Six years after the clarion call to “redesign health care for people who use it,” care designed around the needs of those with multimorbidity is still the exception rather than the rule.
Addressing the challenge of multimorbidity requires more than new NICE guidelines. We need a new approach to professional practice that recognises the value of minimally disruptive medicine, and involves patients in leading the conversation about what needs to change. It also means thinking harder about prevention—and prevention of inequalities—in the context of multimorbidity.
Change is now needed in two areas.
First, a shift in professional practice that pays more attention to the benefits of minimally disruptive medicine for people with multimorbidity.
As well as the burden of illness, many people living with multiple long-term conditions experience a cumulative workload that arises from treatment. This “burden of treatment” includes organising appointments, following up on test results, and adhering to complex multiple medication regimes—the collective demands of which can leave many patients feeling overwhelmed, adding paradoxically to the work of being sick.
The SHERPA framework recently described in the Lancet—which analyses the burden of care and explicitly focuses on patient priorities as the driver of decision-making—is one example of a clinical approach with promise. Grounded in three simple steps: share problems, link problems, plan together, it offers a useful tool that could help doctors with the non-trivial challenge of translating evidence-based medicine into good care for people with multimorbidity. [1,2,3]
This shift in professional practice needs to focus on doing less, when less is best, given the potentially cumulative impacts of over-investigation and over-treatment for patients with multimorbidity. Emergent conversations about where the medical model adds value, and where it does not, are an encouraging start. The challenge now is to better reflect such thinking in the everyday practice of medicine, to improve care for people with multimorbidity.
Progress needs, and will indeed be strengthened by, patients and carers being more involved in leading conversations about how health and care systems need to change to improve care for those with multimorbidity, as the Richmond Group have already suggested. A stronger voice for people with multiple conditions—within health policy, and in both research and setting the research agenda—is necessary so that what matters most to patients is reflected in research and policy priorities.
Second, we need to widen the angle of our lens on the problem, reconceptualising multimorbidity as an issue beyond health services.
Multimorbidity results from the cumulative impacts of adverse health across our lifespan. There is a strong social gradient here: people living in deprived communities are more likely to experience multimorbidity, and to experience it 10 to 15 years earlier than those living in affluent areas. They are also likely to experience worse care, including shorter primary care consultations.
This mismatch fits with what we know about the “‘inverse care law”, and shows how differences in the way health services are provided can exacerbate inequalities in health for people with multimorbidity. Yet the prevention of multimorbidity—and prevention of inequalities among people with it—have been largely unaddressed in literature to date.
If we are serious about reducing the social gradient of multimorbidity, we must attend to the environments that influence health across our lifespan, including wider social determinants and the important role of early childhood experience.
Research has shown that adverse childhood experiences are associated with a higher risk of multimorbidity later in life. This relationship is independent of behavioural lifestyle and persists even when statistically controlling for factors such as smoking, physical activity and diet. In the context of a 7% rise in child poverty between 2015 and 2022, as predicted by the Institute for Fiscal Studies, it seems likely that the impact of poverty and adversity on children’s health today will continue to shape the early onset of multimorbidity for many years to come.
New clinical guidelines or a new national strategy are only part of the solution to the challenge of multimorbidity. Just as important will be a shift in professional practice toward delivering minimally disruptive medicine, involving patients in redesigning care, and greater attention to prevention and health inequalities in the context of multimorbidity.
Competing interests: None declared