People with multiple long term conditions
Key contact/author: Piers Simey, Consultant in Public Health, Buckinghamshire
County Council
Introduction
This section focuses on the needs of people with two or more long term conditions –
the standard definition for multimorbidity. A long term condition is one that can be
managed but often cannot be cured, and common examples include heart disease,
stroke, cancer, diabetes and arthritis. The number of people with long term
conditions is increasing, and the majority of people aged over 65 may now have
multiple conditionsi.
Why is this issue important?
People with multiple conditions have poorer health outcomes. Death rates are
higher and hospital admissions are more likely, and for longer periodsii iii. Functional
ability and quality of life is often reduced, and people with multiple conditions are
more likely to be depressed and be on multiple drug treatment regimes which are
difficult to manageiv v. The risk of poorer mental health rises with increased numbers
of physical conditionsvi.
Clinical care for people with long term conditions can be complex. Evidence for
managing long term conditions is usually based on research focusing on single
conditions which often exclude people with multiple conditionsvii. People with
multiple conditions have more problems with the coordination of their care and they
experience more medical errorsviii.
People living in deprived areas seem to develop and be diagnosed with multiple
conditions more than a decade earlier than those in the least deprived areas ix. This
will contribute to lower life expectancy and more years spent in poor health. Adverse
effects on mental health are also stronger for people living in deprived areasx.
Need in the population – current and future
Who’s affected/at risk and why?
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Multiple conditions are more common with age, but significant numbers of people
aged under 65 will also be affected
Some minority ethnic groups are more affected by certain long term conditions,
such as diabetes and heart disease
Long term conditions are more common for people living in more deprived areas
Around a third of people with a long term condition may also have a mental
health problem, typically depression or anxiety. People with cardiovascular
disease, diabetes, chronic obstructive pulmonary disease and chronic
musculoskeletal disorders are particularly affected.
Some long term conditions are more common for people with learning disabilities.
People with serious mental illness often have poor physical health.
Size of issue
More than 90,000 people in Buckinghamshire in July 2012 had two or more long
term conditions, as identified by initial analysis using the Adjusted Clinical Groups
(ACG) system used in primary care1. This was 17.6% of those registered with a
Buckinghamshire GP2, and the proportion was very similar for both clinical
commissioning groups. More than half of people (53.8%) aged over 65 had two or
more long term conditions, compared with one in ten people aged under 65.
Figure 1 sets out how the numbers of long term conditions that people have
increases with age in Buckinghamshire. The blue area in the chart shows the
proportion with no long term conditions, while the layers on top show the proportion
with increasing numbers of conditions for each age group. Less than one in ten
children aged 0-4 years old (8.4%) had at least one condition, rising to a third of
adults aged 35 to 44 (33.9%) and almost four fifths of those aged 65+ (77.1%).
Having multiple long term conditions is the norm for older people: half of those aged
80+ (50.2%) had three or more long term conditions, around a fifth had either two
conditions (19.2%) or one (17.3%), and only 13.4% had no identified long term
condition.
Figure 1: Number of long term conditions by age group in Buckinghamshire
Percentage of people with chronic conditions by age band in
Buckinghamshire (July 2012)
100%
90%
80%
Percentage
70%
8+
7
60%
6
50%
5
4
40%
3
2
30%
1
0
20%
10%
0%
00to04
05to11
12to17
18to34
35to44
45to54
55to64
65to69
70to74
75to79
80to84
85+
Age Band
Source: ACG system, July 2012
Almost one in five females (19.1%) of any age have two or more long term
conditions, compared to 16.0% of males. Figure 2 shows that a higher proportion of
1
The ACG system identifies people with long term conditions on the basis of (a) being on one or more
of 19 QOF registers; and/or (b) having a condition from a selected range considered to be life-long.
Data is only currently available on the total number of long term conditions affecting each individual
2
524,300 people were registered with a Buckinghamshire GP in April 2012. The ACG system
analysed data for 516,500 of these people.
people aged 65+ living in the most deprived quintile in Buckinghamshire have two or
more long term conditions compared to those living in the least deprived quintile
(57.2% vs 52.0%). Further analysis of the numbers and characteristics of those
affected will be carried out once data becomes available. This will remain an area of
active study.
