Defined Terms   Business Plan   Invitation Letter   Attachment    SWOT Analysis  
Annexure C (ii)(b)

© Australian Health Ministers’ Conference 2005
Action area: Self-management
Self-management is about people being actively involved in their own health care. All people with chronic disease self manage to some extent at all times, although the ability and resources to do this vary across the lifespan and at different stages of illness. Self-management principles aim to optimise people’s capacity to self manage throughout the continuum of chronic disease prevention and care.
Self-management requires the person, their family and carers, service providers and the health system working together to achieve better health outcomes. Self-management is underpinned by the person being at the centre of their own health care, and involves the skills and resources that a person needs to negotiate the health system and maximise their quality of life across the continuum of prevention and care.
Embedding the principles of self-management in the health system means that a person is supported by the system to: 
•	understand the nature of their illness including risk factors and co-morbidities
•	have knowledge of their treatment options and be able to make informed choices regarding treatments
•	actively participate in decision making with health professionals, family and carers, and other supports in terms of continuing care
•	follow a treatment or care plan that has been negotiated and agreed with their health care providers, family and carers, and other supports
•	monitor signs and symptoms of change in their health condition and have an action plan to respond to identified changes
•	manage the impact of the disease on their physical, emotional and social life and have better mental health and wellbeing as a result
•	adopt a lifestyle that reduces risks and promotes health through prevention and early intervention
•	have confidence in their ability to use support services and make decisions regarding their health and quality of life.
Self-management involves all the levels of the health system—individuals, their families and carers, service providers, health organisations, the wider health system and the community. Self-management principles must be firmly embedded throughout the continuum of chronic disease prevention and care, and this requires a major cultural shift in work practices and service delivery. 
Current approaches to self-management
A wide range of approaches can be used to develop and support self-management. Self help and internet based resources, telephone counselling, mentoring and peer based support have all been applied to helping people with chronic disease develop skills of problem solving, decision making, resource use, forming partnerships with service providers, planning, and self tailoring health actions and interventions to be personally relevant.49 
Comprehensive packaged programs to enhance self-management have also been developed and evaluated. Examples of these include the Flinders Model, which is a clinician led model that integrates self-management with medical management. This model emphasises the education and training of the primary health care workforce to help people with chronic illness achieve sustainable and longer term gains. It provides tools that enable health practitioners to support their patients to self manage.
The Stanford model focuses on peer leadership. People with chronic disease learn from each other through sharing experiences and collective problem solving within a group setting. This program has been extensively trialled in the Sharing Health Care Initiative, and is well established in most states and territories.
The Flinders and Stanford models are synergistic and complementary, and are offered jointly in some states and territories. However, evaluations have shown that the uptake of these program approaches is not optimal: the vast majority of people offered the programs do not enrol and most of those who do are women.50 
Other types of self-management approaches may be more attractive to men, and effective ways to adapt such approaches for Aboriginal and Torres Strait Islander peoples and people from culturally and linguistically diverse backgrounds need to be developed.
In practice, however, support for self-management is not established as an integral component of the health care system. To achieve this, a range of system supports need to be developed or enhanced, with recognition that self-management approaches are a valid and essential component of health care and adequate resourcing.
Future directions for self-management
Reorienting the health system to support self-management
Incorporating self-management within the health system requires a significant change in focus. Currently, funding for self-management approaches is set against an acute care system that, by virtue of its crisis response, tends to receive budgetary priority. In contrast, the longer term, collaborative and multidisciplinary planning that supports self-management encounters many systemic barriers.
Self-management should be routinely encouraged through all health care encounters. There are many opportunities in the development and progression of chronic disease to engage the person in learning and behaviour change. Health professionals need to be oriented toward this engagement and skilled at identifying and taking advantage of these opportunities. 
The ability of individuals to self manage is likely to be enhanced the earlier it is started. So, support for self-management should commence at the earliest possible opportunity, and include people at risk of disease and in the early stages of chronic disease.
All the entry points to the health care system provide opportunities to provide information and referral to other services that help people develop their skills for self-management. The roles of hospitals, community pharmacies, allied health services, Aboriginal health services, community health services and residential care in supporting self-management must be encouraged. 
Acute and specialist health professionals must also understand their responsibility to support self-management. These health services have a powerful impact on people’s confidence and ability to self manage, often seeing people at a time when they are most vulnerable and open to change.
