Managing several long-term conditions together
A joined-up, person-led way of looking after someone who lives with several long-term health problems at once, so that care, medicines and appointments work together around what matters most to them.
✓ Medically reviewed by a GMC-registered consultant · last reviewed September 2026 · next review September 2027 · how we review
In short
- It is a joined-up review of someone with several long-term conditions, led by what matters most to them rather than by each illness separately.
- It does not cure the conditions and is not about adding treatment; often the most helpful step is safely reducing medicines or appointments that are doing little good.
- A first thorough review often takes 45–60 minutes and leads to a shared written plan that is reviewed again over time.
- Good care is coordinated, with one clear point of contact and a plan everyone involved can see — fragmented, one-clinic-at-a-time care is the main thing this approach tries to avoid.
A plain-English summary. The detail — including risks and recovery — is below.
At a glance
A general guide. Your specialist will give you advice for your situation.
Care is organised around your priorities rather than each illness separately.
An acute, severe or rapidly worsening problem (such as suspected stroke, sepsis or a heart attack) needs emergency care first, not a planned review.
A longer, more thorough conversation across all your conditions, medicines and home life, focused on what matters most to you.
A clear written plan setting out priorities, medicine changes and who is responsible for what.
A longer, more thorough conversation across all your conditions, medicines and home life, focused on what matters...
You agree, or soon receive, a written plan setting out priorities, medicine changes, who does what, and how to get...
Any medicine changes settle in. You may be asked to watch for specific symptoms or have a blood test or...
An early review checks the plan is working, side effects have improved, and nothing important has been missed.
What does managing several long-term conditions together mean?
Many older people live with more than one long-term condition at the same time — for example diabetes, heart disease, arthritis, kidney problems or memory difficulties. This is sometimes called multimorbidity, or having multiple long-term conditions. When conditions are looked at one at a time, a person can end up with many separate clinics, lots of tablets and advice that pulls in different directions.
Managing conditions together means stepping back and looking at the whole person, not just each illness on its own. A geriatrician (a doctor specialising in older people's health) or a GP, often with nurses, pharmacists, therapists and social care, reviews the medical, mental, practical and social side of someone's life. This holistic review is at the heart of what is called comprehensive geriatric assessment.
The aim is not to add more treatment. It is to agree what matters most to the person, to make medicines and appointments less of a burden, to stop treatments that are doing little good, and to plan ahead. It cannot cure the underlying conditions, but it can improve day-to-day life, safety and confidence.
Types, options & approaches
There may be different ways to do this. The right approach depends on the clinical question and your circumstances.
Single-condition care versus a joined-up approach
| Feature | One condition at a time | Joined-up approach |
|---|---|---|
| Focus | Each illness separately | The whole person and their priorities |
| Medicines | Can build up over time | Reviewed together; some may be stopped |
| Appointments | Many separate clinics | Prioritised and coordinated |
| Decisions | Guideline-led per disease | Led by what matters to you |
| Best when | A single new problem | Several conditions, frailty or high treatment burden |
Most people benefit from a mix: standard care for new problems, plus a joined-up review when conditions, medicines or appointments become hard to manage.
Preparing for your treatment
- Bring an up-to-date list of all medicines, including patches, inhalers, eye drops, creams and anything bought over the counter or online.
- Write down what matters most to you — for example staying independent, avoiding hospital, keeping a clear head, or being able to get out and see people.
- Note any medicines that you feel are not helping, are hard to take, or cause side effects.
- Bring recent letters, test results and the names of the clinics and teams already involved.
- If memory or hearing is a problem, bring a family member or carer who knows your day-to-day life.
- Think about questions such as how you are managing at home, falls, mood, sleep, eating and getting around.
- Let the team know about any wishes for the future, including anything already written down such as a care plan or advance decision.
What happens
The clinician sets aside more time than a usual appointment — often 45 to 60 minutes — and may split it over more than one visit. They go through your conditions, medicines, mood, memory, mobility, eating, continence, social support and home setup, and look for reversible problems that are dragging you down.
They will ask what matters most to you and what you want from your care. Together you agree which treatments to continue, reduce or stop, which appointments are most important, and what the plan is if things change. A pharmacist may review medicines in detail, and therapists or social care may be brought in.
You should leave with, or soon receive, a clear plan that says who is responsible for what, when you will be reviewed, and how to get help. Ideally this plan is shared with your GP and other teams so everyone is working from the same page.
Is this treatment right for me?
A good consultation should explore whether it's the right choice for you now — including reasons to wait or consider something else.
