Queensland Strategy for Chronic Disease 2005-2015 promoting a healthier Queensland a partnership approach Queensland
Queensland Strategy for Chronic Disease 2005-2015 A partnership approach The Queensland Strategy for Chronic Disease 2005-2015 is being progressed under a partnership approach. Key partners represented on the steering committee include: Queensland Health Australian Government Department of Health and Ageing General Practice Alliance Queensland Divisions of General Practice Community Health Agency Group Centre for Primary Health Care, University of Queensland. Key informants include: Community Controlled Health Services expert clinicians public and private health service managers the private health sector District Health Councils Divisions of General Practice Queensland Government agencies non-government organisations peak representative groups consumer groups universities health insurance organisations local councils. Consultancy support has been provided by: Centre for Primary Health Care, University of Queensland The Cognitive Institute Australian Institute for Primary Care, La Trobe University. Queensland Strategy for Chronic Disease 2005-2015 ISBN 1-921021-13-6 Queensland Strategy for Chronic Disease 2005-2015 Published by Queensland Health December 2005 The State of Queensland, Queensland Health, 2005. Copyright protects this publication. However, Queensland Health has no objection to this material being reproduced with acknowledgment, except for commercial purposes. Permission to reproduce for commercial purposes should be sought from the Senior Administration Officer, Policy, Planning and Resourcing Division, Queensland Health, GPO Box 48, Brisbane QLD 4001.
Queensland Strategy for Chronic Disease 2005-2015 Table of contents Foreword... 3 Executive summary... 4 Introduction... 9 Defining the scope, goals and principles... 14 Scope...14 Goals...15 Principles...15 Context... 19 Burden of disease and behavioural risk factors in Queensland...19 Contemporary models of health care for preventing and managing chronic disease...21 Target populations...22 Methodology... 24 The Queensland conceptual framework for chronic disease prevention and management...25 Evidence-based interventions to prevent, detect and manage chronic disease...27 Strategies supporting activity across the health continuum... 28 System enablers... 28 Positive policy environment and community capacity...28 Health system organisation: quality health care services...29 Self-management...29 Information systems and decision support...30 Delivery system design: workforce...31 Strategies supporting activity at stages in the health continuum... 33 Primary prevention: preventing and reducing risk factors... 33 Overview...33 Raise community awareness and promote consistent messages...37 Encourage behaviour change that promotes health and wellbeing...37 Increase workforce capacity and infrastructure for action to reduce population risk factor levels...38 Create healthy environments...40 Focus on the early years of life, children and young people...41 Monitoring and surveillance, evaluation and intervention research...42 Secondary prevention... 42 Early detection and early management of disease markers...42 Management and tertiary prevention... 43 Management and the acute-primary health care interface...43 Palliative care...45 Rehabilitation...46 Implementation of the Strategy... 47 Evaluation of the Strategy... 49 Glossary... 54 List of footnotes... 63 1
Foreword Queensland Strategy for Chronic Disease 2005-2015 Foreword The Queensland Government has embarked on a major transformation of the public health system. We have committed a record $6.367 billion in just over five years to 2010-11, including $4.431 billion of new money. This funding will relieve immediate service pressures, provide more doctors, nurses and allied health staff, and identify smarter ways to deliver health services. Our renewal program follows on from the Queensland Health Systems Review. Peter Forster, who headed the Review, identified the need to balance acute hospital care with a stronger focus on prevention and early management of chronic disease. Our massive injection of funding will help Queensland Health to better promote healthy lifestyles to prevent or reduce illness, to identify disease earlier, and to better manage existing conditions. In this context, the Queensland Strategy for Chronic Disease 2005-2015 forms a critical component of the Queensland public health system s renewal. It is no secret that Queensland has the highest rate of preventable deaths of any state in Australia. More than one-third of all deaths in Queensland are the result of a chronic disease heart disease, heart failure, stroke, respiratory disease, diabetes and kidney disease that could have been prevented. An estimated seven in every 10 patients seen by a General Practitioner have at least one chronic disease. To keep Queenslanders healthier and help reduce these deaths, the Queensland Government has developed the Queensland Strategy for Chronic Disease 2005-2015, in partnership with a broad range of service providers and other stakeholders. This new Strategy helps prevent chronic disease by reducing risk factors like smoking, poor diet, lack of physical activity and alcohol misuse. For people with a chronic disease, the Strategy helps them identify and manage their disease earlier, and access services faster. When a person s disease is not properly managed, it can lead to unnecessary complications and hospital admissions. This new statewide Strategy involves the full spectrum of services involved in patient care from hospitals to General Practitioners, community health centres, and private and non-government health services. 2
Queensland Strategy for Chronic Disease 2005-2015 Foreword The Strategy helps all Queenslanders, but particularly those people who live in rural and remote areas, Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds, and people who are experiencing socio-economic disadvantage, who often have more risk factors and higher rates of chronic disease. The reform of our health system offers a real opportunity to improve the health of all Queenslanders by preventing or better managing chronic disease, encouraging greater personal responsibility for health and building partnerships with the Australian Government, the private sector, non-government organisations, the community and individual consumers. This is a first, but significant, step forward in helping to prevent and better manage chronic disease in Queensland. Peter Beattie MP Premier and Treasurer Stephen Robertson MP Minister for Health 3
