National Strategic Framework for Chronic Conditions

Objectives

The National Strategic Framework for Chronic Conditions provides an eight-year national framework, from 2017 to 2025, to help all Australians live healthier lives through effective prevention and management of chronic conditions. It replaces the National Chronic Disease Strategy 2005 and associated service-improvement frameworks, while complementing existing state, national and international policies.[1]Its overarching purpose is to reduce the health, social and economic burden of chronic conditions through a consistent, integrated and non-disease-specific approach that addresses shared determinants, risk factors, multimorbidity and quality of life across the life course.[2][3]

• Focus on prevention for a healthier Australia, including action on shared behavioural and biomedical risks, social determinants and protective factors.[4][5]
• Provide efficient, effective and appropriate person-centred care so people with chronic conditions can optimise quality of life, with fewer complications, multimorbidities, disability and premature deaths.[6][7]
• Target priority populations experiencing disproportionate chronic-condition burdens and inequitable outcomes, including Aboriginal and Torres Strait Islander people, culturally and linguistically diverse communities, older people, carers, people facing socioeconomic disadvantage, rural and remote communities, people with disability or mental illness, and people who are or have been incarcerated.[8][9]
• Promote health and reduce risk through healthy lifestyles, health literacy, early identification of risks, evidence-based interventions and stronger prevention evidence.[10][11]
• Address critical life stages and transitions, from antenatal and early-life prevention through childhood, adolescence, adulthood and older age, recognising that developmental, social and environmental changes can affect health behaviours and risks.[12][13]
• Improve timely and appropriate detection and intervention through health checks, integrated risk assessment, evidence-based screening, referral pathways and follow-up, while reducing over-diagnosis, unnecessary procedures and avoidable costs to individuals and families.[14][15]
• Strengthen active engagement, continuity of care, accessible health services, secure information sharing and supportive systems that work around people’s needs.[6][16]
• Advance Aboriginal and Torres Strait Islander health by reducing chronic-condition disparities, supporting culturally safe and locally responsive services, and contributing to efforts to close the life-expectancy gap by 2031.[9][17]

Implementation

Implementation uses an outcomes-focused, systemic and person-centred model in which partners develop policies, strategies, actions and services within their respective responsibilities, charters and governance arrangements.[2][18]The Framework is designed to enhance existing activity, support innovative responses and coordinate national action without altering government responsibilities.[1]Its implementation is guided by equity, collaboration and partnerships, access, evidence-based practice, person-centred care, sustainability, accountability, transparency and shared responsibility.[19]

• Coordinate action across governments at national, state, territory and local levels; public and private health sectors; non-government organisations; industry; researchers; communities; individuals; carers and families.[1][20]
• Partner beyond the health sector with housing, education, employment, transport, environment and social services to address social, economic and environmental determinants of health.[1]
• Use Strategic Priority Areas and phased outcomes to support flexible implementation, comprising short-term Phase 1 outcomes, longer-term Phase 2 outcomes and aspirational outcomes; no uniform implementation timetable is set because partners are at different stages of progress.[4]
• Deliver prevention through coordinated interventions across populations, settings, sectors and life stages, including schools, workplaces, communities, general practice, online communications and urban environments.[5][11]
• Strengthen primary health care, multidisciplinary practice and integration between primary, community, acute, mental health, aged care and disability services, particularly for people with complex needs or multiple chronic conditions.[21][22]
• Improve access by addressing physical availability, affordability, cultural safety, acceptability, transport, remoteness, language and health-literacy barriers, including through clinically appropriate telehealth, videoconferencing, digital health, out-of-hospital and at-home services.[23][24]
• Support active participation in care through shared decision-making, personalised goals, integrated care plans, self-management, health-literacy support and advance care planning where appropriate.[25][26]
• Develop a trained, resourced and appropriately distributed workforce able to communicate effectively, use technology, work to full scope of practice and provide culturally competent care.[20][27]
• Enable secure information sharing, data linkage, research, knowledge exchange and evidence translation across national, state, territory, regional and local systems, including use of My Health Record and appropriate de-identified data.[27][28]
• Deliver targeted, community-led and culturally safe action for Aboriginal and Torres Strait Islander people, involving communities, Elders, leaders, Aboriginal Community Controlled Health Organisations, health professionals and peak bodies in service planning, design, implementation and evaluation.[17][29]
• Monitor progress at the levels of objectives, priority areas and outcomes, using example indicators and partner-level monitoring of relevant activities; example measures cover risk factors, morbidity, mortality, service access, patient experience, multimorbidity, disability and workforce measures.[4][30][7]
• Use data from bodies including the Australian Institute of Health and Welfare, Australian Bureau of Statistics and Commonwealth Department of Health, while recognising that some indicators are not routinely available and no single measure can capture Framework-wide impact.[31][32]
• Establish organisational reporting processes and contribute to nationally consistent performance measures and public reporting, aligned where feasible with World Health Organization reporting requirements under the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020.[33]
• Review the Framework every three years with partners, experts and jurisdictions, informed by progress against its objectives.[1][33]

