Embedding a multiple health condition approach across NHS Greater Manchester

Abstract

Here, we present two real-world examples of how a prioritised, person-centred, multiple health condition approach - also termed a multimorbidity approach - has been applied to long-term condition management in general practice in Greater Manchester. The first example is the implementation of targeted multiple health condition reviews via a population health management approach across general practice in the City of Manchester. The second example is the development of a person-centred risk stratification tool, focused on unmet cardiovascular need, called 'CVNeed'. This tool provides a unique approach to highlighting the highest unmet need and, thus, the largest return on investment to the system from proactive efforts. These examples demonstrate how a person-centred, multiple health condition approach to long-term condition management, enabled by data intelligence to drive prioritisation of clinical need, can help to address longstanding health inequalities and unwarranted variation in health outcomes. This work also highlights the potential for integrated care systems (ICS) to work collaboratively to tackle health inequalities at a system, locality and neighbourhood level, thus making significant strides toward achieving the vision set out in the Greater Manchester Integrated Care Partnership (ICP) Strategy.