Executive Summary Queensland Strategy for Chronic Disease 2005-2015 Executive summary The Queensland Strategy for Chronic Disease 2005-2015 (the Strategy ) is being progressed in partnership with the Queensland Government and key partners. This statewide Strategy aims to engage all stakeholders involved in the prevention, intervention and management of chronic diseases at a system, service and individual level across the continuum of care. It identifies evidence-based approaches to prevent or reduce behavioural and lifestyle risk factors, and support better care for people with chronic disease and their carers/families. The Strategy aims to address barriers to quality chronic disease care, address the current pressure on the acute hospital system by reducing avoidable hospitalisations, and identify more systematic and sustainable approaches to the prevention and management of chronic disease across Queensland. The Queensland Government, through the Smart State: Health 2020 Directions Statement, 1 has identified the prevention and management of chronic diseases as one of its major strategic priorities for the coming decade. In Queensland, cardiovascular disease (coronary heart disease, heart failure and stroke), chronic respiratory disease (chronic obstructive pulmonary disease (COPD) and asthma), type 2 diabetes mellitus, and renal disease account for a significant proportion of morbidity experienced by the population and for more than one-third of all deaths in the state. Depression as a co-morbidity to these chronic diseases also affects the functioning and quality of life of affected people. Poor nutrition, physical inactivity, tobacco smoking and alcohol misuse are four common underlying risk factors associated with these diseases. The Strategy will manage the current and growing pressures on the health care system both now and in the future, and address the impact of chronic diseases and risk factors on individuals, families and communities in Queensland from 2005 to 2015. A significant priority is to better manage the care for people who already have chronic diseases and avoid hospitalisation wherever possible. Concurrent investment is also required around the strategies to achieve longer-term outcomes of reduced prevalence and incidence. The goals of the Strategy are to: reduce avoidable hospital admissions in the short-term improve the quality of life for people with chronic disease in the short-to-medium-term reduce the incidence and prevalence of chronic disease in the medium-to-longer-term. 1 Queensland Health. Smart State: Health 2020 Directions Statement. Brisbane: Queensland Health, 2002. In parallel with the development of the Queensland Strategy for Chronic Disease 2005-2015 is the development of three place-based initiatives in North Lakes and surrounds, Logan-Beaudesert, and Innisfail. These initiatives focus on producing integrated service delivery models at the local level across the continuum of care. The goal of the three place-based initiatives is to develop a new way of working which engages a range of public and private providers in partnership to address the health needs of local populations. To fully achieve the goals of the Strategy and the place-based initiatives, a collaborative approach is required which needs to be supported by all partners in the Queensland health sector, including the Australian Government, other Queensland government departments, public and private health professionals, nongovernment and community organisations, consumer representatives and the academic sector. 4
Queensland Strategy for Chronic Disease 2005-2015 Executive Summary The concept of partnership is fundamental to driving the implementation of the Strategy. In this context, partnerships are required at a number of levels. Reflecting the current Australian health system, these partnerships will operate at the government-to-government level (including federal, state and local levels), across government at the state level, and across service providers at the local level (testing of different approaches to partnership is occurring in the three place-based initiatives). The health of a population is determined by a broad range of environmental, psychosocial and behavioural determinants. However, the Strategy focuses, in particular, on those gains that can be made in relation to chronic disease, through: improved primary prevention of risk factors better integrated early detection and management of risk factors and disease markers (secondary prevention) effective management of existing disease and prevention of complications (tertiary prevention). System enablers and evidence-based strategies at the individual and wholeof-population levels are being implemented to improve the prevention and management of chronic disease, particularly addressing the needs of various groups including Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds and people from rural and remote areas. The Strategy incorporates a range of approaches that contribute to preventing disease and promoting health for all Queenslanders, by: including both population-wide and at-risk group approaches involving sectors working together at national, state and local levels focusing on and addressing key risk and protective factors addressing lifestyle and behavioural risk factors addressing equity issues in relation to people in low socioeconomic circumstances, Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds and people from rural and remote areas taking a life-course perspective. The implementation of the Strategy will support better access to primary health care, improve and support an integrated and coordinated approach to preventing common risk factors and provide more efficient and targeted use of health resources across the health continuum. 5