May not be suitable if…
- An acute, severe or rapidly worsening problem (such as suspected stroke, sepsis or a heart attack) needs emergency care first, not a planned review.
- A single new symptom in someone otherwise well is usually better dealt with through ordinary care rather than a full multimorbidity review.
- If the person clearly does not want a wide-ranging review, their wishes come first; the approach is offered, not imposed.
- It is not a substitute for specialist diagnosis when a specific new condition needs investigating.
Delay or rearrange if…
- There is an acute illness or infection that should be treated and allowed to settle first.
- The person is too unwell or distressed to take part meaningfully on the day.
- Key information is missing — recent results, the full medicine list, or input from a carer who knows daily life.
- A crisis (such as a recent fall, bereavement or sudden change at home) means support is needed now, with the fuller review to follow.
Alternatives to discuss
- Continuing standard single-condition care if that is genuinely working and the burden is low.
- A focused medication review alone, if medicines are the main concern.
- A community or social-care assessment if practical and home-life needs dominate.
- Referral to a specific specialist if one condition is the main problem.
- Watchful, supportive care led by the person's stated priorities.
Before you decide
Use this as a shared-decision checklist. The aim is not just “can this be done?”, but whether it is right for you, now, with the risks and alternatives clearly understood.
What matters most to me?
Think about symptoms, daily life, work, caring responsibilities, sport, fertility, travel, appearance and anxiety — the right choice depends on your priorities, not just the medical facts.
What are all my options?
Ask about waiting, monitoring, medicines, rehabilitation, a smaller or larger procedure, a different test, NHS referral, or a second opinion where that would help.
What would make me pause?
Active infection, pregnancy, unstable medical problems, smoking, medicines that increase bleeding, poor support at home, or feeling pressured are all reasons to slow down and get tailored advice.
What happens if I do nothing today?
For some problems, waiting is safe; for others, delay can make treatment harder. A good consultation should explain the trade-off in plain English.
Benefits
- Care is organised around your priorities rather than each illness separately.
- Medicines are reviewed together, which can reduce side effects, interactions and the daily burden of tablets.
- Fewer, better-targeted appointments instead of many uncoordinated ones.
- Problems such as falls, low mood, poor nutrition or memory worries are picked up and addressed.
- A clear plan and point of contact, which can reduce confusion and emergency admissions.
- Space to talk about what you want for the future and to plan ahead calmly.
Risks & complications
- Stopping or reducing a medicine can occasionally bring back a symptom, which is why changes are made carefully and reviewed.
- It can feel like a lot to take in, especially if several changes are suggested at once.
- Talking about independence, the future or what you can no longer do can be emotional.
- It takes time and more than one conversation to get the plan right.
- A symptom flare after a medicine change that needs the dose restarting or adjusting.
- Disagreement between you, family and clinicians about priorities, which needs careful discussion.
- Plans that are not properly shared between teams, so the joined-up benefit is lost.
- A serious problem from withdrawing a medicine too quickly (for example certain heart, epilepsy or steroid medicines), which is why these are changed slowly and monitored.
- Important wishes being recorded inaccurately if they are not checked back with you.
The biggest pitfall is not a medical complication but care that stays fragmented — lots of separate clinics, nobody holding the whole picture, and medicines that are never reviewed. Ask who is coordinating your care, how medicine changes will be monitored, and how your plan will be shared with everyone involved.
Published figures to discuss
This is a way of organising care rather than a single procedure, so there are no meaningful complication percentages. The main risks relate to medicine changes and to care staying fragmented. Comprehensive geriatric assessment is well supported by evidence for helping older people stay independent, but benefit varies with how it is delivered and followed up, and it cannot stop underlying conditions progressing.
| Figure | Reported range | How to interpret it | Source / confidence |
|---|---|---|---|
| Treatment burden from multiple appointments, tests and medicines | Common in multimorbidity | A good plan weighs workload and quality of life, not just disease-specific targets. | Guide sourcesClinical context |
| Medicine interactions and adverse drug events | Risk rises with the number of regular medicines, especially 10 or more | Medication review should look for duplicated treatment, anticholinergic burden, kidney dosing and medicines without current benefit. | NICE NG56 — Multimorbidity: clinical assessment and managementnice.org.ukSource-linked context |
| Single-condition guidelines giving conflicting advice | Common in frail older adults | Targets for blood pressure, glucose, cholesterol or anticoagulation may need individualising. | Guide sourcesClinical context |
| Unplanned hospital admission | Higher with frailty, cognitive impairment, poor mobility and weak support | Anticipatory care plans, escalation decisions and named contacts can reduce crisis-driven care. | Guide sourcesClinical context |
These are literature figures, not a personalised prediction. Your own risks and likely benefits depend on your circumstances, your health, and how your care is carried out and followed up.
