Caring for people with chronic conditions: a health system perspective
International Journal of Integrated Care, 16 March 2009 - ISSN 1568-4156
Book review
Caring for people with chronic conditions: a health system perspective
Edited by Ellen Nolte and Martin McKee
Maidenhead: Open University Press/McGraw-Hill, 2008, pp 259,
(European Observatory on Health Systems and Policies Series),
ISBN 978 0 335 23370 0
Mark Dobrow, PhD, Scientist, Cancer Services and Policy Research Unit, Cancer Care Ontario, Assistant Professor, Health Policy, Management and Evaluation, University of Toronto, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada E-mail:

This book focuses on a range of health system and policy issues related to caring for people with chronic conditions. Edited by the London School of Hygiene and Tropical Medicine’s Ellen Nolte and Martin McKee, this book features contributions from twenty different authors based in five European and three non-European countries. This volume represents the newest addition to the European Observatory on Health Systems and Policies Series, which “…seeks to contribute to the evolution of a more evidence-based approach to policy formulation in the health sector (p. v)”.

The editors note in their introductory chapter that the book “…is not a practical manual on how to implement a disease management programme (p. 8)”. Rather, the editors frame the work more broadly, concerned with how national and system level variables influence the development of context-specific policy solutions for the management of chronic disease.

Slotted between introductory and concluding chapters prepared by the editors, there are eight chapters addressing two main foci. The first part of the book sets out the context for chronic care, with chapters devoted to describing the shifting disease and economic burdens associated with chronic conditions along with a chapter setting out key chronic disease risk factors. The second part of the book sets this evolving chronic disease burden against a range of health system and policy issues, with chapters examining approaches to integrated service delivery, the role of self-management models, health human resource challenges, the role of decision support systems for chronic disease management and the relationship between health system payment/financing models and chronic care.

The importance of integrated care features prominently throughout the book. Chapter 4, in particular, provides an insightful review on integration, comparing, contrasting and clarifying integrated care and disease management approaches as they relate to chronic care; Chapter 7 sets out integrated care and multidisciplinary approaches as key factors that characterize the human resource challenges facing chronic care; and the two editors pen the final chapter (Chapter 10) where they examine further the barriers to improved coordination of care.

Although the European Observatory’s focus on the “…comprehensive and rigorous analysis of the dynamics of health care systems in Europe… (p. v)” (emphasis added) is often misleading and regrettably constrained, it is encouraging to note that with contributing authors based both in and outside of Europe along with evidence drawn from across the world, the current volume clearly presents guidance and insights that extend beyond Europe.

The final chapter provides a nice summary for considering the impact of varied clinical, organizational and system contexts on the implementation and potential success of different chronic care models and approaches. The editors conclude that three key elements need to be addressed in the care of chronic disease: (1) sustained financing, (2) skilled/motivated health professionals and (3) supportive information systems.

The book’s main value is in its presentation of chronic disease from multiple disciplines and perspectives. From epidemiology to economics, from primary care to organizational behaviour, and from information management systems to finance, this book maintains a coherent focus on key health system and policy issues related to chronic care throughout the multi-authored volume. As the editors indicate, this book is most appropriate for health policy-makers and healthcare managers that are tackling health system/policy decisions regarding chronic disease; however it is a useful read for anyone interested in the evolving context for chronic care.

The volume includes numerous references to a companion volume, which unfortunately I have not read, but presumably presents a number of case studies related to chronic care. In some instances, readers are directed to the companion volume for supporting details, which is less helpful than letting the current volume stand on its own.

Overall, the book walks a delicate balance between evidence and advocacy regarding the care of people with chronic conditions. Nolte and McKee conclude the volume with the following: “A first step is to recognize that something must be done. A second, which we hope will be facilitated by the evidence provided in this book, is to realize that something actually can be done, and that they can do it (p. 240)”. The overarching desire to match the need for evidence with the reality that advocates (including policy-makers) need a reasoned voice makes the book well suited to health policy deliberations.