Executive Summary Queensland Strategy for Chronic Disease 2005-2015 In order to progress the Strategy, a number of key areas have been identified: Strategies supporting activity across the health continuum System enablers Positive policy environment and community capacity 1. Enhance positive policy environment and community capacity through governance arrangements and partnerships with key stakeholders Health system organisation: quality health care services 2. Create mechanisms that promote safe, high quality care Self-management 3. Empower and prepare individuals to manage their health and health care Information systems and decision support 4. Organise information systems and decision support to facilitate efficient and effective care Delivery system design: workforce 5. Recruit, develop and retain an appropriately skilled workforce Strategies supporting activity at stages in the health continuum Primary prevention: preventing and reducing risk factors Raise community awareness and promote consistent messages 6. Implement and evaluate social marketing campaigns 7. Disseminate and promote evidence-based guidelines for targeted population groups Encourage behaviour change that promotes health and wellbeing 8. Enhance effective quit smoking strategies 9. Implement Aboriginal and Torres Strait Islander anti-smoking strategies 10. Expand the reach of effective alcohol harm reduction programs 11. Increase the availability of group-based, behaviour change, healthy lifestyle interventions 12. Extend the availability and sustainability of evidence-based physical activity and nutrition programs and interventions across identified priority settings and target population groups 6
Queensland Strategy for Chronic Disease 2005-2015 Executive Summary Increase workforce capacity and infrastructure for action to reduce population risk factor levels 13. Increase the workforce to undertake campaign support and prevention activities in relation to alcohol and tobacco 14. Enhance alcohol treatment capacity 15. Extend geographic reach and dose of evidence-based primary prevention nutrition and physical activity interventions 16. Disseminate and promote evidence-based practice and strategies to the workforce 17. Enhance primary health care capacity to provide lifestyle and behavioural risk factor advice and support Create healthy environments 18. Encourage acceptance and compliance with legislation relating to the sale and use of tobacco products and increase enforcement capacity 19. Implement the Queensland Health Smoking Management Policy 20. Encourage acceptance and compliance with legislation relating to the sale and use of alcohol 21. Improve access to, and availability of, healthy foods throughout Queensland, particularly in rural and remote areas, by implementing initiatives under the food supply priority action area of Eat Well Queensland 2000-2012: Smart Eating for a Healthier State and supporting the national food supply in remote areas project 22. Implement coordinated cross-sectoral approaches to address physical activity at the state, regional and local levels Focus on the early years of life, children and young people 23. Provide information and support to parents in relation to smoking, poor nutrition, physical inactivity and excessive alcohol consumption 24. Improve the nutritional health of mothers, infants and children 25. Coordinate implementation and evaluation of the Smart State Healthy Weight in Children and Young People Action Plan: Eat Well, Be Active Healthy Kids for Life 26. Implement strategies to prevent young people from smoking Monitoring and surveillance, evaluation and intervention research 27. Advocate for, implement and enhance risk factor monitoring and surveillance 28. Implement evaluation and intervention research findings from the three place-based initiatives and three demonstration projects for healthy weight Secondary prevention Early detection and early management of disease markers 29. Enhance primary health care capacity to implement a coordinated, systematic approach to opportunistic early detection and management of disease markers that targets vulnerable/at-risk populations 7
Executive Summary Queensland Strategy for Chronic Disease 2005-2015 Management and tertiary prevention Management and the acute-primary health care interface 30. Support improvements in acute management and care coordination within and across services Palliative care 31. Support the development and implementation of a statewide, integrated framework for palliative care Rehabilitation 32. Increase the capacity of the rehabilitation sector to provide timely, coordinated and integrated cardiac, stroke and pulmonary rehabilitation services Implementation Implementation of the Queensland Strategy for Chronic Disease 2005-2015 requires significant reform of current practice by all partners, support for change-management and new investment. Funding of $155 million has been allocated towards the implementation of the Queensland Strategy for Chronic Disease 2005-2015 for the period 2005-2009. In addition, components of the budget for Aboriginal and Torres Strait Islander Peoples health, the cancer budget (tobacco component) and the budget for cardiac services will support implementation. A governance mechanism representative of key partners will be established to provide guidance and accountability for implementation of the Strategy. Evaluation of the Strategy The development and application of an evaluation framework is critical to measure performance, including effectiveness, efficiency and outcomes of the Strategy. An evaluation framework, developed by the Centre for Primary Health Care, University of Queensland, in consultation with a multi-stakeholder working group, is being used to monitor the process, impact and outcomes of the strategies against the predetermined three- and 10-year goals. 8
Queensland Strategy for Chronic Disease 2005-2015 Introduction Introduction The prevention and management of chronic disease and the risk factors that underpin its development is a major health priority for Queensland over the next decade. The Queensland Strategy for Chronic Disease 2005-2015 is being progressed by the Queensland Government and key partners to identify ways to prevent or reduce lifestyle and behavioural risk factors and support better care for people with chronic disease. The Strategy has many aims including addressing the current pressure on the acute hospital system by avoiding hospitalisations, addressing barriers to good chronic disease care, and identifying strategies to support more systematic and sustainable approaches to the prevention and management of chronic disease across Queensland. In Australia, there is a lack of consensus on what constitutes chronic disease. The Consultation Draft of the National Chronic Disease Strategy identifies that chronic diseases usually: have complex and multiple causes have a gradual onset are long-term and persistent, leading to a gradual deterioration of health occur across the life cycle, although they become more prevalent with older age compromise quality of life through physical limitations and disability are the most common and leading cause of premature mortality, although they may not be immediately life threatening. 