Monitoring & Evaluation

The Framework adopts an outcomes-focused monitoring and accountability approach, combining objective-level measures of success, example indicators, partner-level monitoring and periodic review. Progress is intended to be assessed at the levels of the three Objectives, Strategic Priority Areas and their phased outcomes, recognising that no single indicator can capture the complex, long-term effects of chronic-condition prevention and management.[4]

• Use nationally agreed performance measures, where feasible aligned with Australia’s reporting commitments under the World Health Organization Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020, to support consistent monitoring of activities and achievements.[33]
• Monitor prevention through indicators of morbidity, mortality, disease burden and risk factors, including major chronic-disease mortality, cancer incidence, mental illness, disability, alcohol-related harm, smoking, diet, physical activity, blood pressure, blood glucose, cholesterol, overweight and obesity.[30]
• Track early-life and preventive-care measures, including smoking during pregnancy, low birth weight, breastfeeding, childhood tobacco-smoke exposure, developmental checks, immunisation, cancer screening, preventive drug therapy and counselling, and timely diagnostic follow-up after positive screening.[31][32]
• Assess Objective 2 through measures of health literacy, patient experience, care plans, chronic-disease and diabetes management, psychiatric follow-up, access and waiting times, potentially preventable hospitalisations, bulk-billing, out-of-pocket expenditure, unmet need, workforce availability, digital-health uptake, readmissions, multimorbidity, disability and premature mortality.[7][34]
• Measure Objective 3 using socioeconomic, behavioural, physiological, service-access, cultural-safety, workforce, accreditation, readmission, multimorbidity and disability indicators, including measures specific to Aboriginal and Torres Strait Islander people.[35][18]

Named data and indicator agencies include the Australian Institute of Health and Welfare, the Australian Bureau of Statistics, the Commonwealth Department of Health and, for some measures, the National Heart Foundation.[30][31][7]Some proposed measures are not routinely available, and the Framework identifies limitations in indicator comprehensiveness and data availability.[31][33]

Data infrastructure is a central implementation enabler. Consistent, quality data, secure real-time information sharing, data linkage, research, knowledge exchange and evidence translation are intended to support monitoring, service design, safety, quality improvement and policy development.[20][27][28]Partners are expected to establish organisational reporting processes and monitor and evaluate their own policies, strategies, actions and services against relevant outcomes, refining measures as more robust and relevant data become available.[4][33]

Continuous quality improvement and performance review may be undertaken by individuals and teams, with people living with chronic conditions engaged in monitoring and evaluating service performance.[28]Community participation in planning, design and evaluation is also integral to Aboriginal and Torres Strait Islander health and targeted action for priority populations.[29][36]Improved self-identification and health-system data collection are intended to strengthen the completeness and accuracy of Aboriginal and Torres Strait Islander health information.[17]

Formal national and state-level reporting is anticipated throughout the Framework’s life, supported by further collaborative development of a public reporting mechanism and companion document using existing work and available data.[33]The Framework is to be reviewed every three years during its 2017–2025 period, collaboratively involving Partners, experts and jurisdictions and informed by progress against its objectives.[1][33]Although principles include accountability, transparency and clear responsibilities, the supplied material does not set out a detailed reporting timetable, formal evaluation methodology, universal target values or a single named accountability body.[19][30][33]

Costing & Financing

The Framework presents prevention, coordinated care and efficient use of resources as essential to health-system sustainability, but does not establish a dedicated implementation budget, financing plan or quantified funding gap. Prevention is expected to generate long-term health and economic benefits and reduce health-related expenditure, while better chronic-condition management is intended to ease pressure on the health system.[37][5]

• Recognise that chronic conditions create high and potentially increasing expenditure through frequent and prolonged use of services and medicines, multimorbidity, rising treatment and medication costs, and increasing service demand.[21][3]
• Record estimated direct health-care expenditure of approximately 27 billion Australian dollars for selected costly chronic disease groups in 2008–2009, equal to 36 per cent of allocated health expenditure.[3]
• Recognise that the overall economic burden is likely to exceed this estimate because data do not cover all chronic conditions and may omit non-health costs such as residential care and lost productivity.[3]
• Allocate and distribute resources, including funding, adequately and efficiently over the long term according to identified health needs.[20]
• Use partnerships to improve resource efficiency, reduce duplication and support sustained approaches for identified populations.[12]
• Consider funding and incentives that account for access barriers, alongside innovative funding and care models that support coordination, flexible team-based care, telehealth and digital-health delivery.[23][24][27]

The Framework identifies financial barriers faced by people with chronic conditions, particularly where multiple medicines and services create travel, accommodation, support-service and unreimbursed-care expenses.[24]Timely and appropriate detection and intervention are also intended to reduce unnecessary procedures, excessive financial outlay and avoidable costs for individuals and families.[14]

Greater investment and sustained effort are identified as necessary for populations experiencing disproportionate chronic-disease burdens and inequitable outcomes, while investment in community empowerment is linked to resilience, ownership and sustained health improvements.[9][36]However, the supplied material does not specify programme budgets, funding sources, allocation amounts, financing mechanisms, resource-mobilisation targets, costing methods, funding gaps or quantified economic assumptions for implementing the Framework.[4][16][33]