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Chronic conditions are ?health problems that require ongoing management over a period of years or decades? (WHO 2002). They include conditions in which lifestyle factors may increase risk, such as diabetes, cardiovascular disease, asthma and cancer, as well as mental disorders like depression and schizophrenia, and some communicable diseases such as HIV/AIDS. They also include physical disabilities, such as blindness or persistent pain, which can result from inadequate management of an existing chronic condition.
A WHO (2002) report states that health care systems were originally developed to respond to acute conditions, and are not well-suited to respond to patients presenting with chronic conditions, although these now take up the majority of health service resources. The report suggests that changes are needed at the macro (policy), meso (organisational /community) and micro (individual patient care) levels.
Baum (2008) outlines the development of the health care system and suggests that with the introduction of community health services in the 1970s, some steps were made towards improving chronic care management at the macro level. However, the Howard Coalition Government of 1996 ? 2007 emphasised individualism and personal responsibility, and supported increased privatisation of health services, measures which are unlikely to lead to improved health promotion or primary health care.
The current South Australian Government also appears to be taking a step away from chronic care self-management, at least as far as ?community? mental health services are concerned. Recently, mental health services have been separated from community health services and are now under separate clinical governance. The community mental health team accepts referral of clients with more serious and acute mental disorders. The team?s role is to assess, case manage, develop a care plan with the client (but according to a health service template) and discharge as soon as practicable. The mental health worker can refer the client to a non government organisation for psychosocial support from workers who may or may not have professional qualifications. IPRSS (Interpersonal Psychosocial Rehabilitation and Support Service) is one such scheme, but the psychosocial support is aimed specifically at assisting the client to reconnect with the community (perhaps one aspect of self-management) and is again supposed to be time-limited. Clients with less serious mental health problems may be referred by their GP to Medicare funded ?psychologists? (but actually workers with a range of professional qualifications who have counselling skills) for a set number of counselling appointments. One might wonder who the GP can refer to, in order that their patient with a chronic psychiatric disorder can receive self-management support.
At the micro level, Thille and Russell (2010) have demonstrated that different physicians can have differing interpretations of ?self-management?, from regular check ups, coupled with information and instructions (a top down approach) to collaboration with the patients and acknowledgement of their priorities, whether medical or not. The perspective of the individual worker, or the culture of the specific organisation can make a difference to the client outcomes, according to whether the person with the chronic condition is treated as a true partner in their care and supported to self-manage their condition, or whether they are just given advice by the health professional.
References
Baum, F. (2008) The New Public Health, 3rd Edn. Oxford University Press, South Melbourne, Victoria.
Thille, P. & Russell, G. (2010) ?Giving Patients Responsibility of Fostering Mutual Response-Ability: Family Physicians? Constructions of Effective Chronic Illness Management? in Qualitative Health Research 2010 20:1343.
World Health Organisation (2002) Innovative Care for Chronic Conditions: Building Blocks for Action. World health Organisation, Geneva.
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