2 The Strategy focuses on a number of chronic diseases that significantly affect Queenslanders, namely type 2 diabetes mellitus, cardiovascular disease (coronary heart disease, heart failure and stroke), chronic respiratory disease (chronic obstructive pulmonary disease and asthma) and renal disease. Depression is also included as a co-morbidity of these chronic diseases. The Strategy also focuses on the prevention of common risk factors that significantly contribute to the development of these chronic diseases, including tobacco smoking, poor nutrition, physical inactivity and alcohol misuse. To reduce the burden that chronic disease places on the Queensland population and its health system, better chronic disease prevention and management is needed. Queensland Health and partners recognise the need for more flexible service delivery models. Also recognised is the need for health workforce realignment to meet changing patterns of service delivery and to respond to community expectations. These outcomes will be realised by supporting and improving the capacity of the community and individuals to prevent and better manage risk factors and established chronic disease. The Strategy identifies key statewide chronic disease prevention and management strategies that have emerged following a review of current evidence and a series of expert advisory and multi-stakeholder consultation workshops conducted across Queensland. It is intended that these strategies will be used by policy makers, health care providers, public health specialists, the wider health community, the non-government sector and consumers, to reduce the impact of chronic diseases and their risk factors and to improve the quality of life for Queenslanders with, or at risk of developing, chronic disease. 2 Australian Government Department of Health and Ageing. Consultation Draft of the National Chronic Disease Strategy. May-June 2005. Canberra: Australian Government, 2005. 9
Introduction Queensland Strategy for Chronic Disease 2005-2015 Death rates due to coronary heart disease (CHD) in Queensland (2000-2002) are the highest of the Australian states. Queensland also has relatively high rates of smoking, risky drinking, physical inactivity and obesity.* * Australian Bureau of Statistics. Australian Social Trends 2004. ABS Cat. No. 4102.0. Canberra: Australian Bureau of Statistics, 2004. 3 Queensland Health. Smart State: Health 2020 Directions Statement. Brisbane: Queensland Health, 2002 4 Queensland Health. Health Determinants Queensland 2004. Brisbane: Queensland Health, 2004. In Australia, as in many other countries, chronic disease is a major contributor to the burden of disease. Factors contributing to this increasing burden of disease include an ageing population, increasing prevalence of lifestyle and behavioural risk factors, improved survival from advances in treatment and an increased prevalence of some chronic diseases. The burden of chronic disease is shared unequally across the population. People in low socioeconomic circumstances, Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds and people from rural and remote areas have higher levels of disability, morbidity and mortality from chronic disease, compared to the rest of the population. In Queensland, cardiovascular disease, chronic respiratory disease, type 2 diabetes mellitus and renal disease account for a significant proportion of morbidity experienced by the Queensland population and more than one-third of all deaths in the state. The Queensland Government, through the Smart State: Health 2020 Directions Statement, 3 has identified the prevention and management of chronic disease as one of its major strategic priorities for the coming decade. The health system in Queensland is experiencing a number of system pressures resulting from both increasing demands on services and constraints on their supply. The factors increasing demand include increasing dependency of public sector patients, the growing impact of chronic and complex medical caseloads, and the need for sub-acute care, rehabilitation and step down provisions. The factors constraining supply include the ageing of the workforce, an inflexible labour market, inequitable distribution of the workforce and strong international competition for health professionals. Many factors determine and influence health. It is now understood that health status results from a complex interaction of social, economic, environmental, behavioural and genetic factors. 4 Health determinants are those factors that have either a positive or a negative influence on health at the individual or population level. Health determinants can be broadly divided into upstream determinants (education, employment, income, living and working conditions), midstream determinants (health behaviours, supportive environments and psychosocial factors) and downstream determinants (physiological and biological factors). The influences on the health of Queenslanders go well beyond the scope of health agencies. The work of many government and non-government agencies, industry and community groups impacts directly and indirectly on the health of Queenslanders. There is now good evidence that a range of interventions are effective in preventing chronic disease and in promoting health and wellbeing through action on the broad range of determinants of health and ill-health. The key challenges are to ensure that these interventions are ongoing and system-wide, and at a level sufficient to achieve broad based population-wide outcomes, as well as reduce health inequalities across population sub-groups. In parallel with the Strategy is the implementation of three place-based initiatives in North Lakes and surrounds, Logan-Beaudesert, and Innisfail. These initiatives are producing integrated local service delivery models spanning the continuum of care. They are developing new ways of working to engage a range of public and private providers, other key organisations, individuals, their families and carers, working in partnership to address the health needs of the local populations. 10
