BMJ: Changing the narrative around self-management

3 May, 2021

We enjoyed Partha Kar’s recent BMJ paper "Changing the narrative around self-management" and we agree with Partha Kar that the pandemic has changed the narrative. We also agree with Partha Kar that “a patient spends around 0.02% of their year in direct contact with the NHS for their diabetes management, if we assume four visits of 30 minutes each, leaving 99.98% of their time having to deal with the challenges of the disease.” We agree that this narrative involves self- management and peer support.

But, how can we change the narrative?

One step towards changing the narrative will be to define and name the new narrative. We see the new narrative as a fourth domain of healthcare.

We think the change should begin with a straightforward change of nomenclature.

Parveen Kumar, in *Kumar and Clark’s Clinical Medicine, edited by > Michael L Clark, 8th ed describes primary, secondary and tertiary healthcare. We would like a fourth level of healthcare to be defined and named – patients’ enacted care and added to the list of tiers of care described in Kumar and Clark’s “Clinical Medicine”. We don’ know what to call this new tier of care (narrative).

In most cases care begins in the home, with individuals managing their health and self-caring until they think they need help. So, we cannot see that it is logical to make care at home level four. This might marginalize care at home. Care at home should be the first level, whatever you call it.

The patient doesn't start to deliver care after going through three levels of clinicians.

We also feel that the change should be adopted in all clinical education.

Perhaps the BMJ could take a straw poll on what to name this new narrative/tier of care?

Partha Kar: Changing the narrative around self-management BMJ 2021; 373 doi: (Published 21 April 2021) Cite this as: BMJ 2021;373:n989

'One of the biggest challenges for any healthcare system is how to support patients with chronic disease. While focusing on the availability of healthcare professionals is understandable, this may mean neglecting the basic tenets of chronic disease management and the greater challenge that lies elsewhere.

'To me, managing chronic disease well is founded on three basic principles: self- management, peer support, and access to trained professionals. We do not spend enough time and effort on the first two.

'For instance, in self-management much attention is given to what the healthcare system perceives to be the best way to deliver it instead of what is actually needed or even relevant today. A case in point is education programmes in diabetes care. Until the start of the covid-19 pandemic these programmes still focused on delivering learning through face-to-face, classroom-style sessions, despite the fact that a huge range of tasks—from banking to booking cinema tickets and flights—are today carried out on smartphones in the palms of our hands.

'The debate over encouraging modernisation of this cornerstone of self-management has stalled, as many simply assumed that introducing new technologies would lead to the replacement of current arrangements. In fact, the strategy for a population that varies with age, deprivation, ethnicity, and other characteristics should combine traditional and modern approaches...'


HIFA profile: Richard Fitton is a retired family doctor - GP, British Medical Association. Professional interests: Health literacy, patient partnership of trust and implementation of healthcare with professionals, family and public involvement in the prevention of modern lifestyle diseases, patients using access to professional records to overcome confidentiality barriers to care, patients as part of the policing of the use of their patient data

Email address: richardpeterfitton7 AT