In the specific context of self-management support,

this guide covers the following practical elements of
the House of Care:

•• Commissioning and planning that embeds

self-management support within services and
ensures that people have access to a range of
support that complements their medical care
(the floor or foundations of the House of Care).

12 A practical guide to self-management support

•• People with long-term health conditions
and their carers are supported to develop
the knowledge, skills and confidence to better
manage their own health, for example through
courses or coaching (one of the walls of the
House of Care).

•• Health and care professionals, health

coaches and others who support people
with long-term health conditions having the
knowledge and skills for clinical tasks and
collaborative consultations, which have been
shown to be effective in supporting and
enabling people to self-manage (another wall of
the House of Care).

•• Organisational systems and processes that

enable support for people to self-manage and
that help professionals to support them (the roof
of the House of Care).

•• Peer and community support (formal or

informal support between people with similar
conditions or experiences within a community)
that is considered ‘more than medicine’ (part of
the floor of the House of Care, but a section in its
own right within this guide).

Putting it into practice: an overview 13

The effectiveness of self-management support
depends on how the approach is implemented,
rather than just the tools. Some key learning from
people who have implemented self-management
support is summarised in Figure 3.

Figure 3: Key lessons for implementing

self-management support9

Recognise
that people are Train whole
Remember:
different and tailor
changing
teams, not just
interventions
appropriately roles, behaviours individuals
and mindsets is vital,
challenging, but not
impossible
Offer people Work with
a range of the voluntary
support options and community
How to embed sector
shared decision Engage
Tools alone health care
making and
are not professionals as
self-management
enough change agents
support into
Design mainstream care
evaluation Adapt the
into change intervention to
processes from the local context
the start
Have a
change strategy
Work on Use a whole
with clear goals
sustainability from the start, system approach
but be flexible to implementing
from the change
outset

14 A practical guide to self-management support

Further reading

Building the House of Care. Health

Foundation.
A case study exploring how Leeds and
Somerset are implementing a coordinated
approach for people with long-term conditions.
[Link]/buildinghouseofcare

The House of Care Toolkit. NHS IQ

Developed in partnership with NHS England
and Coalition for Collaborative Care to support
implementing the House of Care at all levels
[Link]/improvement-programmes/
long-term-conditions-and-integrated-care/long-
term-conditions-improvement-programme/house-
[Link]

Coalition for Collaborative Care

Alliance of people and organisations committed to
making person-centred care happen
[Link]

Putting it into practice: an overview 15

Putting it into practice:
planning and
commissioning

4
Determining what services and support are needed
to enable people to self-manage, and securing
funding for those activities, can come from a
variety of points within a local health economy.
These include clinical commissioning groups
(CCGs), Health Boards (in Scotland) and provider
organisations, as well as national bodies.

The starting point to plan and commission self-

management support is working collaboratively
with people with long-term health conditions to
understand the outcomes that are important to
them and how these can best be achieved.

Outcomes-based commissioning has an emphasis on

moving away from a system that focuses on payment
for activity and instead focuses on commissioning
outcomes that are meaningful to local people. When
this is applied to commissioning self-management
support, clinical outcomes are understood as
contributory to the outcomes that are important
to people – such as maintaining independence by
staying active or in work. People generally need
both clinical and non-clinical support to manage the
different aspects of their conditions to achieve these
broader outcomes. In practice, many outcomes-
based commissioned contracts have relevant process
measures, such as the number of people referred to a
self-management programme or having a care plan.

Putting it into practice: planning and commissioning 17

There is no single approach to deciding what support
to provide and how, but there are key components
that could be considered.

•• Specific self-management support services

– these may be clinical or non-clinical services
focusing on enabling people with long-term health
conditions to self-manage. Examples include
health coaching and structured group education
programmes for people with long-term health
conditions and their carers, or online programmes.

•• Wider services – these recognise that people

need support on an ongoing basis to maintain
their skills and confidence to self-manage and
to manage the wider social and lifestyle aspects
of their health. Examples include services based
in the voluntary and community sector such
as walking groups and condition-specific peer
support groups.

•• Planning organisational processes – to

facilitate services to work in a person-centred
way. Examples include IT systems that ensure
‘informational continuity’ across a range
of providers or enable telephone or Skype
consultations, and a system-wide agreed care
plan template.

