Why we need to act now to tackle the global phenomenon of multi-morbidity
As the number of people with multi-morbidity continues to rise, we must change our approach to give whole-person care rather than treating conditions in isolation
It goes without saying that growing numbers of people are living with long-term conditions.
In England the number of over 50s with two or more conditions has increased from 32% to 43% in the past decade.
But how much do we really know about multi-morbidity and how to treat and prevent it?
Not enough – or certainly that is the conclusion of an in-depth review by the Academy of Medical Sciences into what it calls a global phenomenon.
The working group set up by the academy to investigate the issue says more research is desperately needed into all aspects of multi-morbidity.
Its report says that while it is becoming the norm in the 21st century, there are still ‘massive gaps’ in the knowledge of clinicians.
1 in 3
People with dementia who have depression
Source: Academy of Medical Sciences
Prime among them is what exactly is causing the rise. The researchers said that while the ageing population and obesity are ‘undoubtedly factors’, they do not fully explain the trend.
But it is not just older people who are developing multi-morbidity, according to the report.
The researchers said childhood and adolescent type 2 diabetes was unheard of in the UK 20 years ago.
But that has now changed. It said there were more than 500 children with the condition and a 30-year-old presenting with new onset diabetes is more likely to have type 2 than type 1.
The researchers also said not enough was known about the different ways conditions can cluster together.
How conditions cluster
The researchers produced a list of the top ten most common co-morbidity conditions and then detailed which they were most likely to cluster with – the top three of which are shown below in brackets.
- Coronary heart disease (hypertension, pain and diabetes)
- Hypertension (pain, diabetes and coronary heart disease)
- Heart failure (coronary heart disease, hypertension, atrial fibrillation)
- Stroke (hypertension, coronary heart disease and pain)
- Atrial fibrillation (hypertension, coronary heart disease and heart failure)
- Diabetes (hypertension, coronary heart disease and pain)
- Chronic obstructive pulmonary disease (hypertension, pain and coronary heart disease)
- Painful condition (hypertension, depression and coronary heart disease)
- Depression (pain, hypertension and coronary heart disease)
- Dementia (hypertension, depression and coronary heart disease)
In some people conditions that are similar in origin, such as heart disease and cerebrovascular disease, often coexist. This is known as concordant multi-morbidity.
In other cases – termed discordant multi-morbidity – the co-existing conditions appear unrelated and require different management approaches.
Meanwhile, they said there was plenty of evidence that physical and mental health conditions co-exist. But all too often the mental health problem is seen as secondary to the physical one and patients do not get the treatment and support they need.
The researchers said where the chronic conditions are concordant there was clearly an opportunity to develop better prevention strategies.
But lead researcher Stephen MacMahon says the whole system is simply not geared up to care properly for patients with a variety of long-term conditions.
‘Training for both doctors and nurses is more focused on single conditions,’ he says.
‘It’s the same for the way we test medicines. Although all are rigorously tested, clinical trials for particular medical conditions don’t usually include patients with other conditions – which means there isn’t a bank of good evidence showing how different medicines work together in patients with multi-morbidity.’
The report said this was particularly pressing given that patients can end up on a cocktail of different drugs.
The researchers called for greater research into the area and a rethink about how the NHS – and other health systems – were organised.
National Innovation Centre for Ageing director of engagement Lynne Corner, who was part of the working group, says the emphasis on specialists who treat single conditions is having a detrimental effect on patients.
She describes living with multiple conditions as a ‘full-time job’ for some.
‘You can have five different appointments on five different days with five different teams. That's hard for patients and hard for their families.’
She says the solution lies in developing ‘specialist generalists’ who can provide whole-person care, saying staff such as district nurses, GPs and experts in older people’s care are ideally placed to provide this given the right investment and training.
But British Geriatrics Society nurses and allied health professionals council chair Clifford Kilgore says this is proving difficult in the current climate with the reduction in training budgets that sees university courses oversubscribed and an increasing reliance on e-learning, which he describes as ‘helpful’ but somewhat limited.
‘It is not provided at master’s level which I believe is increasingly necessary for managing complexity and using critical thinking in care.’
The result, he says, is that multi-morbidity remains ‘a challenge for most clinicians’.
1 in 9
People with chronic obstructive pulmonary disease who have diabetes
Source: Academy of Medical Sciences
‘The complexity that is associated with people living with more than one health problem requires staff to understand risks of deterioration, including how different health problems affect each other.’
New approaches to complexity
But he says it is not simply a matter of training as time constraints also hamper efforts to provide first-class care.
‘I see far too many patients on multiple medications and I know that many clinicians struggle to find the time necessary to review these complex situations and to consider stopping some.
‘If we understood the challenges of multi-morbidity more then maybe we would not prescribe as many medications in the first place.’
The multi-morbidity specialists
Newcastle upon Tyne Hospitals NHS Foundation Trust runs a specialist clinic for patients with multiple long-term conditions.
The CRESTA clinic is a joint initiative with Newcastle University housed at the Campus for Ageing and Vitality.
Patients are referred by their GPs and can be seen by a range of specialist nurses and consultants.
It includes clinics in everything from Parkinson’s disease and stroke recovery to chronic fatigue syndrome and motor neurone disease.
Patients can receive testing and treatments as well as physiotherapy and occupational therapy.
The clinic, which was set up in 2012, now sees about 1,200 patients a month. Patients normally attend every six months.
These can be people of any age – it runs a mitochondrial disease clinic that sees babies – but most are older patients with multi-morbidity.
As it is linked to the university, patients can also be put forward for clinical trials.
Clinic sister Lynn Hogg says: ‘Patients will come in and then can spend half a day here seeing all the different specialists.
‘It is a really good way of ensuring those with multiple conditions get the patient-centred care they need without having to endlessly go to different appointments.’
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Nick Evans is a freelance writer