Recently, a rapid review (commissioned by the National Institute for Health and Clinical Excellence) gave a cautious welcome to lay led self management interventions but pointed out that most evaluations were short term and set in the United States, and some of the data were uncontrolled.11
A recent paper by Buszewicz and colleagues provides the longest duration of controlled follow-up to date (one year).12
Of the four evaluations in the UK, two test the arthritis self management programme12 13
and two the chronic disease self management programme, including the national evaluation of the expert patient programme carried out by the National Primary Care Research Centre in Manchester.14 15
The results of these four studies are similar (table[t1]). The good news is that these programmes increase patients' self efficacy—in essence their confidence to change behaviour—and can lead to improved psychological health (although the effect sizes seem small). We found the chronic disease self management programme improved self efficacy in Bangladeshi patients, suggesting that it may be useful for ethnic minorities.15
However, the changes in self efficacy are generally modest and it is unclear how much patients value improvements in self efficacy compared with, say, a reduction in symptoms or a gain in health related quality of life. There are also important negative findings: generic measures of self rated health were unaltered in three of four studies, and more importantly, use of health care has remained stubbornly unaltered. The latter is a considerable disappointment because the expert patient programme has been heavily promoted by the UK Department of Health as part of a drive to reduce use of acute health care.
Several factors may explain the failure of lay led programmes in the UK to reduce the use of health care. Firstly, lay led programmes may do as much to promote consultation as they do to reduce it. The chronic disease self management programme teaches techniques to improve communication with clinicians, so patients may be encouraged to consult more. Secondly, any reductions in unscheduled (emergency) care may be obscured by increases in scheduled care. Thirdly, self management programmes may not be as effective at reducing healthcare use in settings such as the UK, which have universal healthcare coverage and well established primary care. It is unlikely that poor delivery of the programme in the UK is a cause since course tutors are assessed and course quality is strictly monitored. Three trials of the chronic disease self management programme in the United States show inconsistent effects on use of health care.16 17 18
The much cited report of a 40% reduction in physician visits in the United States comes from a methodologically weak, retrospective comparison, in which arthritis patients in the community who had volunteered for self care education were compared with a group of arthritis patients with no explicit interest in self management who were under the care of rheumatologists.19
Trials examining use of health care in the UK are unlikely to have missed an effect of this magnitude.