18 A practical guide to self-management support

•• Providing training for workforces – to
ensure people working in health care (from
clinical professionals to non-clinical coaches
or support workers) have the knowledge, skills
and confidence needed to support people to
self-manage.

There are a number of commissioning strategies

that could be used to encourage providers to deliver
self-management support. English commissioning
levers include, for example, Commissioning for
Quality and Innovation (CQUIN) payments, which
enable commissioners to pay providers for local
improvement initiatives. There are also national
CQUINs that align with self-management support.
Other English examples include the Quality
Outcomes Framework (QOF), Better Together fund,
and ‘direct enhanced’ GP services.

To commission on an outcomes basis, performance

management and measurement systems would have a
focus on evidence of outcomes as well as activity and
costs. Tracking these kinds of outcomes is a new way
of working for the NHS, and many outcomes-based
commissioning schemes are having to set up new
data collection systems to track progress.

Putting it into practice: planning and commissioning 19

 Further reading

Thanks for the Petunias. Year of Care.

A guide to developing and commissioning
non-traditional providers to support the self-
management of people with long-term conditions
[Link]/upload/Professionals/
Year%20of%20Care/[Link]

Need to nurture: outcomes-based

commissioning in the NHS. Health Foundation
Paper detailing the current shape of outcomes
based commissioning in England
[Link]/sites/default/files/
NeedToNurture_1.pdf

Patients In Control: Commissioning to support

self-management of long-term conditions.
South East NHS Commissioning Support Unit
Details stages of commissioning, and key
questions to ask at each stage
[Link]
content/uploads/2015/01/Commissioning-to-
[Link]

20 A practical guide to self-management support

Putting it into practice:
building knowledge,
skills and confidence

5
When health care is designed to support self-
management, people with long-term health
conditions and their carers play a more active role in
managing their own health. This can mean making
difficult lifestyle changes. To do this, they need the
knowledge, skills and confidence to manage not
only their long-term health conditions but also the
practical and emotional impact it has on their lives.
When this happens, people enjoy life more, have less
pain, have improved clinical outcomes and use health
care services less.2

People with long-term health conditions can be

given information to increase their knowledge,
but that is often needed together with other forms
of support to influence behaviour changes such as
taking exercise or practising relaxation techniques.
Some conditions require people to have technical
skills, for example self-administering medication.
Self-efficacy refers to people’s beliefs about their
confidence and control over their own actions,
which might include trying to find further support.
All of these qualities can be important for people
at different times. Figure 4 shows the strengths of
different types of support in relation to the impact on
behaviour change, access to information, technical
skills and self-efficacy.

22 A practical guide to self-management support

Figure 4: Continuum of strategies for self-management
support10
Focus on
self-efficacy Motivational
Telephone interviewing
coaching
Care plans
Goal setting
Information Patient-held records Active group education
provision

Online courses Group education Behaviour

change
Electronic information Self-monitoring

Written information

Focus on
technical skills

Common forms of self-management support

•• Generic structured education courses: these

focus on the common experiences of people with
any long-term health condition and carers, such
as working with health care professionals, coping
with pain and managing fatigue. Examples
include the Stanford Model, known as the Expert
Patient Programme (EPP),11 and the Patient Skills
Programme12 from the Health Foundation. These
can be helpful in encouraging behaviour change.

Example: Patient Skills Programme

[Link]
patient-skills-programme

Putting it into practice: building knowledge, skills and confidence 23

•• Condition-specific structured education
courses: these cover specific skills and knowledge
needed to manage different conditions. Examples
include the DAFNE (Dose Adjusted For Normal
Eating)13 or DESMOND (Diabetes Education
and Self-Management for Ongoing and Newly
Diagnosed)14 courses for people with diabetes.
These can be helpful in encouraging behaviour
change and technical skills.

Example: International Diabetes Federation

Peer Leader Manual
[Link]
peer-leader-manual

•• One-to-one coaching: provided face-to-face,

over the phone or via Skype, this uses reflective
listening and motivational interviewing to
support individuals with making changes
through goal setting. This form of support focuses
on improving self-efficacy and behaviour change.