Key direction 36: Encourage health care entry points to identify opportunities to 
actively promote self-management.
The attitudes and knowledge of many health professionals are significant barriers to the incorporation of self-management principles in the health care system. The health system requires a culture change, whereby training and recruitment procedures, as well as routine practice, give high priority to self-management principles. Health professionals must believe in people’s ability to learn self-management skills and understand their responsibility to support this learning in evidence-based and age relevant and culturally appropriate ways.
People’s adoption of self-management approaches is significantly affected by the quality of their health care relationships. Of special relevance are relationships with primary health care providers, particularly GPs. These are generally the health professionals with whom patients, and their families and carers, develop long term associations. The primary health care provider often coordinates the other health services a person with chronic disease requires over time, and so good communication is essential to optimising self-management across the disease continuum.
Key direction 37: Support curricula development, education and training strategies for 
health care providers to gain knowledge and skills to support self-management, so that 
self-management becomes part of routine clinical practice.
Effective self-management requires more than just providing information to patients and their families and carers. It is about having a collaboratively developed integrated care plan that recognises and prioritises patient decision making and responsibility for day to day health and related decisions and behaviours across the continuum of chronic disease prevention and care.
Care planning that supports self-management requires health care providers to work in collaboration with the patient and their family and carers to identify priorities, set goals and develop specific plans for achieving health goals. There must be ongoing follow up and collaborative problem solving, supported by feedback and reminders, for both service providers and patients.
Progress and outcomes should be measured via action plans that can be reviewed over time as to their effectiveness by the patient and their family and carers, as well as the health care providers.
Key direction 38: Ensure that self-management is part of clinical practice through its 
inclusion in multidisciplinary care planning.
Prioritising patient participation in care planning
Essential to self-management is active patient participation in health care decisions and planning. To enable this, patients must have the capacity to engage in such decisions, by having the right, knowledge, skills, pathways and confidence to be able to do so.
Approaches such as the Expert Patient Program in the UK51 provide models for supporting patient participation. Health services must have in place the policies, procedures and resources that enable patient participation. They must also help people to develop the skills that optimise their ability to participate in their own care.
Access to health records is an important component of patient participation. To progress this, the NSW Electronic Health Record will incorporate the patient held record ‘My Health Record’. Patients will have the ability to view and add to their records online and, thereby, be more involved in their health care.
Key direction 39: Promote the active involvement, and research into the barriers to 
such involvement, of patients, and their families and carers in care planning processes.
Improving the capacity of the peer, disability and carer support sectors
Self-management encompasses a range of daily behaviours, such as taking medicines, having an adequate diet, physical activity, hygiene, stress reduction and social support. Many of these behaviours relate to a broader set of attitudes, behaviours and skills that can include significant lifestyle changes related to risk factors. Self-management also includes coping with changes to life roles and aspirations, and accommodating long term engagement with the health system.
Health professionals have an important role in helping people to identify and achieve appropriate behavioural and lifestyle changes. However, such significant life change requires a wider system of support, beyond that provided by the health system.
Of particular importance are the peer, disability, carer and aged care support sectors. These sectors often take the lead role in developing self-management resources, yet they tend to be poorly resourced and not well integrated with other parts of the health system.
These sectors are also essential in providing psychosocial support and rehabilitation services for people with chronic disease, as well as providing support and respite for their families and carers, and these are essential elements of self-management.
Key direction 40: Improve the capacity of the peer, disability, and carer support sectors 
to provide support for self-management.
Tailoring self-management approaches to individual and community needs
Self-management approaches must be responsive to the unique needs of different individuals, communities and population groups, recognising that the provision of information or resources alone does not mean that people can or will access and use them.
People first need to be aware of and understand the role for self-management. They need information at a depth and level they can comprehend at that point in time. Additional help may be needed to identify barriers to behaviour change, along with support to attain the skills and resources to overcome these barriers.
A diverse range of strategies are required to optimise self-management for different population groups. The widespread preference of people to seek out alternative and complementary medicines must be acknowledged, along with the significant challenge of managing chronic pain. People must be able to adopt approaches that are personally relevant, but it is also essential that these are supported by evidence.
