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Encouraging Self-Care in a Primary Care Setting
By Dr Catti Moss, Member Royal College of General
Practitioners Patient Liaison Group, Dr James Kennedy, Member
RCGP Prescribing Group.
Families and individuals take an important responsibility for
their own healthcare. The extent to which they do this depends
on the knowledge available within the family and social network.
In the years before the introduction of the National Health Service,
the extended family contained people with the knowledge to handle
many acute conditions and most childhood diseases at home. Until
the 1850s, any outside health care advice for ordinary people
would have come from an apothecary. Gradually, around the turn
of the century, specialist pharmacists became more widespread
in the community. These community pharmacists made up prescriptions,
and would help and advise with appropriate non-prescription treatment.
Only after exhausting this route, with no improvement in symptoms,
would a doctor be consulted. The individual and family delivered
most care at home without medical intervention.
The NHS, while generally improving health care in the UK, has
heavily reinforced the doctor's role in treatment. The NHS and
the media have encouraged this trend. This has undermined people's
confidence in their ability to care for many of their own health
problems. But now there are many proven and effective treatments
available over the counter in pharmacies without prescription.
The advent of well-advertised advances in some medical specialities
has also contributed to people losing the confidence to treat
their common everyday ailments at home.
In the last two years however, the Government has
introduced several initiatives aimed at rebuilding the self-care
skills within the family. The NHS White Paper 'The new NHS - Modern,
Dependable' specifically states that this means providing 'easier
and faster advice, and information for people about health, illness
and the NHS so that they are better able to care for themselves
and their families: The public health White Paper 'Saving Lives'
puts the focus on a 'Healthy Citizens' programme. This includes
three elements. The first provides information for people to act
on at home supported by self-care booklets, and NHS Direct by
telephone and on-line. The second teaches children in school to
look after their own health and common ailments and trains them
in resuscitation techniques. The third develops the self-care
management skills of people with chronic medical conditions.
 These
initiatives need to be examined within the context of current
public attitudes and behaviour. Success will need the public to
gain access to reliable health information when and where they
need it. One of the main sources of reputable self-care information
is PAGB, the trade association representing manufacturers of OTC
medicines and food supplements.
Everyday Healthcare
What do people think about their health?
In 1996, the British Market Research Bureau International was
independently commissioned by PAGB to assess consumer attitudes
and behaviour with regard to health in general and minor ill-health
in particular. In the year-long study (1), 2000 consumers were
interviewed face to face in their homes. They were specifically
asked about the minor ailments they had suffered, what they had
done about them and why. 58% of adults said they had consulted
their family doctor in the last twelve months for minor/common
ailments.
What is the amount of minor illness in the
community?
 |
|
| Ailment |
% reported |
| Tiredness |
40 |
| Headache |
33 |
| Muscle aches/pains |
29 |
| Sleeping problems |
23 |
| Stiffness in joints |
22 |
| Back problems |
20 |
| Bruises |
17 |
| Stress/anxiety |
17 |
| Feeling low/depressed |
16 |
| Minor cuts and grazes |
16 |
| Colds |
14 |
| Arthritis |
14 |
| Acne |
12 |
| Hangover |
12 |
|
Adults in the study suffered an average of 5.2 ailments in the
two weeks prior to the study. Women reported more problems than
men, (5.7 and 4.8 respectively). Teenagers (15-19 year-olds) reported
an average of 6.2 ailments and those aged 65 and over an average
of 4.6 ailments.
What are the most common ailments?
91% of respondents reported suffering from at least one sort
of ailment. The most commonly reported ailments are listed to
the right:
There is clearly a great deal of minor ill health in the community.
Dealing with these ailments is a significant problem not only
for the individual suffering symptoms but also for those providing
and funding health care services.
What do people do about their minor ailments?
Based on the findings of this study, the most common response
to minor ailments is to do nothing - the 'wait and see' approach.