Example: Health Coaching by Medical

Assistants to Improve Control of Diabetes,
Hypertension, and Hyperlipidemia in
Low-Income Patients: A Randomized
Controlled Trial
[Link]
health-coaching-medical-assistants-improve-
control-of-diabetes-hypertension-and

24 A practical guide to self-management support

 •• Websites: offering specific programmes
or forums to help people understand their
condition, access information or learn
techniques like relaxation. The focus for this
form of support is providing information.

Example: The Pain Toolkit

[Link]
pain-toolkit

•• Recovery colleges: focusing on support for

people with mental health conditions, these
consist of a range of one-off workshops and
longer courses, covering understanding of
specific mental health conditions, the recovery
model, or general skills such as mindfulness.
Like the group courses detailed above, these
focus on self-efficacy and behaviour change.

Example: Briefing: Recovery colleges

[Link]
briefing-recovery-colleges

Well-commissioned self-management support

programmes for local people provide a range or
combination of options that are appropriate to
people’s needs and preferences, so people can choose
what is best for them. In addition, support must
be easily accessible – such as holding courses in the
evening in non-health-related community venues.

Putting it into practice: building knowledge, skills and confidence 25

Many people with a long-term health condition can
benefit from different forms of self-management
support. Some specific examples are given below.

•• People with low confidence or self-esteem can

benefit from the process of coaching or courses.15

•• People with mental health conditions can benefit

from recovery colleges.16

•• Men of working age can benefit from activity

based groups and one-to-one education.17

•• Carers can benefit from courses where they meet

other carers and can manage the impact of their
caring duties.18

•• Young people can benefit from accessing

online support.2

•• People from different ethnic backgrounds may

benefit from culturally led support.19

It is important to be aware that the groups

highlighted above are often among those least
likely to know about available support. Therefore,
comprehensive recruitment strategies would include
raising awareness among professionals, voluntary
groups, local community, housing or social groups.

26 A practical guide to self-management support

 Much of this support might be provided outside
of a traditional consultation between a health care
professional and someone with a long-term health
condition. However, all of these types of support are
strengthened when backed up by professionals using
skills such as motivational interviewing, goal setting
and problem solving in consultations.

Facilitators and coaches for self-management can

be people with long-term health conditions and
health care professionals or other trained individuals.
Courses with a strong clinical focus may be co-
delivered with a health care professional.

Markers for quality, detailed in national guidelines,

include the training and supervision of people
providing courses and coaching, evidence-based
content, outcome audits and provision of supporting
material.20 These must include outcomes for
participants and operational effectiveness.

Without ongoing support, people’s knowledge, skills

and confidence to self-manage decline over time.21
Many programmes therefore include creating peer
support groups for people completing courses, and at
the very least they can enable people to connect with
peers and other forms of ongoing support.

Putting it into practice: building knowledge, skills and confidence 27

 Further reading

Example case studies:

My Health My Way. Dorset NHS

A comprehensive self-management support service,
providing coaching, courses and peer support
[Link]

Recovery college: From mental health patient to

recovery student. Health Foundation.
A short film showing a recovery college in action.
[Link]/recovery-college

Supporting Self-Management. National Voices.

A summary of the evidence of the programmes to
support people with long-term health conditions
[Link]/sites/[Link].
uk/files/supporting_self-[Link]

Wellbeing Our Way. National Voices.

A programme looking at community and voluntary
groups supporting self-management
[Link]/engagementprogramme

Standards for Health Management Programmes and

Interventions. QISMET.
The national body for quality assurance of self-
management education interventions
[Link]

28 A practical guide to self-management support

Putting it into practice:
peer support and
community assets

6
People with long-term health conditions and
their carers often experience further challenges
that have an impact on their health, such as social
isolation. There is an increasing body of evidence
demonstrating the benefits of peer support and
community groups in combating isolation and
helping people sustain their knowledge, confidence
and skills over time.22,23

The key types of peer and community support are

as follows:

•• Encouraging and enabling self-management

behaviours. This type of support enables people
to learn new skills or share practical experiences
in ways that create mutual support between
people with similar problems. It helps people to
develop and maintain the skills and motivation
they need to manage their health in the context
of their everyday life. Examples include walking
groups or condition-specific support groups.

