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Healthcare in a rural setting

January 2005
Board of Science

Expert patients programme
In the UK, at any one time, as many as 17.5 million adults may be living with a chronic disease and there is a greater prevalence in older people. Increasing longevity in the population has resulted in an increased burden of chronic diseases such as heart disease, stroke, cancer and diabetes mellitus. As previously mentioned, there is a greater proportion of older people living in rural areas. Living with a long-term condition can mean physical and psychological difficulties, socio-economic problems, reduced quality of life and sometimes social exclusion. There is increasing evidence that a patient-centred approach, with patients taking a lead in managing their chronic condition, can help to improve health, quality of life and reduce incapacity. [go to reference 16]

The Expert Patients report (2001) sets out the vision of a more patient-centred NHS. [go to reference 16] Patients with a chronic illness are not seen simply as passive recipients of care, but rather as active partners in the decision-making process, able to take an active role in their own care. Patients’ expertise in their own illness and particular needs should enable them to self-manage the illness in partnership with a healthcare professional. The Expert Patients report proposes developing self-management programmes designed to empower patients to take greater control over their lives.[go to reference 16]

Self-management courses
A typical self-management course is usually led by two volunteer lay tutors and involves attending one session per week lasting two hours and 30 minutes, for six weeks. The course builds skills and resourcefulness and improves confidence to allow the patient to work in partnership with healthcare professionals. The typical contents of a course are shown in key issues [go to reference 11]. Trusts are encouraged to run generic rather than disease-specific courses. Patients then feel less isolated as they realise that many of the problems they encounter are not specific to their own condition. This is particularly important for those in remote areas. Courses are also more accessible to more people, as patients from one locality with different chronic diseases can access the same course. [go to reference 119] By 2007 self-management programmes should be mainstreamed throughout the NHS.

Key issues 11: contents of an expert patients self-management course
• Cognitive skills (mind affecting body for positive change)
• Relaxation and fatigue symptom management
• Anger, fear and frustration management
• The role of healthy eating and exercise
• Communication skills, to open dialogue with doctor and avoid defensive conversations
• Managing medication
• Managing depression
• Planning for the future and making an action plan
• Problem solving
• How to make informed treatment decisions
• How to work in partnership with the health professional team
Source: Lorig K, Gonzlez V & Laurent D (1997). [go to reference 120]

Patients can more effectively manage aspects of their disease such as long-term pain and are given techniques to cope with fatigue and the emotional consequences of the disease. The need for regular medication can be reduced and patients feel more in control of their disease and medication. The course raises self-esteem and patients feel empowered and are less reliant on healthcare services. [go to reference 16]

Providing self-management courses is a low-cost intervention that has a positive impact on the primary care organisation, healthcare professionals and acute Trusts. The courses can reduce a patient’s need to see a healthcare professional, which will consequently free that professional for other people. The duration of each appointment can also be reduced as patients are able to explain their needs more clearly during clinic appointments, are more focused and more able to help the healthcare professional. Fewer hospital stays are necessary and the duration of stay is shortened. This can reduce the stress levels of the healthcare professionals and reduce overall costs in the long term. [go to reference 119]

Self-management courses in rural areas
It has been suggested that patients in rural areas where health services are not easily accessible, may find self-management courses particularly beneficial. If healthcare services are less accessible, patients can feel powerless, isolated and removed from the services that they are reliant upon. Self-management courses can help patients to manage their illness and reduce their dependence upon healthcare services. Courses can also help them to benefit more from the time spent with healthcare professionals through being able to focus on their needs and work in partnership.

Providing expert patients programmes in rural areas presents particular challenges.
• The interface between implementing courses and giving patients access to those courses. At present there are not enough lay tutors to run an adequate number of courses in rural areas. This means that patients in rural and isolated areas do not always have access to courses in their local area. In addition, the lack of public transport in many rural areas prevents some patients from attending courses. Expert patients programmes do not qualify for funding for NHS transport as the courses are not a direct medical intervention implemented by a healthcare professional.
• Self-management courses should be run in community venues rather than medical institutions where possible, to emphasise that the course is a non-medical intervention. It can be challenging to find accessible, comfortable venues with adequate facilities in rural areas.
• The high proportion of elderly people living in rural areas increases the potential burden of care created by a greater percentage of the population developing chronic diseases. This places a high financial burden upon the primary care organisations.

Recommendation 15
Patients in rural and isolated areas need to have access to expert patients selfmanagement courses in their local area.
• The government must prioritise the establishment of expert patients programmes in rural areas and provide sufficient resources for course implementation.
• Government funding is required to enable more volunteer lay tutors to be trained. This will allow more courses to be run in rural areas.
• Transport should be improved to allow patients access to courses that are not held in the immediate vicinity. Funding should be allocated by the NHS.