New guidance to help clinicians improve care for people with multiple long-term conditions
26 March 2025
New guidance for primary care clinicians on how to conduct personalised annual reviews for patients with multiple long-term conditions has been developed by researchers from the Centre for Academic Primary Care, University of Bristol and NIHR Applied Research Collaboration West (ARC West). Patients with multiple long-term conditions need regular reviews to monitor their health, wellbeing and medications.
Between 15-20% of adults have at least three different major long-term conditions. Most general practices review each individual condition in isolation. This is inconvenient for patients and inefficient for practices. These disease-specific reviews fail to treat the patient as a whole person and can neglect the health problems that bother the patient most.
This new approach involves doing a ‘whole-person’ annual review, instead of several individual disease-focused reviews. Research, conducted as part of the Personalised Primary Care for Patients with Multimorbidity (PP4M) Study, indicates that this provides a better patient experience and is also more fulfilling for clinicians.
The guidance includes links to a range of tools clinicians can use to plan and conduct a successful personalised review, including:
an outline structure for the review
how to plan for the change
a template for Emis practices to support the review
“Healthcare professionals in primary care recognise that people with multiple long-term conditions can experience fragmented healthcare. They want to improve their experience of care while supporting them to improve their health. Personalised annual reviews can help to do this.”
Chris Salisbury, Emeritus Professor of Primary Care at the Centre for Academic Primary Care and Co-Investigator on the study, said:
“The new GP contract requires practices to identify groups of patients who are most likely to benefit from continuity of care – those with multiple long term conditions are an obvious example.
“We have developed tools to help practices identify and support these patients. The PP4M approach enables general practices to focus on the patient’s real health needs, in a way that is more efficient and effective and more satisfying for both the patient and the health professional.”
The tools and guidance were developed in close collaboration with patients and public contributors. The PP4M Study was funded by the National Institute for Health and Care Research (NIHR).