The long term plan for the NHS in England aims to “future proof” the NHS for the next 10 years—but doesn’t prescribe an explicit national strategy to address one of the biggest challenges facing the health service: meeting the needs of patients living with multimorbidity.

Recent analysis by the Health Foundation highlights the scale of the challenge, revealing that one-in-four adults in England are now living with two or more health conditions, which is around 14.2 million people in total. Half of all primary and secondary care consultations and admissions are for multimorbid patients. [1]

The number of people living with multiple health conditions is expected to rise significantly over the time frame of the long term plan, with both projected hospital activity and costs up by 14% and £4bn over the next five years respectively.

Multimorbidity is not just a problem of ageing. Nearly a third (30%) of people with 4+ conditions are under 65, and this is higher in deprived areas. [1] For patients, the impact of living with multimorbidity can be profound. People with multiple health conditions have poorer quality of life, difficulties with everyday activities and a greater risk of premature death. [2-6]

The challenge of multimorbidity is being increasingly recognised by other organisations, including the Richmond group of charities, the Academy of Medical Sciences, the Royal College of General Practitioners, and the Chief Medical Officer. [7-10]

The long term plan rightly acknowledges that our population is ageing, with an increasing number of people living with frailty and long-term conditions, and outlines several proposals that should also benefit those living with multiple conditions. Making personalised care available to more patients, increasing the number of medical generalists, widening access to social prescribing, improving coordination of care, links with social care, and boosting funding for primary and community care (both sectors that hold much of the management of multimorbid patients) are all logical steps to improve the care for those living with multimorbidity. [11] Improving outpatient services and reducing numbers of face-to-face appointments has the potential to reduce treatment burden. Efforts to improve care for individual conditions—mental health, cancer, diabetes, and heart disease—may have knock on benefits for those living with several of these conditions simultaneously. [12] But, with the plan stopping short of offering an explicit strategy for managing an increasingly multimorbid population, what more is needed?

Perhaps part of the problem is that it’s hard to offer a precise answer. Historically patients with multimorbidity have been excluded from clinical trials, and not prioritised in health service research. [13] The result is that there are many unknowns when it comes to how to provide better care for these patients. The NHS therefore needs to be prepared to experiment with different approaches, alongside robust evaluation strategies to assess their impacts.

Previous NHS plans have included pilots like the vanguards and the pioneers which have provided valuable learning about how the big challenges facing the NHS can be overcome. However, there aren’t further pilots proposed in this plan despite the urgent need to seek out better ways to improve care for people with multiple conditions.

Even if new care models were to be developed, the needs of multimorbid patients are unlikely to be met without a high functioning model of general practice. It’s a service under strain, but patients attend general practice more than any other NHS service and rely on GPs to coordinate their care. Improving access to multidisciplinary teams should allow those with multiple conditions to benefit from a range of specialist services alongside their GP care, and we know that improving continuity of care, longer appointment times when needed, shared decision making, and a holistic view of health have been shown to improve patient’s satisfaction. [14] Without more GPs (and responsibility for the GP workforce lies largely outside the remit of the Long Term Plan), relentlessly rising demand may make it difficult for practices to offer longer appointment times, and national priorities that prize access above continuity risk leaving those with multimorbidity poorly served.

Many of the cross-governmental actions required to ensure that everyone has an equal opportunity to live a healthy life lie outside the remit of the plan. People in disadvantaged areas are at greater risk of developing multimorbidity, and are likely to have multiple health conditions at a younger age (28% of people in the most deprived fifth of England have 4+ conditions, compared with 16% in the least deprived fifth). The £900m real terms reduction in public health funding between 2014/15 and 2019/20, and cuts to local government funding, will make things worse, not better. Multimorbidity is both a cause and consequence of poverty, and the NHS will struggle to improve the lives of patients in the face of underinvestment in public services.  

The plan sets out promising component parts of an approach to the challenges of frailty and ageing, but falls short of delivering an explicit national strategy for multimorbidity. There is another opportunity now for local systems to take in to account the needs of these patients as they develop their own implementation plans. While the NHS alone will never be able to prevent multimorbidity, the NHS will have to treat it. Future proofing services means that services are designed around the needs of the patients they will serve, and that will increasingly mean people with multiple conditions.

 

Sarah Deeny, assistant director, data analytics, Health Foundation

 

 

 

 

Rebecca Fisher, GP and policy fellow, Health Foundation

 

 

 

 

References:

1. Stafford M, Steventon A, Thorlby R, Fisher R, Turton C, Deeny S. Briefing: Understanding the health care needs of people with multiple health conditions. The Health Foundation, Nov 2018
2. Kanesarajah J, Waller M, Whitty JA, Mishra GD. Multimorbidity and quality of life at mid-life: A systematic review of general population studies. Maturitas. 2018; 109: 53-62. 6.
3. Williams JS, Egede LE. The association between multimorbidity and quality of life, health status and functional disability. Am J Med Sci. 2016; 352: 45–52. 7.
4. Boakye D, Rillmann B, Walter V, Jansen L, Hoffmeister M, Brenner H. Impact of comorbidity and frailty on prognosis in colorectal cancer patients: A systematic review and meta-analysis. Cancer Treat Rev. 2018; 64: 30–9. 8.
5. Rushton CA, Satchithananda DK, Jones PW, Kadam UT. Non-cardiovascular comorbidity, severity and prognosis in non-selected heart failure populations: A systematic review and meta-analysis. Int J Cardiol. 2015; 196: 98–106. 9.
6. Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care. 2012; 50: 1109–18.
7. Hardeep Aiden  Multimorbidity Understanding the challenge. A report for The Richmond Group of Charities 2019 https://richmondgroupofcharities.org.uk/sites/default/files/multimorbidity_-_understanding_the_challenge.pdf
8. Academy of Medical Sciences. Multimorbidity: a priority for global health research https://acmedsci.ac.uk/policy/policy-projects/multimorbidity
9. RCP Responding to the health needs of patients with multiborbidity: a vision for general practice
10. Davies, S.C. “Annual Report of the Chief Medical Officer, 2018 Health 2040 – Better Health Within Reach”: Department of Health and Social Care (2018)
11. https://www.england.nhs.uk/personalisedcare/comprehensive-model-of-personalised-care/
12. NHS. The NHS long term plan. 2019. https://www.longtermplan.nhs.uk/
13. Buffel du Vaure C, Dechartres A, Battin C, et al Exclusion of patients with concomitant chronic conditions in ongoing randomised controlled trials targeting 10 common chronic conditions and registered at ClinicalTrials.gov: a systematic review of registration details BMJ Open 2016;6:e012265. doi:10.1136/bmjopen-2016-012265
14. Salisbury C, Man M-S, Bower P, Guthrie B, Chaplin K, Gaunt DM et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet, 2018; 392 (10141): 41–50.