•• Providing social and emotional support.

This type of support may or may not centre on
peers with similar experiences or conditions,
but can normalise the rollercoaster of emotions
that living with a long-term health condition
entails. Examples include online forums or
lunch clubs.

30 A practical guide to self-management support

•• Supporting people to address wider
social and lifestyle aspects of their health.
This type of support can help people develop
health behaviours, reduce isolation, develop a
sense of belonging, and cope with some of the
broader social determinants of health. Examples
include craft classes and advice on employment
and finances.

All of this support can be provided by people with

long-term health conditions, in volunteer or peer
roles, which can also have a positive and direct
impact on their own health and self-management
confidence.24

Peer and community support is beneficial because

it can:

•• help people to maintain the knowledge, skills

and confidence to self-manage

•• be available to people ‘on demand’, when they

need it

•• support non-clinical aspects of health, such as

loneliness and confidence

•• be tailored, so people can access support for what

is important to them and suits them.

Putting it into practice: peer support and community assets 31

To get the best out of peer and community support,
there needs to be a wide and appropriate range
of support available to people, that is routinely
integrated into the health care system and care
pathways. Approaches often include providing a
single point of access to a range of options, such as
the examples below.

•• Social prescribing – the health care

professional and person identify together the
type of activities that will be of benefit, with
the professional writing a ‘prescription’ directly
to a service or referring the individual to an
intermediary, such as a link worker, with whom
a package of services can be constructed.

•• Signposting – this acts as a bridge between health

care professionals and the social activities available,
and can be done by a variety of people including
health trainers, wellbeing coaches, navigators,
and voluntary community services networks.

32 A practical guide to self-management support

Further reading

I have never had a patient tell me medicine

changed their life. Ollie Hart, C4CC
A blog by a GP discussing the impact of peer and
community support for their patients
[Link]
gp/i-have-never-had-a-patient-tell-me-medicine-
changed-their-life/

More Than Medicine. Nesta.

A detailed report on social interventions that
complement clinical care
[Link]/sites/default/files/more_than_
[Link]

Developing the power of strong inclusive

communities. Think Local Act Personal.
Background to community development and
support
[Link]/_library/
Resources/BCC/Report/TLAP_Developing_the_
Power_Brochure_FINAL.pdf

Peers For Progress

International organisation promoting best practice
in peer support
[Link]

Putting it into practice: peer support and community assets 33

Putting it into practice:
workforce
development

7
Self-management support involves a cultural shift
in how we understand the roles, responsibilities
and relationship between people living with long-
term conditions and the health and social care
professionals and others who support them.

All practitioners can use the skills and approaches

of self-management support in their practice. For
health professionals, it means not only providing
clinical care, but helping people to think about their
strengths and abilities, identifying their information
needs and the changes they can make in their lives
to take control, reach their goals and maintain their
health and wellbeing.

The tools that provide a structure to achieve this are

as follows:

•• Care and support planning: helps people set

their own aims, then plan the support and care
needed to achieve them.25

•• Collaborative agenda setting: at the start of

the consultation, the practitioner and the person
talk about and agree the health issues to explore
and the problems to solve.

•• Recognising and exploring ambivalence:

practitioners can explore people’s readiness to
change, then respond accordingly.

Putting it into practice: workforce development 35

•• Goal setting, action planning and follow-up:
the practitioner supports the person to identify
a goal they want to achieve and break this down
into small achievable actions. Following up goals
later involves developing problem-solving skills
and exploring solutions to barriers, as well as
positive affirmation of progress and effort.

All of these approaches are underpinned by the use of

core communication skills that build relationships of
trust and rapport. These skills include: open-ended
questioning; reflection; empathy; affirmation and
normalisation; summarising; signposting; active
listening and non-verbal communication. Further
skills include health coaching approaches and helping
people to explore the importance to them and their
confidence of making changes.

Approaches can also be adapted to reflect each

person’s level of knowledge, skills and confidence
around managing their health condition.

