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Co-Creating Health
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What is self-management?


  • involves an individual learning more about their condition and making supported decisions based on this
  • aims to enable people to make daily decisions that will maintain or improve their health
  • assumes a person's own priorities/aims/goals are what are most likely to motivate them to change their behaviour.
  • is an essential part of any health service


Chronic care modelCo-Creating Health builds on the wealth of UK and international experience and innovations in the management of long-term conditions. In particular, it draws on the chronic care model developed by Professor Wagner and colleagues in Seattle, USA.

The chronic care model is based on the assumption that the way clinical teams interact with patients makes a significant difference to patients' health outcomes.

There are two key elements of these interactions:

  • they should be characterised by collaboration and partnership
  • they need to be structured around explicit, evidence-based processes that help service users to self-manage their condition effectively.

The three enablers

The three enablers: patients, clinicians and the healthcare systemAt the heart of Co-Creating Health initiative are three processes: agenda setting, goal setting and follow up. These are called the enablers.

The first enabler: agenda setting

This involves:

  • Establishing, building and maintaining a positive, trusting relationship with patients
  • Determining the extent to which patients want to participate in treatment options
  • Defining clinical problems in terms that both the clinician and patient are comfortable with
  • Knowing the patient's cultural  and religious background, customs and possible barriers/limitations to treatment that can result from it

The second enabler: goal setting

This involves:

  • Collaborating with the patient in defining problems, setting treatment goals and planning care
  • Offering the patient real healthcare choices and respecting the choice when it is made
  • Customising treatment recommendations in response to patients' preferences and beliefs
  • Discussing treatment options with the patient to highlight their pros and cons

The third enabler: goal follow-up

This involves:

  • Jointly agreeing the methods by which the patients' progress will be evaluated and monitored
  • Providing a point of contact for patient and his/her family/caregivers if any problems/questions occur between appointments
  • Actively following up on patient's adherence to treatment recommendation