What happens afterwards
There is no physical recovery. What matters afterwards is whether the plan actually makes daily life easier and safer, and whether it is reviewed and adjusted as your health and priorities change.
- Needing more than one conversation to feel comfortable with the plan.
- Mixed feelings about reducing medicines you have taken for years.
- A short adjustment period after medicine changes while your body settles.
- Realising priorities shift over time, so the plan needs updating.
- Feeling relieved that someone is finally looking at the whole picture.
Aftercare
- Keep your medicine list up to date and bring it to every appointment.
- Follow any monitoring asked for, such as blood tests, weight or blood-pressure checks.
- Report new or returning symptoms after a medicine change rather than waiting.
- Use your named contact or coordinator if you are unsure who to ask.
- Take the agreed plan to hospital or other clinics so everyone sees the same information.
- Tell the team if your priorities, home situation or support changes.
- Ask for the plan to be reviewed if you feel overwhelmed by treatment again.
- Full, current medicine list (including over-the-counter and creams)
- Notes on what matters most to you
- List of clinics and teams already involved
- Recent letters and test results
- A family member or carer to attend if helpful
- Questions about medicines, mobility, mood and home life
- Any existing care plan or advance wishes
⚠ Get urgent help if…
- A new or much worse symptom soon after a medicine is stopped or changed.
- Falls, dizziness or fainting, especially after a blood-pressure or heart medicine change.
- Confusion, drowsiness or a sudden change in alertness.
- Chest pain, breathlessness, or a fast or irregular heartbeat.
- Signs of low blood sugar in diabetes (shakiness, sweating, confusion) after medicine changes.
- Not being able to keep down food, drink or essential medicines.
- Any symptom that frightens you or a carer — seek urgent help rather than waiting for the next review.
Who to contact: your clinician, clinic or test provider first (keep their number to hand). For urgent advice when you can't reach them, call NHS 111. In an emergency, call 999.
General guidance — it doesn't replace the specific advice your specialist gives you.
Results & realistic expectations
A good outcome is not a cure but a life that feels more manageable: fewer unnecessary tablets, appointments that make sense, problems addressed, and a plan that reflects your wishes. Success is measured in your terms — independence, comfort, fewer crises or simply less hassle — not by treating every condition to a target.
It cannot stop the underlying conditions progressing, and it cannot guarantee fewer hospital visits, but it gives the best chance of care that works for you rather than against you.
Plans for long-term conditions are never final. As health, abilities and priorities change, the plan should be reviewed and adjusted — sooner after a fall, a hospital stay, a new diagnosis or a bereavement. A plan that is set once and never revisited slowly drifts away from what the person actually needs.
Related tests, treatments or support
This approach often sits alongside specialist clinics (such as heart, kidney or diabetes care), community nursing, therapy, pharmacy reviews and social care. The point of the joined-up review is to make sure these all pull in the same direction and around the same agreed priorities.
Follow-up & long-term care
Follow-up is usually arranged at the review and depends on how much has changed. Expect an earlier check after significant medicine changes, then reviews at regular intervals agreed with you. Your GP usually holds the ongoing plan, with specialist or geriatric input as needed.
- Regular medication reviews, ideally at least yearly or after any major change.
- Agreed monitoring such as blood tests, blood pressure or weight where relevant.
- Periodic check of mobility, mood, memory and home safety.
- Updating the plan and any advance wishes as priorities change.
- Keeping a shared, current record across the teams involved.
Repeat, follow-on and what comes next
- Plans are expected to be revised over time — after medicine changes, falls, hospital stays or shifts in what matters to the person.
- Some medicine reductions need a second attempt or fine-tuning if a symptom returns.
- A plan that is never reviewed gradually stops fitting the person's real needs.
Ask what happens if the result is unclear or needs repeating, and what is included if further tests or follow-up are needed.
What good aftercare looks like
- A clear written plan setting out priorities, medicine changes and who is responsible for what.
- A named contact or coordinator the person and family can reach between appointments.
- Agreed monitoring after medicine changes, with clear advice on what to watch for.
- The plan shared with the GP and other teams, and taken to any hospital visit.
- Scheduled reviews, brought forward if health or priorities change.
What affects the cost
Costs vary a great deal between people and providers, and we don't publish prices. What matters is understanding what drives the cost and making sure your quote is complete. The main things that affect it:
- The length and depth of the review, and whether it is split over more than one appointment.