Organisations have an important role in supporting

their practitioners to develop and use these skills
and embed them into practice. This means providing
training and ongoing support and adapting systems
and processes. Elements of self-management support
are now part of revalidation criteria for doctors.26

36 A practical guide to self-management support

All members of a team (such as GPs, nurses and practice
receptionists) can benefit from training. Training
whole teams or workforce groups together27 is key to:

•• ensuring common understanding of self-

management support and core tools and techniques

•• creating a common language and culture

•• creating a critical mass of trained practitioners

within a team or service to put the skills into
practice across a service or organisation

•• improving the ease with which self-management

support can be tested and adopted

•• enabling practitioners to support each other

through the training and later when using the
skills in practice.

A combination of face-to-face, role modelling and

e-learning teaching methods can be used. Ongoing
support to maintain new skills and behaviours
within a team can include action learning sets,
community interest groups and refresher training,
having a senior lead or champion, and building it into
supervisions and team meetings. Train the trainer
programmes and including elements in organisation
induction programmes for new staff can help the
sustainability of training schemes.

Putting it into practice: workforce development 37

 Further reading

Example case study: Cambridgeshire NHS Trust

training
This sets out the experiences of one NHS organisation
delivering training in self-management support
[Link]
files/resources/sms_case_study_care_planning_training_
[Link]

Practitioner Development Programme. Health

Foundation.
This distils evidence about what works into a clear set of
practical tools that clinicians, health coaches and others
can learn and use to support people to self-manage
[Link]
practitioner-development-programme

Agenda setting sheets. Health Foundation

person-centred care resource centre
A range of sample agenda setting sheets for people with
long-term conditions before appointments
[Link]
api_views_fulltext=agenda&f[0]=field_area_of_
care%3A364

continued…

38 A practical guide to self-management support

Practitioner development. Health Foundation
person-centred care resource centre
Collection of resources from a range of sources
supporting practitioner development
[Link]
care/self-management-support/implementing-self-
management-support/practitioner

The Health Coaching Experience in NHS Midlands

and East Health Coaching Review
Review of evidence of large-scale training in
self-management skills for health care professionals
[Link]
attachments/dr_penny_newman_the_health_coaching_
experience_in_nhs_midlands_and_east_0.pdf

Sustaining and spreading self-management support.

Health Foundation.
Lessons from the evaluation of the second phase of the
Co-creating Health project
[Link]/sites/default/files/
[Link]

Putting it into practice: workforce development 39

Putting it into practice:
optimising systems
and processes

8
Changes which enable people to self-manage can be
made at every level, from what is commissioned to
IT systems and individual interactions with people
with long-term health conditions. Examples include
the following:

•• Developing care pathways to create better

links and referrals between statutory,
voluntary and community sectors. For
example, the ALISS project28 is a co-produced
library that can be added to by anyone and
is designed to make information about local
sources of support easier to access.

•• Providing services in different ways. This

could be through support groups, emails, text
messages, and telehealth, to provide ongoing
support between face-to-face appointments.
For example, the telehealth service in Newham
combines different levels of support for people
with a range of conditions via virtual education
and symptom monitoring.29

•• Improving processes to enable people to

play a more active role. This could involve
providing agenda setting sheets, that help people
to think through what they want to get from an

Putting it into practice: optimising systems and processes 41

 appointment; and providing people with test
results in advance of the consultation, so they
prepare questions in advance.

•• Refining IT systems and developing

processes to support health care
professionals. For example, in Ayrshire
and Arran many GPs use the same system so
they have developed a ‘tag’ for the records of
people with COPD to prompt the GP to check
if they have been offered a self-management
programme.30

Assessing readiness to change and commitment to

supporting self-management within an organisation
or team is important, and can be done using tools
such as the Robert Wood Johnson Foundation
assessment.31 Collaborative working between
commissioners, service managers, professionals
and people with long-term health conditions
enables a shared understanding of challenges and
identification of potential solutions.

Embedding processes that support self-management

takes place gradually.32 Having clear goals,
encouraging small changes, evaluating the impact
of changes and making tweaks to processes as often
as necessary before widespread implementation is
important. There are a number of different quality

42 A practical guide to self-management support

improvement tools to support this, such as the Plan,
Do, Study, Act cycle (PDSA). The process needs to
include effective involvement of people with long-
term conditions in the generation of ideas and design
phases. This process will help to engage workforces
at all levels, encourage ‘buy-in’ and a sense of
ownership, and drive cultural change. In the longer
term, it is important to evaluate the effectiveness of
services and any changes made to assess how well
they are meeting people’s needs.

