International Journal of Integrated Care, 4 June 2008 - ISSN 1568-4156
Keynote abstract
Managing chronic illness in Europe: a comparative analysis
Ellen Nolte, Senior Lecturer, London School of Hygiene & Tropical Medicine, UK
Correspondence to: Ellen Nolte, E-mail:

Many countries are experimenting with new models of care delivery involving enhanced integration and coordination of services to better meet the needs of those living with chronic illness. However, the available evidence on the relative value of different forms of integration remains uncertain. This paper will present the findings of a study undertaken in close collaboration with and co-funded by the European Observatory on Health Systems and Policies. It will provide an overview of strategies to chronic disease management that have been developed and/or implemented in five European countries (Denmark, England, France, Germany, Sweden) and Australia. It will also assess some of the contextual factors that enable or hinder implementation of strategies to address chronic illness.

It illustrates the immense diversity among European countries in their approaches to address the rising burden of chronic disease. Approaches not only vary between but also within countries, and reflect to considerable degree the general approaches of health care financing and organisation taken. Thus, in many countries where strong primary care teams exist there has been a progressive shift in the management of many chronic diseases to nurse-led clinics in primary care, for example in England, Sweden and the Netherlands. The involvement of the non-medical profession in France or Germany is low, partly because of legal and professional restrictions on the deployment of nurses outside hospital. Instead, Germany has introduced dedicated disease management programmes which patients and providers can join voluntarily, while France is incentivising the formation of provider networks so as to improve coordination and multidisciplinary working along the continuum of care. The role of patient self-management is being acknowledged as a key component of effective chronic disease management in many countries; yet, systems that support self-management systematically remain relatively weak in many settings.

The sustainability of chronic care models faces considerable challenges in all health care settings. These include administrative and financial obstacles to enhance the coordination and/or integration of health and social/community care services; under/mis-investment in suitable information systems; conflicting policies (e.g. pursuing activity-based funding vs. aiming to shift care into the community); a focus on cost reduction; and the potential impact of electoral cycles.

An effective response to the rising burden of chronic disease requires a health system environment that allows for the development and implementation of structured approaches to chronic disease management. Experience suggests that systems that are characterised by fragmentation of health services are facing considerable challenges in the successful implementation of system-wide strategies to provide care for patients with chronic illness.

chronic illness; disease management

Presentation slides available from: