The thorny question of how to provide appropriate care and support for the approximately 13 million Australians with a chronic condition is back on the agenda, amid claims the current ‘sick system’ is harming patients.

Development is now underway on a national strategic framework, intended to inform the design and implementation of the myriad policies underpinning chronic disease care around the country.

It comes amid a growing national chronic disease burden, with 50% of Australians now living with at least one chronic conditions and approximately 22% experiencing multimorbidity.

The upshot is a multibillion dollar drain on government coffers through spiralling health costs and impacts on patients including reduced access to employment, education and social activities, according to a Department of Health and Aged Care consultation paper.

“Chronic conditions are the leading cause of illness, disability and death in Australia and place a significant burden on the health system, says the paper (link here).

“Data from the National Hospital Morbidity Database in the 2021–22 period showed that 10 selected chronic conditions (arthritis, asthma, back problems, cancer, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, mental health and behavioural conditions, osteoporosis or osteopenia and selected heart, stroke and vascular diseases) contributed to 6 million hospitalisations, accounting for 52% of all hospital admissions.”

Potential areas for future focus highlighted by the paper include improved management of multimorbidity, better continuity of care across life stages and closing gaps as patients transition care as they move through the health system.

But key will be ongoing reform to models of care, which must be effective, evidence-based, person-centred and multi-disciplinary, the authors say.

“There are significant benefits for the patient if a team of health professionals from different disciplines (e.g., general practice, nursing, allied health) collaborate and communicate to address as many aspects of a patient’s care as possible.”

“Work underway on ‘Unleashing the Potential of our Health Workforce – Scope of Practice Review’ will support health practitioners to work to their full scope of practice, in turn supporting access to effective, integrated care.”

AMA president Professor Steve Robson said reform would need to become a top priority.

“Chronic conditions are placing an enormous strain on the healthcare system through increased costs and potentially preventable hospital admissions. We know prevention is much more than spending.”

In its submission, the AMA is calling for improved arrangements to support GP led well-coordinated multidisciplinary care for patients with chronic and complex disease.

“There is opportunity to build on MyMedicare to help streamline care, and to improve the management of patients with chronic conditions,” Professor Robson said.

“GPs are best placed to look holistically at patients but need support in leading a multidisciplinary approach to care, which is often frustrated by the complexity of the health system.”

“People with a chronic disease need top notch medical care from their doctor and also the involvement of a team with nurses, allied health and other supports. That team needs to be well connected, resourced and to truly work together.”

“We need more efficient arrangements that support the provision of well-coordinated multidisciplinary care for patients with chronic and complex disease.

Along with treating disease and risk factors, the AMA highlighted the impact of underlying social determinants of health in contributing to chronic disease.

The AMA submission noted that rates of chronic conditions and overall poorer health outcomes were far higher in Aboriginal and Torres Strait Island peoples, those experiencing socio-economic disadvantage, people in rural and remote areas and people from culturally and linguistically diverse backgrounds.

“All Australians deserve access to their usual doctor to prevent chronic disease and treat early signs,” Professor Robson said.

“We know the fixes for a sick system with chronic problems ― we just need to make the investment.

“Our health is not a cost to be managed, but an investment to be made. The lack of investment in prevention of chronic disease has resulted in a healthcare system that responds to poor health outcomes rather than actively preventing them.”