Ways to support self-management need to recognise the personal context of the person and their capacity to self manage. There may be age, financial, educational, literacy or cultural barriers to self-management. For example: children will require special support to develop their capacity to self manage in age appropriate ways as they mature; adolescents will tend to take up risk behaviours despite health warnings and this risk taking must be recognised; and prison populations have an entrenched culture of tobacco smoking.
For culturally and linguistically diverse populations, cultural differences in definitions of health and expectations around health care behaviours impact on self-management. Language barriers, the use of interpreters, and culturally inappropriate practice must be overcome to enable people from culturally and linguistically diverse background to develop the partnerships with health service providers that support the development of self-management skills.
Finally, the potential stigma of chronic disease, particularly in relation to some of its risk factors and co-morbidities (such as risky and high risk alcohol use and mental illness), can be powerful barriers to effective self-management. 
Communities, governments and the media must work together to provide living environments that support all community members to be actively and effectively engaged in their own health management across the disease continuum and across the lifespan.
Key direction 41: Tailor self-management approaches to the needs of target population 
groups, particularly for Aboriginal and Torres Strait Islander peoples, people who are 
socio-economically disadvantaged and young people.

Implementation actions 
The National Chronic Disease Strategy does not attempt to prescribe how the nationally agreed directions should be actioned at a jurisdictional or local level. Rather, practical implementation plans will need to be developed at national, State/Territory and Australian Government, regional and local levels that identify the priorities and actions relevant to each level.
Many states and territories have already developed their own specific chronic disease strategies, often adopting the framework put forward by the National Public Health Partnership52 and taking a ‘clustered approach’ to chronic disease. This approach acknowledges the common risk factors and co-morbid conditions that relate to a number of the major chronic diseases, and the value of ‘joined up’, or integrated action across different services, sectors and levels of planning.
Examples of leadership across jurisdictions include:
•	New South Wales Chronic Disease Strategy 2006–2009 and New South Wales Chronic Disease Prevention Strategy 2003–2007
•	The Integrated Health Promotion Resource Kit 2003 (Victoria)
•	Queensland Strategy for Chronic Disease 2005–2015
•	Chronic Disease: Prevention and Management Opportunities for South Australia, 2004
•	Chronic Conditions Framework for Western Australia 2005–2010 (unpublished)
•	Northern Territory Preventable Chronic Diseases Strategy
•	Tasmania: Strengthening the Prevention and Management of Chronic Conditions—Policy Framework
•	National Strategic Framework for Aboriginal and Torres Strait Islander Health 
2003–2013.
Concerted action and support to implement these strategies, as well as related national initiatives such as the National Service Improvement Frameworks and the National Mental Health Plan 2003–2008, are essential to achieving progress in chronic disease prevention and care.
However, there is need for increased and more coordinated action throughout Australia to meet the chronic disease health challenge in a timely and sustainable way. Endeavours at national, state/territory and local levels must work together to identify priorities, gaps and investment opportunities.
Of special significance is the need for progress through the following implementation actions.
Building workforce capacity
Fundamental to implementing the NCDS is a health workforce that has the capacity and skills to meet the needs for chronic disease prevention and care now and in the future.
Health workforce shortages have been a significant and emerging challenge for the health sector for some time. Workforce shortages currently exist across most of the key health professions, and these are expected to worsen in the future without effective solutions. Shortages vary according to locality, and although pervasive, are most pronounced in rural and remote regions.
The reasons for the shortages are complex, and solutions require a multi-faceted approach. A major need is to understand how structural, regulatory and funding arrangements (along with the activities of professional bodies) at both a state/territory and national level contribute to current shortages, and the changes that are required to enable supply to better match demand into the future.
Supplying a health workforce that can meet a local community’s needs for chronic disease prevention and care requires matching workforce roles (and underlying skills/competencies) to service delivery needs. It may also require more flexible approaches that enable better use of the current workforce. For example, the capacity of general practice could be strengthened by training and funding practice nurses, community nurses and allied health professionals to undertake some of the chronic disease prevention, detection and management interventions.
The capacity of the health workforce to provide multidisciplinary and integrated care must be a prime focus. This requires consideration of funding and structural arrangements, particularly for primary health care. The development of integrated primary health care networks and services will need to be examined and considered, as well as better support for primary health care providers, in the prevention, detection and management of chronic disease.