Queensland Strategy for Chronic Disease 2005-2015 Introduction The scope of the Strategy means that most interventions relate primarily to midstream and downstream determinants of health. Many of the upstream determinants, whilst fundamental to health status, are not specific to the Strategy. Nevertheless, the need for whole-of-government action in relation to education, employment, income, living and working conditions, given their potential influence on chronic disease prevalence, is acknowledged. To fully achieve the goals of the Strategy and the place-based initiatives, a collaborative approach is required and needs to be supported between all partners in the Queensland health sector, including the Australian Government, other Queensland government departments, public and private health professionals, non-government and community organisations, consumer representatives and the academic sector. Queensland Health is working with a range of partners across the continuum from prevention through detection to management, rehabilitation and palliation. Prevention of the lifestyle and behavioural risk factors at the whole-of-population level requires a whole-of-government approach. Detection, management, rehabilitation and palliation require integration across all health service providers, including the public, private and non-government health sectors. The Strategy serves as the framework for building and strengthening a system-wide response to prevent and reduce the impact of chronic disease in Queensland. An initial priority is to better manage the care for people who already have chronic diseases and avoid hospitalisation where possible. It is also important to invest in strategies that will achieve longer-term outcomes of reduced prevalence and incidence of chronic disease. Primary health care settings are a major focus for the management of chronic diseases. In the past decade, there have been a number of Australia-wide initiatives that have sought to improve the prevention and management of chronic diseases and their risk factors in primary health care settings. These include the development of the Smoking, Nutrition, Alcohol, Physical Activity (SNAP) Framework for General Practice, the Coordinated Care Trials, Enhanced Primary Care, and the Sharing Health Care Initiative, with its focus on improving selfmanagement. There have also been national and state public health strategies for smoking, alcohol, nutrition and physical activity, conducted under the auspices of the National Public Health Partnership and the Intergovernmental Committee on Drugs. Queensland has rates that are higher than the national average for mortality avoidable through primary, secondary and tertiary prevention, for both men and women (see Figure 1). The level of overall preventable mortality is twice as high in men as it is in women. The largest differential is for primary prevention, suggesting that targeted efforts to reduce behavioural risk factors such as tobacco smoking, physical inactivity, poor nutrition and excessive alcohol consumption would result in significant improvements in mortality rates. 11
Introduction Queensland Strategy for Chronic Disease 2005-2015 Figure 1 Primary, secondary and tertiary avoidable mortality: Age-standardised mortality rates for males and females, 2001 Queensland and Australia Source: Harper C, Cardona M, Bright M, Neill A, McClintock C, McCulloch B, Hunter I, Bell M (2004) Health Determinants Queensland 2004. Brisbane: Queensland Health. Queensland has drawn on the learnings from chronic disease initiatives federally and in other states and territories, including: New South Wales NSW Chronic Disease Prevention Strategy 2003-2007 Victoria Integrated Health Promotion Resource Kit; Primary Care Partnerships Strategy 2004-2006; Hospital Admission Risk Program (Victoria) South Australia Chronic Disease: Prevention and management opportunities for South Australia Northern Territory NT Preventable Chronic Disease Strategy National Health Priority Action Council National Chronic Disease Strategy. The Queensland Strategy for Chronic Disease 2005-2015 provides an overarching, consistent and practical framework for the prevention, diagnosis and management of chronic disease by identifying and implementing evidence-based strategies at the individual, whole-of-population, and system levels in Queensland. Full documentation, plus a summary is available on the Queensland Health website at http://www.health.qld.gov.au/publications/corporate/chronstrat2005/default.asp An action plan will guide implementation of the Strategy and will be available on the website from early 2006. 12
Queensland Strategy for Chronic Disease 2005-2015 Introduction Other related national policies include: Smoking, nutrition, alcohol and physical activity: Smoking, Nutrition, Alcohol, Physical Activity (SNAP) Framework for General Practice National Tobacco Strategy 2004-2009: The Strategy Eat Well Australia 2000-2010 National Alcohol Strategy: A Plan for Action 2001 2003/04 Be Active Australia: A Health Sector Framework for Action 2005-2010 Child and Youth Health: A Strategic Policy Framework for Children s and Young People s Health 2002-2007 National Agenda for Early Childhood 2004 National Public Health Strategic Framework for Children 2005-2008 Aboriginal and Torres Strait Islander Health: National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003 Productivity Commission s Strategic Framework for Overcoming Indigenous Diseases Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2004-2009 National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000-2010 Other related state-level policies include: Smoking, nutrition, alcohol and physical activity: Towards a Smoke-Free Future: Queensland Tobacco Action Plan 2005-2010 (draft) Eat Well Queensland 2002-2012: Smart Eating for a Healthier State Finding the Balance: Queensland Alcohol Action Plan 2003/2004 2006/2007 Meeting the challenges of substance misuse A strategy addressing the misuse of substances, including alcohol, in Aboriginal and Torres Strait Islander Queensland 10,000 Steps Active-Ate Child and Youth Health: Get Active Queensland Children and Young People Strategy - Smart State Healthy Weight in Children and Young People Action Plan: Eat Well, Be Active Healthy Kids for Life Aboriginal and Torres Strait Islander Health: Queensland Implementation Plan for the National Strategic Framework for Aboriginal and Torres Strait Islander Health Framework for Action by Governments Strategic Policy for Aboriginal and Torres Strait Islander Children and Young People s Health 2005-2010 Queensland Health s Indigenous Environmental Health Strategy 2001-2006 Multicultural Health: Multicultural Queensland: making a world of difference Queensland Government Multicultural Policy 2004 Report on the review of the implementation of the Queensland Health Multicultural Policy Statement and the Queensland Health Language Services Policy Statement 13
