MJA
MJA

The United Kingdom Expert Patients Programme: results and implications from a national evaluation

Anne Rogers, Anne Kennedy, Peter Bower, Caroline Gardner, Claire Gately, Victoria Lee, David Reeves and Gerry Richardson
Med J Aust 2008; 189 (10): S21. || doi: 10.5694/j.1326-5377.2008.tb02205.x
Published online: 17 November 2008

The United Kingdom Department of Health envisages service delivery for long-term conditions designed around three tiers:

The Expert Patients Programme (EPP) is a central element of chronic disease management policy in the UK. The program aims to deliver self-management support and improve the quality of life of people with long-term conditions by developing generic self-management skills and improving people’s confidence and motivation to take more effective control over their lives and illnesses.

The mainstay of the EPP is a 6-week course based on the Chronic Disease Self-Management Program, which was developed and licensed by Stanford University.1 Historically, volunteer organisations in the UK pioneered the use of peer-led training. In contrast, the EPP course was designed to be delivered within the National Health Service (NHS) by trained lay volunteers or paid trainers through health care organisations. During the pilot stage of the EPP, the course operated on an open-referral basis, and was available to anyone with a long-term condition. Box 1 gives details of the course content and delivery during the pilot phase (2002–2006).

Initially, the EPP was administered by Primary Care Trusts (PCTs; primary care organisations responsible for commissioning, organising and delivering community care). It is now operated by a community interest company set up by the UK Government to market and deliver courses and diversify the program. By the end of the pilot phase, the EPP had the capacity to train about 12 000 participants per year.

Evaluating the Expert Patients Programme

We conducted a national evaluation of the EPP, focused on the extent to which health service organisations could implement and mainstream such a program, and the clinical and cost-effectiveness of the EPP. A range of methods was used for the national evaluation:

Effectiveness and cost-effectiveness

We recruited 629 patients with a range of self-defined long-term conditions to a randomised controlled trial. Outcomes were assessed in all patients regardless of the number of sessions attended (intention-to-treat analysis). Our comparator group was a 6-month waiting-list control group (a non-waiting-list comparator was excluded on the grounds of the ethical issues arising from denying access to treatment). Three primary outcome measures of effectiveness were examined 6 months after recruitment:

Additionally, cost-effectiveness outcomes were based on a comprehensive assessment of the costs of the program (primary care, specialist, community, medication and out-of-pocket costs) combined with a measure of health-related quality of life (EQ-5D,3 which measures self-reported mobility, pain, anxiety/depression, self-management, and ability to perform usual activities).4 The patterns of scores, weighted by UK population, allow estimates of quality-adjusted life-year (QALY) gains, and the economic analysis combines with these estimates to examine cost per unit gain in QALYs.

The main results are summarised in Box 2 and full results have been published previously.5 The “effect size” is a measure of the overall impact of the program and can be used to compare the impact of the EPP with other interventions. Based on the effect size, referral to the program had a moderate positive impact on self-efficacy, a smaller impact on reported energy, and little impact on routine health services utilisation (Box 2).5 Patients showed improvement in health-related quality of life equivalent to providing them with an extra week of perfect health per year, and combining costs and outcomes showed the program was likely to be cost-effective.5 This reflected the fact that the program improved health-related quality of life but did not add to the total costs of care, because reductions in service use (especially expensive inpatient stays) offset the costs of providing the self-management skills course (Box 3). One issue to note is that patients’ out-of-pocket expenses increased.

The role of the Expert Patients Programme in context

The results of the trial suggested that the model of training used is likely to make a positive contribution to the management of long-term conditions. Additionally, the EPP has set a clear new agenda for such management. It has centred on developing an approach which is user-focused, based on individuals who are active and able to solve problems themselves and challenge an over-medicalised approach to the management of long-term conditions. Nonetheless, some key questions remain, including:

Can the program engage with all patients with long-term conditions?

As the EPP was conceptualised as a public health intervention, reach and engagement become key factors in equitably connecting with those most likely to benefit. Our process evaluation revealed that the EPP appealed most to white middle-class people with long-term conditions who already viewed themselves as effective self-managers.7 A key limitation was that, relative to the numbers of people in the population with a chronic illness condition who were likely to benefit, there was poor uptake and attendance. Another study examining a lay-led self-management initiative, of ethnic minority groups living in a deprived inner-city area, found similar results.8

How important is self-efficacy to patients?

Traditionally, self-efficacy has been thought to mediate the effects of lay-led self-management courses. That is, the course increases patients’ confidence in their ability to manage their problems, which in turn improves other outcomes. Although research using discrete choice methods has shown that self-efficacy is something that is clearly valued among the participants of the EPP trial,9 the importance of self-efficacy as an outcome rather than process measure may have been overstated.

Using mixed qualitative methods, we found that some expectations were not dealt with because the self-management skills training program prioritised improvements in self-efficacy and did not engage with patients’ material and social needs. An approach that focuses on self-efficacy may inadvertently sideline the relevance of social inequalities in patients with long-term conditions, and patients’ personal experience and their adaptation to their long-term conditions.

For instance, social comparison is a process that is important in enhancing self-efficacy in group-based programs, but this can have a negative effect. Being poor and ill brings with it the possibility of shame and insecurity,10 which may be reinforced in group situations. Attention to people’s self-defined needs and access to comprehensive welfare support payments might be as or more important in improving self-management than programs based on psychological outcomes such as self-efficacy.

What is the role of other models and approaches?

A final consideration is the extent to which different approaches to self-management support need to be considered in the light of limitations to the current patient-focused approaches to self-management support. We suggest a different focus may be required. Patients with long-term conditions already have relationships with clinicians and services. We have suggested elsewhere the need for self-management interventions to focus on three levels: the patient, the organisation, and the health professional.14 Augmenting and modifying what patients already do to manage their health and illness may have little impact if clinicians are not ready to engage patients in a shared approach to care, supported by the wider context of the health service in which they work, and without considering the access patients already have to social and material resources in their everyday lives.

Conclusion

Lay-led self-management skills training courses used as the basis of the EPP were moderately effective in improving self-efficacy and energy levels in people with long-term health conditions and are likely to be cost-effective. Such courses are useful additions to the range of current services for the management of long-term conditions, and implementation via primary care organisations was shown to be feasible. In its current form, the EPP is helpful for some individuals and is valuable as one of a range of options. However, other options, which take account of existing patient management strategies and their contact with services, together with recognition of social and material resources, may be preferable in the longer term. Rather than being concentrated on a single course, central resources for self-management support should also be directed at a variety of systems and interventions that are able to meet the wide range of needs of patients with long-term conditions.

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