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23 April 2021

Three year focus on multimorbidity in South London highlights inequality

A three-year research programme on multiple long-term condition (mLTCs) in South London is shedding light on complex inequalities that put people at risk from these conditions.

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The COVID-19 pandemic has shed an important light on multimorbidity and health inequalities. People with underlying long-term conditions were at greater risk of severe Covid-19 disease (i.e. hospital admissions and death). Individuals from certain ethnic groups and living in deprived communities were also at increased risk. These socioeconomic inequalities also put people at a disadvantage with multimorbidity.

The research team, which started before the COVID-19 pandemic, is led by Principal Investigators Dr Mark Ashworth, Reader in Primary Care and Dr Hiten Dodhia, Visiting Lecturer, from the School of Population Health Sciences and a team of researchers from King’s. Additional support came from Outcomes Based Healthcare (OBH) and Impact on Urban Health. The projected was also supported by an Advisory Group of experts from across research, public health, data and policy-influencing sectors, and is chaired by Professor John Newton, Director of Health Improvement, Public Health England.

The research started with the development of a definition for mLTCs. The definition used in this research programme is when someone has two or more long-term conditions, from a list of 32 conditions. It was co-developed by King’s, OBH and Impact on Urban Health, based on local importance, and other criteria set out by local stakeholders and a scoping review of literature on mLTCs.

The research team were the first to look at the how the patterns and clustering of multimorbidity over 15 years has an impact on primary care service demand. Analysis by Marina Soley Bori, a health economist, showed that multimorbidity trebles the demand for primary care, and even more so in the presence of depression.

The team have also been ahead of the curve in understanding the importance of multimorbidity, and how socioeconomic factors such as ethnicity, income and geographical locality affect the patterning and clustering of mLTCs. A recent publication of this research in Lancet Regional Health led by statistician Alessandra Bisquera found that one in five people in South London live with mLTCs. Five different clusters of mLTCs were also identified with different patterns across the life course.

Further work by the team is now looking at the transition between different states (e.g. moving from one to many or dying from long term conditions over time) using Markov chain modelling. Early findings from this shows people from Black ethnicity or those living in deprived communities and women are more likely to progress from 1 to 2 Long-Term Conditions, or from 2-3 Long-Term Conditions.

The qualitative research aims to complement the statistical and health economics research exploring people’s lived experience of developing and living with mLTCs. Early findings of the research led by Rebecca Lynch based on interviews of people with multimorbidity identified key implications for policy and practice.

The work had a particular focus on South London. Another key finding is that people living in deprived communities in Lambeth experience their multimorbidity some 10-15 years earlier than those living in the least deprived communities; similarly, Black ethnicity people experience their multimorbidity 10-15 years earlier than White ethnicity people. A report [LINK] detailing the research has been published today.

It is hugely important for local and national decision makers to understand multimorbidity. This is because once a person has ‘multimorbidity’, healthcare demand increases substantially. We have been able to demonstrate that patients with multimorbidity have three times the primary care utilisation rate of people without multimorbidity. Importantly, not all Long-Term Conditions increase utilisation rates to the same extent.

Dr Mark Ashworth, from the School of Population Health & Environmental Sciences

The focus on South London has meant the research team looked at specific communities.

Dr Hiten Dodhia who chairs the Lambeth DataNet Steering Committee explained: “The granular detail of the Lambeth DataNet primary care data has been extremely helpful for the statistical and economic elements of this research. We have been able to identify higher proportions of the Portuguese community with untreated cardiovascular risk factors and a higher prevalence of cardiovascular conditions. We’ve also found hypertension to be the most common Long-Term Condition in the Black ethnicity community but we found markedly low levels of case detection for hypertension in the Somali community, the largest refugee community in Lambeth. The findings mean we can target hypertension case finding and treatment options within the Black community.”

Dr Ashworth added: “Covid-19 has changed everything. It’s suddenly meant that all those health inequalities we already knew about have been shown up in a harsher light, many contributing to huge mortality excess in those at risk. NHS supported schemes before but now - interest is much greater.”

A spokesperson from Impact on Urban Health said: “The data analysis done by King’s has been published in our new report Easing Pressures, which paints a stark picture of the unfair, unequal burden of ill-health in urban areas. Health inequity is complex and growing, and affects those living with other forms inequality the hardest, such as women, Black people and those living in deprived neighbourhoods. People’s housing, jobs and finances can made the burden of health inequalities even heavier.

“However, this is not inevitable. By going beyond the healthcare system and working with employers, landlords, lenders and others, we are able to change the social and economic factors that drive ill-health, and improve the quality of people’s jobs, homes, finances and the neighbourhoods they live in. With the right focus, we can make cities into places that are healthy for everyone that live in them.”

The team will continue to develop the concept of multimorbidity and present their findings in publications and conferences.


In this story

Mark  Ashworth

Professor of Primary Care