Abstract
There are various reasons why efforts to promote “support for self-management” have rarely delivered the kinds of sustainable improvements in healthcare experiences, health and wellbeing that policy leaders internationally have hoped for. This paper explains how the basis of failure is in some respects built into the ideas that underpin many of these efforts. When (the promotion of) support for self-management is narrowly oriented towards educating and motivating patients to adopt the behaviours recommended for disease control, it implicitly reflects and perpetuates limited and somewhat instrumental views of patients. It tends to: restrict the pursuit of respectful and enabling ‘partnership working’; run the risk of undermining patients’ self-evaluative attitudes (and then of failing to notice that as harmful); limit recognition of the supportive value of clinician-patient relationships; and obscure the practical and ethical tensions that clinicians face in the delivery of support for self-management. We suggest that a focus on enabling people to live (and die) well with their long-term conditions is a promising starting point for a more adequate conception of support for self-management. We then outline the theoretical advantages that a capabilities approach to thinking about living well can bring to the development of an account of support for self-management, explaining, for example, how it can accommodate the range of what matters to people (both generally and more specifically) for living well, help keep the importance of disease control in perspective, recognize social influences on people’s values, behaviours and wellbeing, and illuminate more of the rich potential and practical and ethical challenges of supporting self-management in practice.
Highlights
The concept of support for self-management continues to attract significant interest from health policy leaders internationally as increasing numbers of people are living with long-term conditions
1 The Institute of Medicine and this paper focus on the support given to people with long-term conditions by health professionals working in formal health services
We have offered a potentially important explanation for the extent to which the support for self-management that health services and professionals offer people with long term conditions can fall short of the multiple policy ambitions associated with the concept, especially in domains associated with respecting and enabling patients as human moral agents
Summary
The concept of support for self-management continues to attract significant interest from health policy leaders internationally as increasing numbers of people are living with long-term conditions. Professionals can sometimes support people by, for example: acknowledging their suffering and the difficulties of accepting and dealing with the various implications of long-term conditions [18, 22]; providing the kind of ‘‘moral support’’ that reassures someone that they are not alone, are being taken seriously, and are not being unfairly and negatively judged; letting someone know that they are ‘‘there for you’’ (which does not necessarily imply being personally available 24/7); and communicating in the kinds of respectful, caring and affirmative ways that help people to retain/develop a valued self-identity, personal narrative and sense of meaning in their life in the face of a new diagnosis or the ongoing challenges and/or deterioration of lifelong conditions [15, 27] These ways of behaving and relating can support people in ways that go beyond (or do not involve) working directly to enable them to take a particular action or achieve a particular goal, but they have potential to leave people feeling better in or about themselves and to strengthen important aspects of their autonomy [16, 31, 35]. A Capabilities Approach and its Potential for Theorizing Support for Self-Management
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