© Nick Downham, Cressbrook Ltd and Grace Neal, Programme Lead SWL ICB – 2025
Significant changes are occurring in primary care. While there is a focus on improving access and new models such as neighbourhood health models and integrated neighbourhood teams, we must remember that the need for robust, effective general practice has not gone away. Central to this is good long-term condition (LTC) management. It may not be sexy or new, but LTC planned care matters. Without effective models of long-term condition management and planned care, practices and the wider system will continue to struggle. Multi-morbidity care is central to this. Even though we often organise and structure around single conditions, it is no surprise to anyone that a huge number of people often have more than one condition. The result is a fragmented model of care, leading to avoidable costs, confusion, inefficient capacity use, and duplicated efforts. From the perspective of the individual, it can cause repeated visits to practices, multiple professional voices, duplication, repetition of story and further confusion.
Over the past year, SWL ICB has been exploring the potential for integrating care steps for individuals with multiple long-term conditions in primary care. We know that some practices are a long way towards multi-morbidity care, while many are just starting to consider the applicability. There is still much debate about the potential and need for multi-morbidity care; this blog aims to highlight the opportunities at the process level.
The scale of the opportunity:
The simple cross-referencing grid below outlines the cardiometabolic conditions along the top and the care process steps listed down the side. Shared processes are highlighted in dark pink. It shows that a great many of the steps in the care process are common across all cardio-metabolic conditions [2]. It shows the potential of integrating across conditions (horizontally)[1]. Since many people have many of these conditions, there is huge potential to eliminate a lot of duplication and simplify processes.
Common process steps across cardio-metabolic multi-morbidity care.
And yet, in many practices and other care settings, we organise around the condition (vertical columns) rather than the person. This not only means we call the patient in multiple times, often repeating blood tests, checks, diagnostics, and consultations, but we also duplicate efforts, incur avoidable spending, and sub-optimise care.
When considered in this way, the possibilities become obvious. Realising this potential requires groundwork and practices need support. With recent focus on access and same-day care, there has been less focus on planned long-term condition care in many practices, even though many people looping around urgent same-day care are people with long-term conditions.
Moving to a macro view, it is worth reminding ourselves that LTC planned care systems are the bread and butter of robust general practice, which in turn are the foundation of all high-performing health systems.
SWL ICB is developing support for practices that include:
- Model processes.
- Critique of different multi-morbidity models.
- Searches.
- Integrated templates.
- Communication templates.
- Lessons learned.
- Implementation guidance.
Important work and interesting stuff. Hope this is useful.
Thanks to Dr Vanessa Fairfield, Caroline Tasker and Dr Aarti Velani for their input on the grid.
[1] For the quality improvement professionals out there, this technique of process visualisation is similar to what you would undertake in value stream identification
[2]This grid does not take into account that many of the T2DM 8 Core Care Processes are also shared, such as BP and Cholesterol. Therefore, the case for integrating multi-morbidity care is even stronger if those care processes were listed separately.