Further reading

Patient and Family Centred Care Toolkit.

The King’s Fund.
Step-by-step guide to understanding people’s
experiences of care and what needs to change
[Link]/projects/pfcc

Quality improvement made simple.

Health Foundation.
A quick guide covering different QI approaches
[Link]/sites/default/files/
[Link]

continued…

Putting it into practice: optimising systems and processes 43

 Co-producing services – co-creating health.
1000 Lives Wales
Report from Welsh project sharing learning
[Link]/sitesplus/
documents/1011/T4I%20(8)%[Link]

Patient Leadership: the start of a new

conversation. National Voices.
Introduction to Patient Leadership and co-
production of change
[Link]/sites/www.
[Link]/files/patient_leadership_
briefing_note_0.pdf

Ideas into action: Person-centred care in

practice. Health Foundation.
Summary of key learning points from self-
management implementation
[Link]/sites/default/files/
[Link]

44 A practical guide to self-management support

Putting it into practice:
measurement and
evaluation

9
Effective measurement and evaluation of self-
management support can provide evidence of
impact and insight into potential improvements.
This can be done at the individual level, service
and organisational level, and commissioning and
planning level, taking into account what is important
at each level. Measurements from different levels can
be combined to provide a complete picture of the
effectiveness of self-management support. Although
tricky, there are emerging resources that can help
with measuring what really matters.

Individual level

Developing an understanding of individuals’

experiences and their desired outcomes enables
tailored support to be delivered to people with
long-term health conditions. This takes into
account people’s sense of wellbeing, quality of life,
disability, emotion, sense of social support and their
confidence to self-manage. Clinical outcomes are also
important, such as biomedical disease markers and
medication usage.

46 A practical guide to self-management support

A range of tools exist to measure this, such as:

•• Patient Activation Measure (PAM)33

•• Health Education Impact Questionnaire

(HEIQ)34

•• Patient Reported Outcome Measures (PROMs)35

•• Person Centred Outcome Measures (PCOM)

or Personally Determined Outcome Measures
(PDOMs).36,37

Qualitative approaches such as surveys and

interviews with service users can also be effective,
alongside emotional touch points and narratives.
A combination of these can be best as it can
be challenging to find a measure that captures
everything related to the individual.

Service and organisational level

Measures at the individual level can be aggregated

with service data to provide detail on where and how
improvements can be made. This focuses on service
users’ access to timely and appropriate services and
outcomes for workforces such as job satisfaction and
rates of sickness absence.

Putting it into practice: measurement and evaluation 47

Measurement tools include:

•• Consultation and Relational Empathy (CARE)

Measure38

•• Person-Centred Care Assessment tool39

•• Health Literacy Questionnaire.40

Observing clinical encounters and service user-led

‘mystery shopping’ can also provide insight into
these areas.

Commissioning and planning level

Focusing at a population level, outcomes for local

people, impact of local services and associated
cost-effectiveness can be incorporated. This
understanding can help commissioners support
current services and develop new services to
effectively promote self-management support.

Informed by meaningful involvement of people

with long-term health conditions, measurement
and evaluation can help create insight to drive
changes to support self-management as effectively
and efficiently as possible.

48 A practical guide to self-management support

Traditional measurement and evaluation commonly
focus on activity and clinical outcomes, with little
consideration of what people with long-term health
conditions think is important. Person-centred
outcomes can be complex to design and measure, but
working together with people with long-term health
conditions to co-design measurement and evaluation
approaches will ensure a person-centred focus.

Further reading
Helping measure person-centred care. Health
Foundation.
An in-depth summary of the evidence, techniques
and strategies for measuring person-centred care
[Link]/sites/default/files/
[Link]
Evaluation: what to consider. Health Foundation.
A quick guide to support evaluation
[Link]/sites/default/files/
[Link]
Measuring what really matters. Dr Alf Collins.
Thought paper on the challenges and
opportunities of measuring person-centred care
[Link]/sites/default/files/
[Link]

Putting it into practice: measurement and evaluation 49

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