Health care systems face increasing needs from citizens with chronic conditions. A look into the crystal ball shows that by 2015, chronic non-communicable diseases will be the inevitable biggest killer in all parts of the world - in the developing parts but definitely in industrialised places as well. Here, as much as 87% of all deaths will be caused by chronic non-communicable diseases.¹ At present, 35 million people die from chronic diseases a year: cardiovascular diseases causing 18 million, cancer 8 million, and chronic pulmonary diseases 4 million deaths.

These overwhelming arguments have headlined chronic conditions. However, do we get the full picture as a guide for health care planning when we use deaths as the end point?

Some chronic conditions do not primarily cause death but suffering. Mental and neurological diseases are known as one group of chronic conditions that causes much suffering and disability. The prevalence of mental illness is 25%, and 31% of all lived disability years are associated with neuropsychiatric conditions.² Furthermore, it has been suggested that 15-35% of the world's population suffers from musculoskeletal conditions. Nevertheless, though causing much disability, only about 100,000 deaths can be attributed to musculoskeletal conditions. The question is then should we focus on deaths or years with disability when deciding what makes chronic conditions?

Most societies may state that an important goal of their health care systems is to reduce suffering and make people live longer and live better lives. In health policy this is often modelled on equal access and health outcome for equal needs. However, access and need are extremely dependent on resource allocation, organisation and prioritisation.³ Resources are limited and investing in peoples' health must balance benefits for the societies and efficiency and fairness for the individual citizen. Conscientious politicians and administrators must channel resources allocated to chronic conditions based on cost-effectiveness of interventions⁴ and potential individual benefits for patients.⁵ Thus, focusing on chronic conditions may also be a matter of cost-effectiveness for society vs. ethics and equity for the patient?

"The chronic condition battle"

Apparently, there is basis for a "chronic condition battle" rooted in diverse positions in ranking consequences of chronic conditions. In this light, we may better understand why, e.g. some medical specialities draw attention to the special needs for their particular chronic conditions.⁶

Family medicine may not have these difficulties in defining what makes a chronic condition: being the frontline medical expertise in health care we are forced to and experienced in combining aspects of death, suffering and expenses into a language understood by patients, fitting a doctor-patient-dialog and still preserving time for other patients.⁷ Furthermore, at least 50% of family practice patients with chronic conditions have two or more conditions at the same time⁸ amplifying the need to integrate and coordinate different aspects of the impact on the patient's health.

What is left is a need for a clinical sound definition of how health professionals should define a chronic condition. A feasible one is shown in Box 1. Embedded in "chronic" is an arbitrary minimum time and often six months is used.⁹ Yet, what is more interesting is the use of epidemiologic knowledge about prognosis, the knowledge from clinical research on the effects of our interventions and that the intervention must be applied repetitively. This definition is independent of choosing between deaths, suffering or expenses. Meanwhile, it focuses on what we can offer and what the patient and the society can expect.

As family physicians we cannot take some chronic conditions more seriously than others just because it is stylish or seems reasonable. In family practice, patients with chronic conditions rely on our skills and knowledge on what is the best care. Thus, family medicine research has to contribute with epidemiological and clinical knowledge about chronic conditions by initiating new studies and synthesise old knowledge. In health services research we must create and test effective strategies to improve the performance of the total health care system; primarily enhance the cooperation between family practice and other areas of the health care system. In this way we can guide administrators on a) the prognoses of chronic conditions if untreated, b) the possibilities for and benefits from intervention in family practice, c) the cost-effectiveness of interventions in family practice and d) the potential for integrated health care where family practice is an essential part.

We must rely on and encourage stakeholders' talent in initiating clinical, epidemiological and health services research, medical technology assessment and quality improvement so that the necessary resources, most efficient structures and public health interventions are put forward so that people know what to expect and what society expects from people.