In the United Kingdom, the Department of Health is promoting self-management of chronic diseases through its Expert Patients Initiative. This is supported by Barlow et al's review of the extensive self-management literature and in particular the chronic disease self-management programme (CDSMP) developed by Lorig at Stanford University. Barlow et al suggest that self-management works, but identify some evaluation problems: no gold standard definition of self-management; multi-component programmes that are hard to compare; non-standard measures of health not subjected to psychometric testing; and cost-effectiveness that is poorly studied. This presentation will firstly address some more fundamental philosophical issues that are often underplayed in the medical literature and policy documents. It also introduces a model for thinking about the implementation of self-management in primary care.

Policy makers assume that 'empowerment', 'responsibility' and 'control' are good things patients should want. Conversely, self-management could be seen as a complex way of ensuring professional control and promulgating a medical model of health. Patients' thoughts and feelings about the nature of self-management may help to explain its slow integration into everyday practice. For example, data from our on going qualitative research suggests that: people with poor health knowledge may be happy to rely on those with professional training; a desire to take responsibility for health and healthcare cannot be assumed; and those assessed as 'able to cope' might also be vulnerable to dramatic changes in circumstances.

The components of the CDSMP can be related to certain general models of physical and mental well-being: Antonovsky's sense of coherence and Ryan & Deci's self-determination theory. This comparison suggests that it may be useful to think of well-being and self-management as educational processes that can be more or less dynamic. The implications of this will be explored. The usefulness of tailoring educational resources to match personality and learning style is widely accepted. Components of self-management programmes are not generally selected in such an individualised way, which may be another barrier to wide spread use and usefulness. Many more people may be persuaded to like self-management, but it is likely to be an acquired taste and we should give more regard to the options made available.

An overall model of self-management is presented, which illustrates how collaboration to improve health might be linked to partners' knowledge and understanding, sense of responsibility and coping strategies. This model might be used to explain how practical self-management works or to diagnose problems implementing self-management in a practice setting. For self-management to be successfully mainstreamed it must be flexible to meet patients' needs. Resources are also required to regularly assess self-management and provide back up on demand, which may be labour intensive. Pilot projects may fail to identify all the practical problems and resistance that will be encountered in everyday practice because early adopting participants are motivated and self selected.

References
Antonovsky A (1987). Unraveling the mystery of health: how people manage stress and stay well.
San Francisco: Jossey Bass.
Barlow J et al (2002). Self-management approaches for people with chronic conditions: a review. Patient Education & Counseling, 48, 177-187.
Ryan RM and Deci EL (2000) Self determination theory and the facilitation of intrinsic motivation, social development and well-being. American Psychologist, 55, 68-78.