Self-Management, the future, wearables and leading a theme
Professor Richard McManus is Professor of Primary in the Nuffield Department of Primary Care Health Sciences, University of Oxford, and a practicing GP. Among his responsibilities, Richard leads a programme of research around self-monitoring of blood pressure in hypertension and pregnancy, and is theme lead for the NIHR CLAHRC 'Patient Self Management of Chronic Disease' theme.
How, as a GP, did you get involved in research?
I’d done some research as part of my medical degree, looking at gestational diabetes, so had some early experience. But this never quite got to a stage where I felt I was getting proper, useful outputs.
So, after qualifying as a GP I began looking for research training roles. At that time, with no NIHR, there were few to choose from. I managed to get on to one of the few that were available, run by Richard Hobbs at the University of Birmingham.
This led to the completion of an MSc, whilst working about half-time in a practice. From there, I completed a doctoral training fellowship, and continued down the research path to my current NIHR Professor Fellowship.
Could you tell me a bit more about the ‘patient self-management of chronic disease’ theme you lead on?
Patient self-management is a key policy area for the NHS and we have a strong track record in the area – particularly with respect to cardiovascular disease – and so it was a natural choice for the CLAHRC.
The medical profession has changed a lot over the past 50 years. It's moved from a more paternalistic profession, to one which is much more receptive.
For the self-management theme we took the decision to have a big focus on training. Because of the collaborative way the CLAHRC works – using matched funding from charities, industry and the University of Oxford – for relatively modest funding from the CLAHRC directly, we managed to get three or four DPhils completely funded.
Amongst the DPhil projects, one is looking at self-management of diabetes and decisions about risk in diabetes. One is looking at using self-monitoring to detect ‘masked blood pressure’. This is where blood pressure is high outside of a clinic where it's normally measured, so it doesn’t always get picked up but still presents a risk to the patient.
And, finally, one DPhil project examining self-management of weight, that’s co-funded by the NIHR School for Primary Care Research.
We have two other main projects. The first examines self-management of hypertension following pregnancy and builds on our work in the TASMIN studies in essential hypertension. It has a further DPhil which is co-funded with my professorship. The second focuses on self-management of bipolar disorder and in turn builds on the True Colours platform.
We’ve also have work looking at the implementation of different self-management interventions. And there's a technology theme which underpins many of the projects; about building apps and so on to aid self-management.
Why do you think self-management is an important area to look at?
I think it’s now generally recognised that people tend to have better outcomes when they have more control over their own care.
The medical profession has changed a lot over the past 50 years. It's moved from a more paternalistic profession, to one which is much more receptive. Open to the concept of a shared ownership of problems; with patients acting in expert capacities themselves, working with their physicians.
Take, for example, our own work in self-management of high blood pressure. The patients who self-managed their blood pressure were found to have significantly better control of it than those in standard care, where a GP would measure and adjust in the clinic.
Do self-management approaches tend to lead to reduced costs?
From a national policy perspective self-management is often seen as a way of reducing costs. And there are definitely examples where self-management does reduce costs.
In my own experience it tends not to increase costs, but does tend to improve effectiveness. So it’s more cost-effective: better outcomes for the same investment.
Looking 20-30 years in to the future, how much of a part do you expect self-management to take in the NHS?
I do think it will become common in the next 20-30 years. But, I think it’s important to remember that there are always going to be people who will never want to, or be able to, self-manage.
For example, patients who, for reasons of disability or age, might not be able to self-manage. But I think there’s also potential there. Potential for co-working with carers, such as spouses or children, in managing these people’s conditions.
There will also always be people with complicated conditions for which some type of self-management might not be appropriate, or possible. For example, patients with multiple different illnesses (multi-morbidity).
What do you think the role of technology will be in the future of self-management?
I think this is very much an unknown at the moment.
Things like wearable technologies can allow you to collect enormous amounts of data. This could be about all sorts of things, from heart rate and blood pressure, to, maybe in the future, even glucose and cortisol levels, for example.
Wearable technologies also have the potential to be able to pick up subtle things that are currently hard to pick up in clinic. Things like occult arrhythmia, and alert you or your GP in way that can’t be done at the moment.
The other thing is that one has to be very careful about the validity of data. You have to be sure of the accuracy of the data if you’re going to use it to make a judgement about somebody’s health and care. So a lot of work will have to go into that as well.
So, what do you actually spend most of your time doing?
I'm currently running a number of trials, such as the TASMIN-4 trial, which aims to recruit 1100 people and is about three quarters of the way there so far. This is funded via an NIHR programme grant and there’s also a whole series of linked projects within that, including using self-monitoring to screen for high blood pressure.
We’re also currently trying to build up the evidence for funding some similar work in pregnancy and are awaiting the outcome of a further large grant application.
Of course, I also do a lot of supervision of DPhil students. In total I have six at the moment. I take quite seriously the development of people who could come and work in our speciality.
There’s a dearth of academic GPs for example, less than 1% of GPs are academics. As 90% of patient contacts are through general practice, there’s a lot of things we do that are probably not as evidence-based as they could be. Building up the academic workforce is important to try to rectify this.
I also do quite a bit of mentoring, both with people in Oxford and nationally.
I also have a lot of collaborative work, on various other projects, with people in Birmingham, London, Southampton and Cambridge.
What’s next on your to-do list for today?
At the moment I’m working on a series of project proposals for funding on the next stage of the CLAHRC.
We’re also writing up a number of things at the moment. Including a large collaboration of 20 international groups on what’s called an ‘individual patient data meta-analysis’, which we’re just about to submit for publication.
Then, thinking about the ‘Next Big Thing’. We had a workshop just last week thinking about new research idea and coming up with new proposals for grant applications.