Introduction Queensland Strategy for Chronic Disease 2005-2015 Defining the scope, goals and principles Scope The Strategy guides the approach and direction taken at a system level in Queensland to prevent and manage chronic disease. The following chronic diseases have been identified as the focus for initial action: cardiovascular disease (coronary heart disease, heart failure and stroke) type 2 diabetes mellitus renal disease chronic respiratory disease (chronic obstructive pulmonary disease (COPD) and asthma). It is envisaged that increased coordination and integration across services and sectors, and the implementation of evidence-based management programs will yield better health outcomes for a much broader range of chronic diseases. Mental health problems, particularly depression, often co-occur with chronic disease. Depression, as a co-morbidity of these chronic diseases is considered within the Strategy, and a number of guiding principles have been developed to improve the psychological wellbeing of people with chronic disease. Other mental health problems and mental illness are being addressed through implementation of the Ten Year Mental Health Strategy for Queensland, 5 the Queensland Mental Health Strategic Plan 2003-2008 6 and implementation at the state level of the National Mental Health Plan 2003-2008. 7 The immediate underlying lifestyle and behavioural risk factors for the chronic diseases being addressed through the Strategy are: poor nutrition physical inactivity alcohol misuse tobacco smoking. System enablers and evidence-based strategies at the individual and wholeof-population levels are being implemented to improve the prevention and management of chronic disease, particularly addressing the needs of various groups including Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds and people from rural and remote areas. 5 Queensland Health. Ten Year Mental Health Strategy for Queensland. Brisbane: Queensland Health, 1996. 6 Queensland Health. Queensland Mental Health Strategic Plan 2003-2008. Brisbane: Queensland Health, 2003. 7 Australian Health Ministers. National Mental Health Plan 2003-2008. Canberra: Australian Government, 2003. 14
Queensland Strategy for Chronic Disease 2005-2015 Introduction Goals By 2008: Demonstrate that the implementation of evidence-based strategies is on track as per endorsed resourced plans Improve the quality of life for people with the chronic diseases in scope Demonstrate a reduction in the number of avoidable admissions to hospital. By 2015: Reduce the age-standardised incidence and prevalence rates of the chronic diseases in scope, and their immediate underlying lifestyle and behavioural risk factors Improve the quality of life for people with the chronic diseases in scope. Principles The Queensland Strategy for Chronic Disease 2005 2015 provides an overarching framework at the statewide level to outline key directions for building and strengthening a system-wide response to the prevention and management of chronic disease. Within this overarching framework, the following guiding principles have been identified that underpin the development and delivery of all components within the Strategy, and provide an impetus for effective chronic disease prevention and management activities across the continuum. Achieving respectful and committed person-centred care and optimal self-care Person-centred care respects and positions people at the centre of care, including their interaction and experience with the health system, for a particular episode of care, in different clinical settings and across the course of life. The person is seen as an integral part of the process of care and an expert on his or her own experience of illness. Chronic disease affects families, carers and the wider community. A person-centred approach to care supports respect, dignity and autonomy and promotes informed decision-making. Self-management and empowerment of people in managing chronic illness is essential in achieving person-centred care and optimal self-care. The person is part of the team of healing and integral to the healing itself, not just the subject of service delivery from the health system. Encompassing prevention and the continuum of care The Strategy encompasses primary, secondary and tertiary prevention, as well as all aspects of the continuum of care, including identifying and minimising risk at the population level, early detection, management (including self-management approaches and reducing disease progression and associated complications), rehabilitation, and end of life care. Integrating appropriate prevention activities is a key consideration at all stages of this continuum. The full range of health settings (for example primary and community care, Aboriginal and Torres Strait Islander primary health care services, hospitals, more specialised care) and other sectors is being embraced. 15
