Confed Viewpoint blogs

The major conditions strategy - just another NHS plan?

Insights into the benefits of a multimorbidity approach to managing major conditions that goes beyond the NHS.
Dr Layla McCay, Ruth Lowe

15 August 2023

Up to 80 per cent of what affects physical and mental health comes from outside the health system, making NHS action alone not enough to improve healthy life expectancy gap. 


This article was first published by the BMJ on 14 August 2023

The major conditions strategy will be one of this government’s last health strategies before next year’s general election. The Secretary of State for Health and Social Care, Steve Barclay, has set it three aims: narrow the healthy life expectancy gap; reduce ill-health related labour market inactivity; and alleviate pressure on the health service. These are not actions that can be achieved with NHS activity alone. The major conditions strategy combines several expected health papers from the government: cancer, mental health and wellbeing, and dementia, to name a few. Perhaps unsurprisingly, condition-specific campaigners and organisations continue to request standalone strategies.

Does dividing healthcare planning into condition-shaped siloes make sense, though? While deeper dives into each condition will no doubt be valuable next steps, some healthcare leaders are supportive of the strategy bringing different conditions together. This approach - a multimorbidity approach - reflects how patients experience illness and therefore how they interact with the health system. A cancer diagnosis, for example, is strongly associated with a risk of first-onset mental health conditions; and patients with poor cardiovascular health are substantially more likely to develop musculoskeletal disorders. More than a quarter of the adult population in England are currently living with two or more long-term conditions, and this is forecast to increase over the coming decades. Recent projections found that by 2040, the number of people living with major illness is projected to rise by over a third. For people living with multimorbidity and their carers, this means spending a vast amount of time and energy accessing different services, complying with multiple complex treatment plans and coordinating care.

Any strategy dealing with multimorbidity must address the persistent inequalities in their prevalence

Multimorbidity also has a significant impact on the health system. Patients with multimorbidity are the country’s highest users of health and social care services and experience the most unplanned admissions and outpatient care. One-third of all patients admitted to hospital have five or more health conditions.

And any strategy dealing with multimorbidity must address the persistent inequalities in their prevalence - in Scotland’s most deprived areas, patients develop multimorbidity ten to 15 years earlier than in the least deprived areas.

What is working that the strategy must sustain?

Structures such as integrated care systems (ICSs) and primary care networks (PCNs), are already in place to facilitate a multimorbidity approach to the health service that provides care closer to home and communities, keeping people healthy, able to maintain employment, and enjoy time with loved ones. These structures don’t need radical change - they need to be sustained, through investment and support.

PCNs, for example, are yet to be committed to beyond 2024, when the current five-year framework for the GP contract ends. Ensuring stability for primary care practitioners will be essential to the strategy’s successful implementation, given that primary care is where many of the major conditions are diagnosed, treated, and managed.

How can the strategy look beyond the NHS to achieve its aims?

Up to 80 per cent of what affects our physical and mental health comes from outside of the health system

Half a century on from the first Whitehall study, by now, those of us working in health policy are well versed that up to 80 per cent of what affects our physical and mental health comes from outside of the health system. NHS action alone can’t narrow the healthy life expectancy gap, reduce ill-health-related labour market inactivity, or alleviate pressure on the health service.

As such, there are certain actions that the government must take to create the conditions for a healthy society.

Prevention through regulation

Tobacco and obesity are linked to all of the strategy’s chosen conditions and have substantial impact on inequalities in healthy life expectancy. Recent independent reviews have recommended the regulation of these markets: The Khan Review, Making Smoking Obsolete, suggested a polluter pays levy whereby stop smoking services are funded by additional taxation on tobacco companies; and the National Food Strategy: Part Two called for a salt and sugar reformulation tax. Ultimately, the state pays for its own inaction: tobacco costs the NHS in England £2.6 billion per year, and wider society around £17 billion per year. Obesity, the other highest cause of preventable illness and death in the country, is estimated to cost the NHS £6 billion per year.

Address structural factors such as racism, poverty and gender inequality which drive inequalities in the conditions

Alleviating pressure on the health system requires a shift from treating illness, to treating the conditions that cause illness. To do this, the strategy must go beyond place-based inequalities and address the full spectrum of drivers of disparities in the conditions, including racism, gender inequality, and poverty. The strategy must explicitly consider the differential impact on women and men as a golden thread throughout, take the opportunity to create central consensus on ethnicity data to be used in healthcare, and be explicitly linked with work to address the causes of ill health in communities such as fuel poverty and housing insecurity.

Health in all policies

The strategy should mandate health equity impact assessments of all new government policies

The major conditions strategy is inherently cross-governmental in its inception: it’s taking forward the government’s health mission from the levelling up white paper. It is clear that embedding this cross-government approach in the implementation and delivery of the strategy is an essential component for success in this mission. The strategy should therefore mandate health equity impact assessments of all new government policies.

Take a life-course approach

Finally, while multimorbidity is more common in adults than in children, adopting a life-course approach so people are born well, live well, and age well is essential for reducing the prevalence of the major conditions.

Preventing the onset of disease in young people is critical, both for the patient and for the cost to the system. This is especially true for mental health conditions. Despite this, the government is currently only committed to providing mental health support teams in just over one in four schools. To embed a preventative, life-course approach, and reduce regional inequality, healthcare leaders are calling for a commitment from government to fund mental health support teams in all schools.

Layla McCay is director of policy at the NHS Confederation. You can follow Layla on Twitter @LaylaMcCay

Ruth Lowe is policy associate at the NHS Confederation. You can follow the NHS Confederation on Twitter @NHSConfed