Care for the chronically ill: the future role of health care professionals and their patients.

In future decades the number of chronically ill will increase drastically. A function-orientated approach, substitution and transmural care would seem to be the key objectives for the necessary improvement in care. There will be significant changes in the task division of care provided by specialists, general practitioners and paramedics. At the same time, patients will be able to increase their own potential for self-care. Who will play which role in future will have to be considered against the background of the various phases in the course of a chronic disease. In the initial stages, in particular, there will be ample opportunity to involve patients more in their own care. This will have a positive influence on learning to live with a chronic disease, dependence on medical help and the course of the disease itself. Transdisciplinary collaboration, that means interactive collaboration with the necessary mutual knowledge and understanding of the working methods, should form the basis of the care in all phases of a chronic disease. Different carers are involved in each phase of care for the chronically ill, but since the general practitioner is involved in all phases, it is obvious that the necessary organization of collaboration between the various carers (including the patient) should be coordinated by the general practitioner.