Introduction Queensland Strategy for Chronic Disease 2005-2015 Providing the most effective interventions Effective interventions are those that achieve the desired outcome, based on the best available evidence at the time. They are also frequently amenable to modification to suit the context of a particular individual, family or community. The provision of effective interventions has the capacity to delay the progression of the disease, the onset of complications and disabilities including co-morbidities, reduce hospitalisations, improve quality of life, and maintain participation in the workforce, functional capacity and independence. Addressing the needs of disadvantaged groups The particular needs of disadvantaged groups in accessing and receiving effective interventions is addressed, recognising their specific cultural, physical, and emotional needs. Disadvantaged groups might include Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds, people living in rural and remote areas, people from socioeconomically disadvantaged backgrounds, frail older people, people with a psychological or mental health disorder and people with a disability. Promoting integrated multidisciplinary care Integrated care recognises both the total care and support needs of people with chronic diseases or those at risk of developing these diseases, including consideration of care planning, psychosocial issues, co-morbidities and regular monitoring and reviews. Integrated care also recognises the importance of other sectors in the development, care and community response to chronic disease. The focus is on health professionals and health services working together in an integrated, seamless, and coordinated way and enhancing the interface between health and other sectors. Working together in partnership and collaboration Effective interventions for the prevention, early detection and timely management of chronic disease require commitment and goodwill from the community, government, non-government and private sectors. Chronic disease prevention and management requires the establishment of partnerships on a number of levels. This includes partnering with people with chronic disease, their families and carers, their communities and other service providers involved in their care. 8 Working in partnership and collaboration creates the environment and provides opportunities to embed the Strategy in a sustainable way. Respect for the contributions of each stakeholder by the others is vital. Building on current best practice models The Strategy builds on, and is informed by, current international, national, state and territory-based initiatives, and promotes practical evidence-based approaches to prevention and management of chronic disease. However, innovative and new approaches that might produce potential benefits are also sought and encouraged. 8 World Health Organization. Preparing a Health Care Workforce for the 21st Century. The Challenge of Chronic Conditions. Geneva: WHO, 2005. 16
Queensland Strategy for Chronic Disease 2005-2015 Introduction Principles for psychological health The Strategy embraces a number of guiding principles to improve the psychological wellbeing of people with chronic disease. These include understanding that: the development of a chronic disease is a challenge to the psychological and social wellbeing of the individual and their family it is important to appreciate that the meaning of illness and the personal experience of illness can differ between people, even though they may have the same physical condition people respond to the diagnosis of chronic disease in different ways depending on their prior psychological and social health. Therefore, some people are more at risk of adverse psychological responses than others with the same condition depression and anxiety are common experiences associated with chronic disease, and can be either pre-existent to, or a consequence of, the presence of a chronic disease depression itself is a risk factor for some chronic diseases, and can affect adherence to medical regimes, the effectiveness of care, the potential speed of recovery and increase the risk of poor outcomes effective and high quality care for people with chronic disease must incorporate assessment of psychological and social health status and appropriate responses where these are adversely affected training for staff in providing care for people with chronic disease must incorporate recognition of, and appropriate skills development in responding to, psychological distress self-management frameworks will incorporate the need to foster resiliency, one aspect of which is development of self-efficacy self-management frameworks need to recognise that psychological and social wellbeing also involves family and community to effectively manage chronic disease, practitioners need a high sensitivity to the potential presence of depression and anxiety. This should include the use of appropriate screening questions for psychological distress in relevant clinical pathways or care environments, for example, during acute inpatient and rehabilitation care routine assessment of all people with chronic disease should include a psychological assessment to ascertain strengths and vulnerabilities, and referral to appropriate available services where indicated health care managers should recognise the prevalence and impact of depression upon chronic disease by endeavouring to ensure the availability of appropriate services to treat depression in people with chronic disease for whom they are responsible pathways of care must describe appropriate response processes for people identified with potential significant psychological distress effective communication in chronic disease management includes demonstrating to the person with chronic disease a willingness to discuss psychosocial issues effective person-centred communication includes discussions of aspirations and the reality of potential recovery, as well as including the person in a collaborative team by sharing sufficient relevant information, to maximise the chance that the person will self-manage their condition. 17
Introduction Queensland Strategy for Chronic Disease 2005-2015 Principles for Aboriginal and Torres Strait Islander Peoples The Strategy is supported by complementary national and state-level health policy initiatives and developments, including the National Strategic Framework for Aboriginal and Torres Strait Islander Health: Framework for Action by Governments 2003. This Framework highlights nine principles required when planning and delivering services to Aboriginal and Torres Strait Islander peoples, namely: cultural respect an holistic approach to health including attention to physical, spiritual, cultural, emotional and social wellbeing, community capacity and governance whole-of-health-sector responsibility community control of primary health care services government, non-government and private organisations within and outside the health sector working in partnership with the Aboriginal and Torres Strait Islander health sector decision-making capacity devolved to local Aboriginal and Torres Strait Islander communities promoting good health through health promotion and illness prevention activities building the capacity of health services and communities to respond to health needs and to take responsibility for health outcomes accountability for health outcomes and effective use of funds by community controlled and mainstream services. 18