Figure 2: Number of people aged 65+ with 0, one or multiple long term conditions in
Buckinghamshire, by deprivation quintile
Number of People with 0 to 3+ Chronic Conditions, Aged 65+ by Deprivation
Quintile, Bucks
100%
90%
80%
Percentage
70%
60%
3+
50%
2
1
40%
0
30%
20%
10%
0%
1
2
3
4
5
Deprivation Quintile
Source: ACG system, July 2012
Around 70% of the total health budget is spent on the care of people with long term
conditions. In England it has been estimated that every year between £8 billion and
£13 billion of this spend can be attributed to the effects of coexisting mental health
problems xi.
The future
The numbers of people with multiple long term conditions is likely to continue to
increase with the ageing of the population in Buckinghamshire. Unhealthy lifestyles
will also contribute to this rise, along with the impact of the economic downturn on
mental and physical health.
Evidence of what works
A Cochrane review on interventions for people with multiple long term conditions in
the community identified 10 good quality randomised controlled trialsxii. Evidence of
what works was limited and there were mixed results. For health service use, only
one of the five trials reporting on this issue found significant impact on hospital
admissions. Studies considered a range of health related outcomes, with
interventions generally more likely to be effective when they targeted:
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People with specific combinations of common conditions.
o Collaborative care management in the USA by nurses for people with
poorly controlled diabetes and/or heart disease with coexisting depression
significantly improved depression, blood sugar, cholesterol and blood
pressure levels at twelve monthsxiii. The intervention group was more
likely to meet guideline criteria or achieve clinically significant improvement
for these outcomes. Subsequent analysis found that improvements in
depression continued a year after the intervention ended, but the
improvement in the other outcomes was no longer statistically better than
usual carexiv. The intervention cost $1,200 per person. The authors found
the intervention to be cost-effective3 on the basis of adjusted outpatient
costs.
o People with depression and high blood pressure supported by an
integrated care manager significantly improved their blood pressure and
depressive symptoms over six weeksxv.
o Studies targeting specific conditions have had better results than those
including people with a wider set of conditions.
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Problems faced by people with multiple conditions, such as management of
multiple medications. Three studies reporting on prescribing and medication use
found significant benefits in (a) people taking their medications as prescribed; (b)
adjustments to medication by prescribers; or (c) fewer medication related
problems following pharmacist medication review.
Long term conditions and mental health
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NICE recommends that cardiac rehabilitation should include psychological
support, but complex psychological interventions should not be offered
routinelyxvi. NICE also recommends that psychological intervention should be a
core part of pulmonary rehabilitation for people with chronic obstructive
pulmonary diseasexvii.
NICE guidelines are in place for people with depression and a chronic physical
health problem – these are the only NICE guidelines that specifically focus on
multiple long term conditions. Collaborative care should be considered for those
with moderate to severe depression and a long term condition affecting functional
ability, where psychological intervention and/or medication has had no impactxviii.
This should include case management supported by a mental health
professional.
Liaison psychiatry to support people’s mental health needs in hospital – potential
for earlier discharge and fewer readmissionsxix.
NICE guidelines on multimorbidity in primary care
NICE aims to produce guidelines for GPs on managing multimorbidity in 2013/14.
3
Estimated cost per quality adjusted life year under $3,000 (upper estimate)
Current services in relation to need
People with multiple long term conditions can access the range of care services in
place for the population. But there is limited information available on their use of
these services and services may focus on managing single diseases. For example
only one indicator in the current quality and outcomes framework for primary care
specifically relates to people with multiple conditions. In 2011/12, 85.5% of people
in Buckinghamshire with diabetes and/or heart disease had been screened within the
last fifteen months for depression (range across GP practices: 69.4% - 93.6%).
A national pilot project has been established in Wycombe, focusing on access to
psychological therapies for people with chronic obstructive pulmonary disease
(COPD) when they attend rehabilitation. This is an example of a local service set up
to focus specifically on the needs of people with multiple long term conditions.
Unmet needs and service gaps
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Care needs to be organised to consider a person’s multiple long term
conditions, rather than their individual conditions in isolation.
Co-existing mental health problems may be undetected.
Many people with multiple long term conditions will benefit from lifestyle
changes. Supporting behaviour change needs to be a core consideration in
the ongoing care of people with multiple conditions.
Care planning needs to be holistic and lead to outcomes being achieved that
matter to the individual.
Recommendations for consideration by commissioners
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i
Ensure that the care of people with multiple long term conditions is focused on
the individual and their range of needs. This includes shared decisionmaking, increased support for self-management, and care planning that
assesses physical and psychological needs equally at diagnosis and review.
