Multimorbidity, deprivation and the inverse care law
Tackling the spiral of multimorbidity
How do we begin to address the challenges of caring for those living with several chronic medical conditions at once? The condition of multimorbidity, particularly in areas of socioeconomic deprivation, is putting healthcare resources around the world under increasing strain.
Research at our Institute of Health & Wellbeing, led by Professors Frances Mair and Stewart Mercer, has driven the issue into the mainstream of international debate, bringing greater recognition of multimorbidity and identifying possible solutions for healthcare professionals and policymakers.
Professor Mair’s research focuses firstly on the link between multimorbidity and higher treatment burden – the impact on the patient of having to manage their medication, visit the doctor, undergo tests etc. It also looks at the connection between social deprivation and the poor health outcomes of those afflicted with multimorbidity. Thirdly, it addresses the need for approaches in policy and practice that are more tailored to the individual.
Multimorbidity and higher treatment burden
Professor Mair explains: “At Glasgow we’ve been doing a lot of work on the subject of treatment burden. Health services and doctors give patients and their support networks a lot of work to do, and that’s not just about taking tablets. It’s also having to deal with fragmented care. We do provide care in disease specialities but we don’t think sufficiently about how care is coordinated and that can create extra work for patients. The big problem is multiple different caregivers that are not well coordinated.”
This lack of coordination can be seen in scenarios where patients have to attend many different hospital clinics on separate days each week, undergo unnecessary repeated investigations, and are given conflicting advice by different health professionals.
In collaboration with the Mayo Clinic (Minnesota) and the University of Southampton, Professor Mair’s response to treatment burden is Minimally Disruptive Medicine, a system of care that seeks to advance patient goals for their health and treatment, using effective care programmes designed to respect the capacity of individuals with chronic illness, as well as their caregivers.
The delivery of health services requires a shift from our current disease-centred approach to one of person-centred care that prioritises a patient’s needs and goals. Professor Mair and colleagues have responded to this challenge by aiming to raise awareness of the problem of treatment burden.
Cited in the British Medical Journal, Professor Mair’s work identifies why treatment burden should be regarded as an important indicator of quality of care. It has led to this being recognised as a key issue in the management of multimorbidity, in the National Institute for Health & Care Excellence (NICE) multimorbidity guidelines, which were published in 2016.
Social deprivation and the poor health outcomes of the multimorbid
Long-term disorders are the main challenge facing healthcare systems worldwide. Professor Stewart Mercer, Chair in Primary Care Research, and National Lead for Multimorbidity Research (Scottish School of Primary Care) is interested in all aspects of multimorbidity but especially the effects of multimorbidity on quality of life and how this affects younger people from deprived areas.
Over the last decade, he has led a programme of research on developing complex interventions to improve outcomes for patients with multimorbidity, including in deprived areas.
His landmark paper in the Lancet in 2012 which has been cited over 1700 times including in the NICE multimorbidity guidelines, has been influential in steering the issues of multimorbidity and deprivation towards mainstream policy and practice, notes that:
- multimorbidity is the norm in Scottish patients over 50
- although multimorbidity is most common in older people, most people with multimorbidity in Scotland are under 65
- multimorbidity occurs most frequently in deprived areas, 10–15 years earlier than in affluent areas
- there are only small differences between affluent and deprived patient groups in the prevalence of multimorbidity over 80 years of age
- the most common comorbidity in deprived areas is a mental health condition
From this epidemiology and qualitative research he has co-developed the CARE Plus study with GPs and patients in deprived areas of Scotland (known as the Deep End ) which has been tested in an exploratory randomised controlled trial and found to be effective and cost-effective. Full-scale testing of this intervention is planned in the near future.
Contextualised, person-centred approaches in policy and practice
Our high-quality research challenges the single-disease framework by which most healthcare, medical research and medical education is configured. Limiting ourselves to this approach prevents us from providing truly person-centred, holistic healthcare.
Professor Mair explains some of the challenges: “Over the years we have become increasingly focused on disease, rather than the individuals we are caring for. Our guidelines [were] for people with conditions such as stroke, heart failure, diabetes, depression. But none addressed multimorbidity until [the NICE guideline]. We don’t know enough about multimorbidity and the natural progression of disease, and which combination of diseases are more likely to occur together over time, and the patterns and effects on outcomes.”