- Whether a full multidisciplinary assessment is involved (pharmacist, therapists, social care input).
- Whether a detailed medication review is included.
- The number and complexity of conditions and existing specialists involved.
- Whether follow-up reviews, letters and care-planning documents are included.
- Whether home visits or care-home visits are needed rather than clinic appointments.
- The clinician's fee and how long the review will last.
- Whether a medication review by a pharmacist or doctor is included.
- Whether follow-up appointments and plan reviews are included.
- Whether a written care plan and a letter to your GP are provided.
- Who your point of contact will be between appointments.
- What happens, and what it costs, if more assessments or specialists are needed.
- The cancellation policy and arrangements for home or care-home visits if relevant.
On the NHS? Joined-up management of multiple long-term conditions is a core part of NHS care through GPs, geriatric medicine and community teams; private input is usually for a longer or quicker review, more choice or a second opinion.
You're entitled to your total cost in writing — including reports, follow-up and what happens if the result is inconclusive — before you decide.
Consent traps and marketing red flags
These are not small details. They are often where patients lose choice, time to reflect, or realistic expectations.
Consent traps
- Reducing or stopping medicines without clearly explaining why and what to watch for.
- Making the review about hitting disease targets rather than what the person actually wants.
- Recording future wishes or an advance plan without checking them back with the person.
- Not telling the person who is now responsible for what, leaving care fragmented.
- Assuming a carer or relative speaks for the person without involving the person themselves.
Marketing red flags
- Claims that a one-off review or health screen will 'optimise' or 'reverse' ageing or chronic disease.
- Pressure to add more tests, supplements or treatments rather than simplify care.
- Promising fewer hospital admissions or longer life as a guaranteed result.
- A long assessment with no clear plan, no GP letter and no follow-up afterwards.
Choosing a specialist safely
- Check the specialist is on the GMC Specialist Register for this area.
- Make sure they work at a CQC-registered service, and look for membership of the relevant Royal College or professional body.
- You're entitled to time to consider and to have your questions answered before you agree — the specialist who looks after you should explain it, not a salesperson.
- Be wary of pressure: time-limited offers or deposits taken before you've had time to think are red flags, not bargains.
- You're entitled to your total cost in writing — including any follow-up — before you decide.
Questions to ask your medical professional
Take this to your consultation. A good specialist will welcome every one of these.
- Who will coordinate my care and be my main point of contact?
- Which of my medicines could be reduced or stopped, and how will that be monitored?
- Which appointments matter most, and which could be reduced or combined?
- How will my plan be shared with my GP, hospital teams and, if relevant, social care?
- What should I watch for after any medicine change, and who do I call?
- How and when will the plan be reviewed as things change?
- Are you on the GMC Specialist Register for this area, and which Royal College or professional body are you a member of?
- Will you be the specialist who carries out my treatment, and who looks after me afterwards?
- What are the risks for someone like me, and how often do your own patients have a problem or need it repeated or redone?
- What does a realistic result look like — and what can this treatment not achieve?
- What are my options, including waiting, doing nothing for now, or choosing a different approach?
- Can I have written information, results and aftercare instructions in a format I can use, including any accessibility or communication support I need?
- What is the total cost in writing, including any follow-ups, and how much time do I have to decide?
Frequently asked questions
Is this available on the NHS or only privately?
Will I be told to stop my medicines?
Why does the appointment take so long?
What is comprehensive geriatric assessment?
What if my family and I want different things?
Does this mean my conditions are getting worse?
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How we made this page
Medically reviewed by a GMC-registered consultant. Written in plain English, checked against NHS, NICE, GMC and relevant Royal College / specialist-society guidance, and kept under review. No clinic paid to appear on this page, and we publish no pricing. This is general information to help you prepare — it is not a substitute for advice from your own clinician. How we review our guides →
Source hierarchy: UK regulator and NHS/NICE guidance first, then relevant Royal College or specialist-society guidance, then peer-reviewed evidence for procedure-specific figures where available.
Sources & standards: NICE NG56 — Multimorbidity: clinical assessment and management NICE NG56 — Recommendations NICE NG56 — Information for the public British Geriatrics Society — Managing frailty British Geriatrics Society — Comprehensive Geriatric Assessment Hub BGS, Age UK & RCGP — Fit for Frailty best practice guidance (Age and Ageing)
Reviews reflect patients' experience of care, not clinical outcomes. For procedure volumes and outcome data see PHIN.
Last medically reviewed 2026-09-21. Spotted something wrong or out of date? Report an error in this guide.
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