Document resource
To improve the integrated management of multiple long term conditions, clinical guidelines must encompass adapted care for disease complexity, incorporate perspectives from those with lived experience and generalist healthcare providers, and be supported by a stronger evidence baseMultiple long term conditions (MLTC or multimorbidity) refer to the presence of two or more long term conditions.1 Such combinations of conditions are experienced by approximately one third of the population globally2 3; and exhibit a clear social gradient, with individuals in lower socioeconomic groups experiencing higher prevalence and onset at an earlier age.3 4 People with MLTC experience fragmented care, high treatment burden, and avoidable hospital use, which come with personal, social, and economic impacts.5 Clinical guidelines provide evidence based recommendations to support clinical decision making; however, they remain largely focused on single diseases. A single disease focus poses difficulties for MLTC management, especially where recommendations conflict, compete, or are not readily reconciled across a patient's coexisting conditions.In a linked BMJ Medicine paper (doi:10.1136/bmjmed-2025-001495), Pretorius and colleagues reviewed guidelines relevant to the management of single long term conditions in the UK healthcare context (guidance from the National Institute for Health and Care Excellence (NICE), https://www.nice.org.uk/), to understand whether guidelines systematically provide sufficient guidance to support clinicians in adapting care to patients with MLTC.6 The authors reviewed guideline content, as well as the inclusion of lived experience voices and generalist clinical expertise on guideline committees.Prior reviews, typically small in scope, show that single condition guidelines are inadequate for MLTC, rarely reflect patient preferences, and prioritise concordant over discordant conditions.7 8 Concordant conditions share similar physiological profiles and disease management approaches, while discordant conditions are of unrelated pathophysiology and often require different or conflicting treatment approaches.9 Pretorious et al's comprehensive review of 56 NICE guidelines, published between 2013 and 2024 and relevant to 60 single conditions,6 extends that literature by including a much larger number of guidelines spanning wide-ranging conditions selected for their relevance to hospital admissions in the UK,10 and by examining the composition of guideline development panels. The authors highlight that clinical guidelines continue to fall short for people with MLTC.Although most guidelines included commonly coexisting conditions, only 20% explicitly referenced MLTC and none included a dedicated section on adapting care for MLTC complexity.6 Consistent with prior reviews,7 8 most guidelines focused on concordant conditions. Additionally, generalists in the guideline panels were under-represented, and the authors found variable inclusion of public contributors, with lived experience of MLTC rarely specified, weakening usability for frontline practice.6Guidelines reflect the current evidence base that focuses on single conditions and often under-represents people with MLTC.11 As the complexity of an individual's set of conditions increases, so too does the potential for interactions between conditions, including drug interactions and cumulative side effects of treatments. Unless MLTC is given due consideration in single condition guidelines, they may inadvertently intensify treatment burden, diminish the overall effectiveness of care, and surpass the capacity of individuals and their families to manage the complexity involved. Contributions from people with MLTC and their carers would ensure recommendations reflect patient priorities and support shared decision making.12Condition specific guidelines remain essential, and while it is not feasible to generate recommendations for all combinations of conditions, systematic approaches to incorporate MLTC related adapted care, including references to the management of common concordant and discordant conditions, are needed. Pretorius et al call on NICE to act promptly and embed MLTC into evidence review processes, committee design, and guideline structure, moving beyond tokenistic references toward actionable, patient centred guidance.6 Condition specific guidelines should refer to NICE guidance on multimorbidity (NG56),13 which includes general approaches to patient care and how to deal with challenges of polypharmacy and patient centred care. However, this guideline lacks recommendations on the simultaneous management of interlocked conditions and the perpetuating social factors that gave rise to them. Social prescribing by frontline professionals may be part of successful MLTC holistic care.Guidelines focused on single diseases do not reflect the realities of people with MLTC and their families who need holistic, integrated, and person centred models of care rather than a patchwork of single disease recommendations. Strengthening the evidence base for these models of care across health, social, and community systems is essential to improve MLTC recommendations in future guidelines.14 15To test the clinical and cost effectiveness of such holistic models of care across the life course, funders should support innovative research, guided by priorities identified by people with lived experience of MLTC, their carers, and the professionals who support them. This evidence would provide a basis to improving models of care for MLTC and be a step towards developing robust MLTC management recommendations within single disease guidelines.