Chronic disease self-management education programs: challenges ahead

The Australian Government budget for the 2006–07 financial year has an unprecedented provision for the implementation of chronic disease self-management education and training activities over the next 5 years. Major initiatives are outlined in Box 1.

The focus on self-management is not surprising given the burden of chronic disease in Australia and the shift in health policy towards patient-centred care. Chronic disease now contributes to over 70% of the disease burden in Australia, a figure that is expected to increase to 80% by 2020.4 The Australian Government has initiated a major focus on chronic disease through the National Chronic Disease Strategy, National Service Improvement Framework and the Blueprint for Chronic Disease Surveillance.1 At the policy level, self-management has risen to prominence through the National Chronic Disease Strategy. It is identified as one of four key action areas along with prevention across the continuum, strengthening early detection and early treatment, and integration and continuity of prevention and care.4 Current evidence suggests that patients with effective self-management skills make better use of health care professionals’ time and have enhanced self-care.5,6 Systematic reviews of the effectiveness of many self-management programs indicate clear clinical benefits for patients with conditions such as diabetes and hypertension, but not for arthritis (Box 2). However, such reviews are limited by the heterogeneity of interventions and outcomes.7-9

Governments have focused on formal self-management education programs to help patients engage in self-care. An example is the recent $36.2 million Australian Government Sharing Health Care Initiative, which explored the suitability of a range of education interventions (Box 3).10 Clear policy directions and the allocation of resources are positive steps towards integrating such activities within the health care system, but Australian policymakers need to take heed of outcomes from educational interventions in other countries if the proposed programs are to be viable.

In the UK, the attempt, since 2002, to integrate the Expert Patients Programme (EPP), an adaptation of the Stanford University chronic disease self-management program (Box 3), into the National Health Service (NHS) has had limited success.11,12 It was anticipated that the EPP would be a valuable option in the health care setting to help health professionals and patients to better manage chronic conditions.13 This seemingly has not been achieved. Future directions, outlined in a recent UK government white paper, Our health, our care, our say, provide for the transition of the EPP into a commercial community interest company to develop, market and deliver self-management programs.14 It is intended that the company will generate new and diverse programs that respond better to patient needs, as the recruitment of eligible patients from diverse backgrounds (eg, ethnic minorities and socially deprived groups) has, so far, been limited.12,14 Furthermore, the company will deliver programs in settings in which NHS organisations have been slow to engage.14

The current national policy focus and resource allocation towards chronic disease prevention and management provide a unique opportunity for real advancement in Australian public health. Self-management education programs are a vehicle for helping patients develop skills and techniques to enhance self-care of their chronic conditions. Based on what we have learnt from international experience, success will be dependent on several factors (Box 5). Engagement of and endorsement by health care professionals will be critical to ensuring that there are sufficient numbers of people who have the capacity to attend and sustain programs and benefit from them.

Such factors need to be addressed using a systematic approach across the health care system to improve coordination of care for patients with chronic conditions. The existing division of responsibilities and funding arrangements between federal and state governments promotes a demand-driven, “fee-for-service” health care system that fails to support the multidisciplinary approach needed for effective chronic disease care.

The Council of Australian Governments’ health services package has prioritised the enhancement of federal and state government primary care programs and services to reduce inefficiencies.1 However, the diversity of organisations and health care professionals involved in providing programs and services across states and territories requires a localised rather than a uniform approach to enhance service coordination.

Models such as Primary Care Partnerships, as adopted in Victoria, have facilitated the formation of alliances among health care agencies and professionals in both metropolitan and regional settings. These partnerships vary in structure and size, covering between two and four municipal/regional areas.19 Funding is provided to support partnership formation, establishment of structured referrals and information management processes to maximise patient access to services and programs. Such a model could be adapted to improve service coordination and facilitate education and training among health care professionals to support chronic disease management. However, networks would also need to encompass local acute sectors to ensure continuity of care. Funding from both federal and state governments could be devolved to dedicated coordinating agencies within the formal networks (eg, community health centres) to pool resources and oversee effective information transfer across networks to enhance a multidisciplinary care approach. Such formal networks would serve as a platform to help integrate self-management education programs across sectors.

Another important factor for optimising uptake of a range of self-management programs at the local level would be raising awareness among health care professionals and fostering their confidence in the quality of the programs. This is being addressed through a component of the Sharing Health Care Initiative, which is expanding a national quality and monitoring system using the Health Education Impact Questionnaire. The questionnaire, developed by the University of Melbourne, gathers and distributes information on the key indicators of successful self-management courses (Box 6).20 The data will provide local evidence on patient outcomes — an important factor in achieving the endorsement of health care professionals. Key barriers to and enablers for integration of self-management programs in Australia are highlighted in Box 7.

For self-management programs to be successfully integrated and sustained in Australian health care, new levels of cooperation through funds pooling and strategic planning between federal and state/territory governments are required. As self-management is only one component of chronic disease care, establishing formal regional alliances and networks across the health care continuum would facilitate primary health care reform and generate opportunities to integrate other chronic disease prevention and care initiatives. Failure to learn from international experience in future planning for self-management education programs in the Australian health care sector will mean that money may be wasted, and a valuable opportunity to generate real and rapid improvements in the quality of chronic disease care will be lost.

7 Barriers to and enablers for the integration of chronic disease self-management education programs into the Australian health care system