Intended for healthcare professionals

Education And Debate

Rethinking management of chronic diseases

BMJ 2004; 328 doi: (Published 22 January 2004) Cite this as: BMJ 2004;328:220
  1. Richard Lewis, visiting fellow (,
  2. Jennifer Dixon, director1
  1. 1Health Policy, King's Fund, London W1G 0AN
  1. Correspondence to: R Lewis
  • Accepted 28 October 2003

Recent organisational changes to the NHS are bound to affect the care of patients with chronic diseases. But will they help or hinder?

Chronic disease represents a huge burden of ill health in the United Kingdom and a large cost to the NHS. Yet for many years government policy has focused on improving access to elective care. Recently, attempts have been made to improve the management of selected chronic conditions through the introduction of national service frameworks together with the associated activity of the NHS Modernisation Agency and the national clinical directors. But the NHS still has no agreed model for managing all chronic diseases. We aim to stimulate debate by suggesting some basic ingredients of good management of chronic diseases and examining how recent policies might influence their development and implementation in the NHS in England.

Basic ingredients of chronic disease management

Workers in chronic care have tried to develop a consensus on the basic ingredients of a model of good management for chronic disease. One model that has gained widespread credibility in the United States is the chronic care model.1 2 The model was constructed after a literature review and considering evidence from a large panel of national experts.3 It recognises that chronic care takes place within three overlapping “galaxies”: the wider community, the healthcare system, and the provider organisation. Box 1 shows the six main components of the model.

Although the importance of each component is likely to be familiar, the interest lies in putting them together in a coherent model. The chronic care model is used in over 500 healthcare organisations in the United States,4 and it has been shown to have positive effects. For example, a review of studies of diabetes management showed that interventions consistent with the chronic care model improved at least one process or outcome …

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