The next most common response is to use an over-the-counter (OTC)
medicine. The third is to use a prescription medicine already
in the home, prescribed for chronic or recurring ailments. A visit
to the doctor was fourth.
|
|
| Ailment |
|
| Used nothing |
46%
|
| Used prescription medicine already in home |
14%
|
| Saw doctor/dentist |
10%
|
| Used OTC medicine |
25%
|
| Used 'home remedy' |
9%
|
|
The study also asked whether people were consulting health professionals
other than their doctor. In only 1% of ailments was a pharmacist's
advice sought; 1% of ailments were taken to a nurse or health
visitor and 2% were taken to some other health professional:
NHS Impact of treating minor ailments
It is important in a debate around self-care and self-medication
to look very carefully at the amount of minor illnesses presented
at a doctor's surgery and assess the implications of such healthcare
behaviour. The BMRB study demonstrated that 10% of minor ailments
are taken to the doctor. This equates to 8% of the population
visiting their doctor per year, or a minimum of 96 million GP
consultations a year. But what happens as a result of these consultations?
Almost two thirds of the consultations conclude in a prescription
being written. An OTC recommendation was made in only 5% of cases.
BMRB calculated that consultations concluded in a prescription
seven times more frequently than an OTC recommendation. These
data beg the questions, 'Why are people going to the GP with minor
conditions?' and 'Why are GPs writing prescriptions for minor
conditions?'
|
|
| Outcome of consultation with doctor |
|
| Prescription |
65% |
| Do nothing/come back if no improvement |
17% |
| Other general advice |
14% |
| Referred elsewhere |
13% |
| OTC recommended |
5% |
| |
Advice about diet |
3% |
|
What are the triggers for GP consultations?
The BMRB study shows that in the vast majority of cases, people
know the ailments they are experiencing and what to do about them.
People will appropriately self-medicate when they are familiar
with the circumstances, they have used the OTC medicine successfully
before and it is available at home.
It can be seen from the tables below that viral infections and
hayfever are the minor ailments most likely to be taken to the
doctor.
| |
This table shows all the actions
that people say they take when they have a minor ailment. |
| Ailment |
%Used nothing
|
%OTC in house
|
%Bought OTC
|
| Headache |
16
|
55
|
17
|
| Athlete's foot |
28
|
34
|
33
|
| Lip problems |
26
|
37
|
26
|
| Migraine |
11
|
41
|
28
|
| Period pains |
33
|
33
|
16
|
| Common cold |
36
|
32
|
23
|
| Flu |
12
|
35
|
24
|
| Sore throat |
27
|
25
|
21
|
| Indigestion |
19
|
30
|
17
|
| Acne/pimples/spots |
50
|
26
|
16
|
| Hangover |
52
|
30
|
3
|
| Hayfever |
35
|
13
|
21
|
| Cough |
42
|
21
|
12
|
|
|
| |
Ailment(continued)
|
%Doctor/dentist
|
%Prescription medicine
in house
|
%Pharmacist advice
|
%Home remedy
|
| Headache |
3
|
15
|
1
|
3
|
| Athlete's foot |
3
|
8
|
1
|
3
|
| Lip problems |
2
|
8
|
5
|
3
|
| Migraine |
9
|
32
|
2
|
3
|
| Period pains |
2
|
8
|
0
|
20
|
| Common cold |
7
|
9
|
4
|
12
|
| Flu |
34
|
13
|
6
|
13
|
| Sore throat |
18
|
11
|
1
|
5
|
| Indigestion |
10
|
26
|
1
|
12
|
| Acne/pimples/spots |
4
|
8
|
2
|
4
|
| Hangover |
0
|
5
|
-
|
13
|
| Hayfever |
7
|
30
|
3
|
1
|
| Cough |
11
|
20
|
3
|
3
|
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Perceptions of OTC medicines
Qualitative research through focus groups (2), conducted in 1994,
revealed that people's perceptions of OTC treatment are mainly
formed by their experience of analgesics and cold remedies. They
do not understand how the medicines work, nor do they know the
normal progression of a cold or viral illness. They are often
confused about whether they have a cold or flu. They worry about
masking symptoms of an underlying disease or of becoming addicted
to the medicine. They are concerned that if they use OTCs then
the medicine will not work when they really need it, that it will
lose its potency. They think that OTC medicines relieve symptoms
and do not cure and that only the doctor has the 'cure' for all
these reasons, people try to minimise their use of medicines.