Develop a model for the implementation of routine case finding in primary
care to identify mental health problems in people with long term conditions.
Ensure access to training on identifying and responding to symptoms of
depression among people with long term conditions.
Include psychological support within local cardiac and pulmonary
rehabilitation programmes.
Barnett, K., Mercer, S., Norbury, M., Watt, G., Wyke, S. and Guthrie, B. (2012). Epidemiology of
multimorbidity and implications for healthcare, research, and medical education: a cross sectional
study. The Lancet, 380: 37-43.
ii
Vogeli, C., Shields, A.E., Lee, T.A., Gibson, T.B., Marder, W.D., Weiss, K.B., and Blumenthal, D.
(2007). Multiple Chronic Conditions: Prevalence, Health Consequences, and Implications for Quality,
Care Management, and Costs. Journal of General Internal Medicine, 22(suppl. 3): 391-5.
iii
France, E.F., Wyke,S., Gunn, J.M., Mair, F., McLean, G., and Mercer, S.W. (2012). A systematic
review of prospective cohort studies of multimorbidity in primary care. British Journal of General
Practice, 62: e297-307.
iv
Fortin, M., Lapointe, L., Hudon, C., Vanasse, A., Ntetu, A.L., and Maltais. (2004). Multimorbidity and
quality of life in primary care: a systematic review. Health & Quality of Life Outcomes, 2: 51.
v
Townsend, A., Hunt, K., and Wyke, S. (2003). Managing multiple morbidity in mid-life: a qualitative
study of attitudes to drug use. BMJ, 327: 837-843.
vi
Barnett, K., Mercer, S., Norbury, M., Watt, G., Wyke, S. and Guthrie, B. (2012). Epidemiology of
multimorbidity and implications for healthcare, research, and medical education: a cross sectional
study. The Lancet, 380: 37-43.
vii
Fortin, M., Dionne, J., Pinho, G., Gignac, J., Almirall, J., and Lapointe, L. (2006). Randomized
controlled trials: do they have external validity for patients with multiple comorbidities? Annals of
Family Medicine, 4: 104-8.
viii
Schoen, C. and Osborn, R. (2010) www.commonwealthfund.org/Surveys/2010/Nov/2010International-Survey.aspx (accessed Oct 28 2012).
ix
Barnett, K., Mercer, S., Norbury, M., Watt, G., Wyke, S. and Guthrie, B. (2012). Epidemiology of
multimorbidity and implications for healthcare, research, and medical education: a cross sectional
study. The Lancet, 380: 37-43.
x
Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M., and Galea, A. (2012). Long term
conditions and mental health. The cost of co-morbidities. The Kings Fund and Centre for Mental
Health.
xi
Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M. and Galea, A. (2012). Long term
conditions and mental health. The cost of co-morbidities. The Kings Fund and Centre for Mental
Health.
xii
Smith, S.M., Soubhi, J., Fortin, M., Hudon, C. and O’Dowd, T. (2012). Interventions for improving
outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database
of Systematic Reviews, Issue 4. Article Number: CD006560.
xiii
Katon, W.J., Lin, E.H., Von Korff, M., Ciechanowski, P., Ludman, E.J., Young, B., Peterson, D.,
Rutter, C.M., McGregor, M. and McCulloch, D. (2010). Collaborative care for patients with depression
and chronic illnesses. New England Journal of Medicine, 363: 2611-20.
xiv
Katon, W.J., Russon, J., Lin, E.H., Schmittdiel, J., Ciechanowski, P., Ludman, E.J., Peterson, D.,
Young, B., and Von Korff, M. (2012). Cost-effectiveness of a multicondition collaborative care
intervention: a randomised controlled trial. Archives of General Psychiatry, 69(5): 506-14.
xv
Bogner, H.R. and de Vries, H.F. (2008). Integration of depression and hypertension treatment: a
pilot randomized controlled trial. Annals of Family Medicine, 6(4): 295-301.
xvi
NICE (2007). Secondary prevention in primary and secondary care for patients following a
myocardial infarction.
xvii
NICE (2010). Management of chronic obstructive pulmonary disease in adults in primary and
secondary care.
xviii
NICE (2009). Depression in adults with a chronic physical health problem.
xix
Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M., and Galea, A. (2012). Long term
conditions and mental health. The cost of co-morbidities. The Kings Fund and Centre for Mental
Health.