The King's Fund: Improving clinical co-ordination of care for people with multiple long-term conditions (22 May 2025)

Summary

This King's Fund report focuses on the clinical co-ordination of care for people with multiple long-term conditions as part of a wider holistic approach. It outlines a set of principles on clinical co-ordination for commissioners and healthcare professionals that should underline a new approach to care for people with multiple long-term conditions.

Content

Key messages

• Clinical care should, by default, consider that people may be presenting with multiple long-term conditions. There are now more and more people living with multiple long-term conditions, and people’s health conditions rarely fall neatly into separate clinical categories. Current models of care based on isolated care plans and siloed service pathways lead to poorer experiences and outcomes for people and inefficiencies for service providers.
• Co-ordinating clinical care is vital for getting the right support for people with multiple long-term conditions. This requires changes in how clinicians work, and how commissioners support them.
• IT systems, information governance and physical infrastructure are all key enablers of clinical co-ordination. It is essential that clinicians understand why and how changes will benefit them and their patients, and that patients and carers are able to access the information they need for their own agency and control.
• Whatever configuration they work in, clinicians need to ensure that they have clearly defined roles and responsibilities, and should develop their understanding of each other’s roles to support more joined-up thinking. Training – including continuing education – is important to support this.
• Removing financial system constraints, such as changing incentives to align with effective care for people with multiple long-term conditions, is an essential part of future-proofing the system against poor-quality provision for the increasing numbers of people living with such conditions.
• Local service design needs to be co-produced based on deep population knowledge as well as drawing on clinician and patient perspectives; there is no one model for caring for people with multiple long-term conditions, but there should be shared principles such as good communication, holistic care and access to information.
• Prioritising the development of outcome-based metrics – in particular those metrics that consider the impact of care co-ordination across conditions – in partnership with patients will help to improve understanding of the approach to care that can best address the needs of people with multiple long-term conditions and enhance the overall quality of that care.