However, if symptoms are 'persisting' - which they define as lasting
for between four and seven days (typically seven for a cold) -
they believe that they must consult the doctor.
People's expectations at this point shift entirely to the GP
and the 'cure: However, the 4-7 day period for self-medication
is often too short for a GP to differentiate between self-limiting
ailments and serious disease. In most cases, the GP would expect
people to try self-medication for about two weeks before presenting
at the surgery.
The BMRB study shows that consumers believe the pharmacist is
a good source of advice (86%), that people should ask the pharmacist
rather than the doctor (61%) and that it is more convenient to
ask the pharmacist (56%).
The study also shows:
- that consumers think it is important to have OTC medicines
for minor problems (79%)
- that the medicines you can buy are just as effective as those
from the doctor (67%)
- that 86% said they would again buy the same OTC medicine they
had previously used.
Nevertheless, the doctor is still the place they go for reassurance,
and the expectation of a 'cure'.
The GP in the consultation
 In
a number of GP focus groups, conducted by McMaster Cawte in 1994
(3), GPs acknowledged the importance of treating minor ailments
through self-medication. They assumed that by the time the patient
approached their doctor they had exhausted all efforts to deal
with the symptoms in this way. This was explored further in the
study conducted by Bradley et al in 1996, 'Attitudes and Behaviour
of Doctors and Patients with regard to Over-The-Counter Medicines'
(4). In this study, conducted in six practices and with a patient
sample of 2,324 patient responses, Bradley et al found that patients
view a GP recommendation of OTC medication more positively than
the GPs making the recommendations think they do.
Room for change in the GP consultation?
An indication for change comes from the results of the Bradley
et al study. The study found that GPs were very conservative,
cautious and even reticent in making OTC recommendations. They
would often write a prescription in addition to making an OTC
recommendation to avoid upsetting the patient.
The majority of the patients, on the other hand, either said
that the GP should routinely ask about prior OTC use (51.6%) or
that it would be a good idea sometimes (16.2%). On their GPs making
an OTC recommendation, again the majority of patients either said
that the GP should do this routinely (16.8%) or that it would
be a good idea (44.3%). Only 5.6% said they would be upset by
their GP recommending an OTC.
If the GP made an OTC recommendation, 54.1% of patients said
they would automatically follow this, 29.5% said they would seek
advice from the pharmacist, 2.5% said they would ask a relative
or friend and 13.9% said they would decide for themselves. This
demonstrates a high level of patient acceptance of GPs making
OTC recommendations.
The above research supports the proposal that the GP consultation
should include the following:
- Ask whether self-medication has already been tried and the
product taken
- Ask the dosage and duration of prior self-medication that
was attempted
- Consider providing a leaflet and/or an OTC recommendation
The direct benefits for the GP of a more detailed consideration
of self-medication are:
- The patient will be confident that the full history of the
condition has been discussed and any potential embarrassment
over using a 'non-doctor' product removed.
- The correct use of OTC medications can disseminated. Therefore
a longer duration of use or a more appropriate OTC medication
may be recommended and any misunderstanding to its use and effects
be corrected.
- A recommendation for an OTC medicine becomes a real option
in the consultation.
- The kind of sharing of knowledge and understanding in the
consultation promotes deeper and more effective patient-doctor
relationship.
A shift in this direction might allow the patient-doctor relationship
to move to a more adult-to-adult footing.
References: (1) BMRB Everyday Healthcare Study
of Self-medication in Great Britain, October 1997 (2) The HPI
Research Group OTC Medicines and Consumers, May 1994 (3) McMaster
Cawte Associates, OTC recommendation by GPs, April 1994 (4) Bradley
CP, Riaz A, Tobias RS, Kenkre JE and Dassu D, Pati, Patient attitudes
to over-the-counter drugs and possible professional responses
to self-medication. Family Practice 1998; 44-50
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