Models of Care for people living with Multiple Long-Term Conditions
Research priority setting
Models of Care for people living with Multiple Long-Term Conditions
Research priority setting
Posted by Jo Butterworth
2 September 2025Summary by Aziza Sallam, Postdoctoral Research Associate
In this workshop, we introduced the project, the research team, and the overall aims of our upcoming scoping review. We then invited the group to discuss three key questions. Below is a summary of their insights:
1. What does good care look like?
Good care is person- and family-centred, recognising the individual beyond their medical conditions. It focuses on improving quality of life, reducing isolation, and addressing the emotional and practical needs of both patients and carers. Effective care is coordinated across services: primary, secondary, social care, and voluntary sectors, avoiding fragmentation and repetition. Poor communication, lack of a single point of contact, and siloed services often lead to confusion, conflicting treatments, and wasted resources. Good care also respects patients’ lived experiences, backgrounds, and languages, avoids stereotyping, and includes carers as vital partners. Addressing polypharmacy, ensuring care continuity, and adopting holistic and inclusive approaches are central. Holistic care also requires holistic research and investment in professional communication skills and training, especially in understanding co-existing conditions and their interactions.
2. When care worked really well for you, what made the difference?
Positive care experiences were marked by good communication, empathy, and consistency across services. Health professionals who took time to explain procedures, treated patients with dignity, and made small but meaningful adjustments had a big impact. Person-centred, flexible care, especially when staff were empowered to step beyond rigid roles, was appreciated. Listening to patients and carers, planning ahead, and making timely decisions improved outcomes. When carers felt heard and respected, and when health professionals collaborated effectively, care was smoother and more reassuring. Rapid response teams and strong relationships with GPs also contributed to good experiences. Crucially, patients and carers valued being treated as individuals and not just as cases to be managed.
3. What is the one thing to research?
Key research priorities include how to reduce inappropriate medication and polypharmacy, improve coordination between services, and ensure better follow-up, especially for those on waiting lists. There is a need to explore the barriers to holistic, joined-up care and how to overcome them, including the role of technology in improving communication and integration across health and social care. Research should also focus on how to make systems more responsive and personalised, ensuring patients don’t fall through the cracks and that care is both effective and compassionate.