Special attention needs to be placed on the role of care coordinators for people with complex care needs. There is also a pressing need to develop the community health sector and community support organisations. Ways to improve access to specialist care, particularly in rural and remote areas, also needed to be considered.
Training and professional development for the current workforce and education for the future workforce needs to incorporate the competencies identified by the WHO for effective chronic disease prevention and care.48 Special emphasis needs to be placed on developing competencies in prevention and supporting self-management.
Accreditation and monitoring processes must be put in place to ensure best practice in chronic disease prevention and care. This will be enhanced through implementation of initiatives such as the National Service Improvement Frameworks and other guidelines for best practice. Better understanding of the cultural appropriateness of care needs to be built into guidelines.
Research and evaluation must also be supported to further develop the evidence base for the prevention, detection and management of chronic disease to inform the development of best practice.
Developing strategic partnerships
Strategic partnerships are required at a number of levels to implement the NCDS:
•	between different levels of government to identify common priorities and align directions for progress at national, state/territory and local levels
•	among relevant national health reform agendas and other national strategies (such as the National Mental Health Strategy and National Public Health Partnership initiatives) to identify common priorities and align strategies to achieve common aims
•	with peak bodies and national stakeholders to identify priorities and advocate for sustainable change
•	with education, training, accreditation and monitoring organisations to develop competencies, ensure standards, and identify and implement best practice
•	with communities, to identify and address local community needs related to chronic disease prevention and care 
•	among health, residential aged care and community services and organisations at local area/region/district levels to create models for formal arrangements and financial agreements to provide integrated chronic disease prevention and care
•	between public, private and non-government provided health, residential aged care and community services through better incentives, flexible funding arrangements and more collaborative planning
•	with patients and their families and carers, to ensure that the focus is on improved patient care and quality of life
•	between health and non-health sectors, services and industries.
Importantly, the health system cannot work in isolation from other sectors, services and industries. Many of the risk and protective factors for the development, progress and complications of chronic disease occur in the settings of everyday life. It is essential that environments for work, education, recreation and community living, along with all health services, support healthy lifestyle choices and reduce the risks for chronic disease.
While the health sector needs to take leadership, advocating, engaging and partnering with other sectors is essential. The significant and sustainable change that is required to achieve the objectives of the NCDS necessitates whole-of-government and whole-of-community approaches.
Enhancing investment and funding opportunities
Investment and funding opportunities need to be found to support and sustain the changes required to implement the NCDS.
A priority is examining flexible funding processes that will support primary health care networks and services to deliver coordinated chronic disease prevention and care. Mechanisms must be considered, including funding incentives, that support access to service arrangements that can provide person centred care that is integrated and multidisciplinary, and that incorporates self-management, health promotion and risk reduction. 
Investing in broadband infrastructure and other information technology infrastructure is essential to provide the foundations for quality and effective chronic disease prevention and care. Significant investment needs to occur in improving patient records so that they support the ‘patient journey’ by being person centred and appropriately shared across services.
Research investment is paramount across the continuum of prevention and care. Research needs to further the evidence base for health promotion, prevention, early detection and best practice management. Research findings must be effectively disseminated and used to inform the development of practice.
Developing infrastructure and information technology support
While there are significant advances in the development of infrastructure and information technology infrastructure, much more needs to be achieved in this area.
Agreed national data systems that can monitor population trends around the prevalence of chronic diseases, their risk factors and co-morbidities, and service use patterns must be urgently progressed. Regional breakdown of data should support local service planning and development. Data needs to be available at the regional and state/territory level for national reporting, including where possible de-identified service use by individuals over time.

Electronic service directories and regional and practice level registries that can be linked to care plans also need to be fast tracked. Information technology infrastructure must support patient registration and recall systems, implementation of unique patient identifiers, electronic referral and electronic health records.
Across all these information systems, agreed national standards are urgently required for secure data exchange and protection of privacy.
Further development and more widespread availability of tele-health approaches are needed to improve service access, particularly to specialist care, in rural and remote areas.
Continued development of protocols must ensure that chronic disease prevention and care is person centred, multidisciplinary, integrated over time and services, and incorporates self-management, health promotion and risk reduction. Agreed protocols and procedures for assessment, referral, intake/admission, discharge and transfer must support seamless transitions across health and community services over time for people of all ages, living situations, cultural backgrounds and levels of complexity of chronic disease. 