Queensland Strategy for Chronic Disease 2005-2015 Introduction Context It is recognised that the health of Queenslanders is very good overall, when compared internationally. 9 However, recent declines in the amount of physical activity, poor nutrition, an increase in overweight and obesity, as well as continuing high levels of smoking and alcohol misuse and an increasing incidence and prevalence of chronic disease require urgent action to ensure the health system in Queensland remains sustainable for the long term. Opportunities exist for improvement in Queensland s health system through the combined efforts of governments, public and private health service providers, the non-government sector, communities and individuals. Burden of disease and behavioural risk factors in Queensland According to Health Determinants Queensland, 10 coronary heart disease (CHD), stroke, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus accounted for 32.6 per cent of premature deaths during 1996-98 11 in Queensland (see Figure 2). For the same period, asthma, type 2 diabetes mellitus, COPD and stroke accounted for 15.1 per cent of disability adjusted life years (a burden of disease measure). The number of Queenslanders with chronic renal failure is growing by 6 per cent per year, resulting in rising costs over the next 10 years, conservatively estimated at $0.8 billion for Queensland. Figure 2 Causes of premature mortality in Queensland 1996-98 a, b Chronic Disease % of total YLL c Coronary Heart Disease 20.1 Stroke 6.8 COPD 3.7 Diabetes type 2 2.0 a The Queensland Burden of Disease Study was being updated at the time of printing. More recent data will be available by December 2005. b Queensland Health. Health Determinants Queensland 2004. Brisbane: Queensland Health, 2004. c Years of life lost (in the population, due to premature mortality) 19 9 Queensland Health. Smart State: Health 2020 Directions Statement. Brisbane: Queensland Health, 2002. 10 Queensland Health. Health Determinants Queensland 2004. Brisbane: Queensland Health, 2004. 11 The Queensland Burden of Disease Study was being updated at the time of printing. More recent data will be available by December 2005.
Introduction Queensland Strategy for Chronic Disease 2005-2015 Mental health disorders were the leading cause of disability burden in Queensland from 1996-1998, accounting for 26.7 per cent of the burden. Affective disorders (including depression and bipolar affective disorder) were the largest specific cause of disability within mental disorders among males and females, accounting for 35 per cent of the total burden attributed to mental disorders. 12 Much of the burden of disease caused by these conditions can be prevented by reducing smoking rates, improving nutrition, increasing physical activity, and reducing rates of harmful and hazardous alcohol consumption. It is recognised that social, economic and environmental factors influence Queenslanders ability to actively pursue healthy lifestyles and consequently increase the burden of disease. 13 Figure 3 illustrates the relationship between chronic diseases and behavioural risk factors. Figure 3 Chronic disease behavioural risk factor matrix Population Well Population Level of Intervention Primary Prevention Condition Poor Nutrition (Obesity) Physical Inactivity (Obesity) Alcohol Misuse Tobacco Use Renal Disease Stroke Coronary Heart Disease Heart Failure Type 2 Diabetes Mellitus * E Chronic Obstructive Pulmonary Disease Asthma * E Depression as a co-morbidity * E * E = emerging evidence 12 Queensland Health. Health Determinants Queensland 2004. Brisbane: Queensland Health, 2004. 13 Queensland Health. Smart State: Health 2020 Directions Statement. Brisbane: Queensland Health, 2002. 20
Queensland Strategy for Chronic Disease 2005-2015 Introduction Contemporary models of health care for preventing and managing chronic disease The health care system in Queensland has historically comprised acute care/ hospital services delivered by Queensland Health and private organisations, a small community health sector, and a general practice focused primary health care sector. The effective management of chronic diseases requires long-term care using the full spectrum of health care services, from primary (health) care to acute care and health maintenance. 14 This changing model of health service delivery requires greater emphasis on primary prevention, an increased focus on communityor home-based services, and the strengthening of partnerships between the community, primary health care providers 15 and the acute care sector. Long-term sustainability of the health system can be achieved by sharing responsibility among government, private providers, non-government agencies and consumers. A greater focus needs to be placed on the care needs of groups including older people, Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds and people from rural and remote areas with chronic disease. To ensure the sustainable delivery of quality health care services, better coordination is required across the acute and primary health care sectors and across the continuum of care. It is important to recognise that, for most of the time, a person at risk of developing or living with a chronic disease is managing their health on a daily basis without the involvement of health care providers. Consequently, these individuals and their carers require the knowledge, skills, ability and tools to manage their own health. A growing body of evidence supports the development of effective self-management programs. Effective prevention and management of chronic disease also includes preventing and managing the co-morbid mental health condition of depression. The evidence suggests that a multidisciplinary team approach to dealing with mental health issues is most effective. Delivering sustainable mental health strategies requires a certain level of practice change and community understanding. It is also acknowledged that some of the prevention and management solutions come from sectors outside the health system, thus requiring a genuine partnership approach. 21 14 Queensland Health Smart State: Health 2020 Directions Statement. Brisbane: Queensland Health, 2002. 15 Queensland Health. Queensland Health Strategic Plan 2004-10. Brisbane: Queensland Health, 2004.