Evaluating progress of the National Chronic Disease Strategy
The National Chronic Disease Strategy will require a mechanism for determining whether its directions have been implemented, and whether these directions have been effective in achieving the objectives. An evaluation plan will need to be developed early in the NCDS to identify a set of performance measures to determine progress.
The evaluation plan should identify two types of performance measures: process indicators to show whether the processes have been put in place to implement each of the directions of the NCDS, and outcome indicators to show whether the objectives have been achieved. It will also be important to gather evidence of areas where additional actions are required to support implementation of the NCDS.
A manageable set of performance measures will need to be prioritised for collection. These must be developed with agreed definitions, standards and sources. They must be evidence-based, with appropriate reliability and validity, and robust enough to enable critical analysis. Both short term and longer term indicators will be required.
Process indicators related to the key directions of the NCDS will need to be developed. As the NCDS does not attempt to prescribe how the nationally agreed directions should be actioned at a jurisdictional or local level, process indicators need to be developed at the level of implementation. Process indicators must reflect the priorities and relevant actions implemented at designated levels—national, individual state and territory, regional and local.
Outcome indicators that show progress toward achieving the objectives of the NCDS will need to address both intermediate impacts, such as hospital readmission rates, and longer term outcomes demonstrating that:
•	chronic disease is being prevented or the onset delayed for individuals and population groups
•	the progression and complications of chronic disease have been reduced
•	the wellbeing and quality of life of individuals living with chronic disease and their families and carers has been improved
•	avoidable hospital admissions and health care procedures have been reduced
•	best practice in the prevention, detection and management of chronic disease has been achieved
•	the workforce has increased capacity to meet population demand for chronic disease prevention and care.
A process for collecting and collating the performance measures also must be determined. Wherever possible, the measures should be collated from available data collections to minimise the cost and burden of information collection.

A great deal of relevant information is already collected. For example, the triennial National Health Survey conducted by the Australian Bureau of Statistics collects data on:
•	indicators of health status (self assessed health status, health transition, quality of life scale, K10 scale to indicate psychological distress, long term conditions focusing in particular on asthma, diabetes, cardiovascular and cancer), and injuries
•	health related actions taken (visits to hospitals and day clinics, consultations with doctors, dentists and other health professionals, use of medications (for national health priority area conditions only), days away from work and other days of reduced activity)
•	health risk factors (smoking, alcohol consumption, diet, exercise, body mass, sun protection, breastfeeding, immunisation)
•	supplementary women’s health items (breast and cervical cancer screening practices, contraceptive/protective behaviours, hormone replacement therapy, breastfeeding history)
•	demographic and socio-economic characteristics.
The Australian Institute of Health and Welfare collates these and other data on the major chronic diseases and their risk factors, and has devoted a website specifically to this area.53 A useful addition to these data, however, would be a composite measure of the overall burden of chronic disease to act as a ‘ready reckoner’ to plot progress.
Another relevant national initiative is the National Health Performance Framework (NHPF), which provides a set of national health performance indicators, and has been prepared biennially since 2001 for the National Health Performance Committee (NHPC).54 
Through the NHPF, the performance of the Australian health system is reported against three tiers of indicators:
•	health status and outcomes—health conditions, human function, life expectancy and wellbeing, deaths (How healthy are Australians? Is it the same for everyone? Where is the most opportunity for improvement?)
•	determinants of health—environmental factors, socio-economic factors, community capacity, health behaviours, person related factors (Are the factors determining health changing for the better? Is it the same for everyone? Where and for whom are they changing for the worse)
•	health system performance—effective, appropriate, efficient, responsive, accessible, safe, continuous, capable, sustainable (How well is the health system performing in delivering quality health actions to improve the health of all Australians? Is it the same for everyone?).
The NHPF is being used by a number of jurisdictions in their own performance reporting, and its indicators are already being collected and collated.
In summary, many of the performance measures relevant to determining progress of the NCDS are currently available; however, other measures will require additional targeted data collections. Along with determining the measures to be collected, a mechanism for collating and reporting the performance measures at the national, state/territory and local levels must be established. Importantly, reporting must be timely and in a format that can be usefully interpreted. Widespread understanding of the progress of the NCDS will facilitate further action toward achieving its overall aim—to reduce the burden of chronic disease for individuals, communities and Australia as a whole.