Efficient Multimorbidity Management

Multimorbidity encapsulates the challenges of generalist care. This project aims to understand barriers and opportunities for offering holistic chronic disease care and to showcase examples of effective practice. This will include assessing ways to streamline chronic disease care and how work can be shared across the multidisciplinary primary care team.

The RCGP has a fundamental translational role in championing new ways of working as outlined in RCGP 2022 Vision: multimorbidity is increasingly relevant due to our ageing population and the complexities arising from improved standards of care for chronic long-term conditions. It is now common for patients to accrue an array of chronic diseases because of shared underlying lifestyle risk factors, such as obesity, malnutrition, smoking, loneliness, poverty, poor dentition, inactivity and excess alcohol. Maximising efficient care for patients with several co-morbidities will benefit individuals but also is crucial if primary care is to cope with the changing prevalence, demands and pharmacological complexities of non-communicable diseases.

Multimorbidity is relevant to and will collaboratively support existing RCGP clinical priority work streams, in particular the Cancer, Physical Activity and Lifestyle and Liver Disease projects, because it intertwines with many of the central themes relevant to these areas.

Aims of the project

  1. To understand barriers to offering holistic chronic disease care (compared to single disease QOF-led care) 
  2. To showcase examples of effective practice, including assessing ways for blood test monitoring to be streamlined and how work can be shared across the multidisciplinary primary care team.
  3. To broadcast the importance of managing multimorbidity efficiently and trigger awareness of the need to tackle underlying shared chronic disease risk factors, thus evolving from existing silo disease models of care

Key outputs 

A report of the RCGP survey of current attitudes to providing multimorbidity care has been developed by the Clinical Champion of the project, Dr Rachel Pryke. Download the report.

Exploration of how template development has been used to support holistic co-morbidity management that focuses on patient priorities and underlying shared risk factors, rather than just QOF boxes. 

Resource development including a set of short ‘Clinical Conversation Cases’ teaching and dissemination tools for publication in InnovAiT to support training in multimorbidity conversations and a list of good practice examples through the RCGP’s quality improvement platform and RCGP Web Index. This will highlight varied examples of how multimorbidity management can be individualised for patients with several co-existing conditions, such as how malnutrition management can improve COPD care or improve outcomes during cancer treatment, or how physical activity approaches can feel feasible for those with complex health problems). Download the summary

Linking and supporting the 3D Bristol study.

Linking with the NICE Implementation Team to identify tangible collaborative steps to promote the NICE 2016 Multimorbidity guidance (NG56). 

Clinical team

Dr Rachel Pryke Dr Rachel Pryke MBBS MRCGP FRCP is a GP and trainer in Worcestershire. She is RCGP Clinical Advisor on obesity and multimorbidity and held a NICE Fellowship from 2015-18. She is an author of many obesity resources including two books and runs primary care obesity and malnutrition training courses throughout the UK. She collaborated with WHO on a European primary care obesity training package

Dr Pryke is a member of the National Child Measuring Programme Board, PHE Obesity Priority Programme Board and sits on World Obesity Clinical Care Committee. She is currently a commissioner on the Lancet/EASL Commission on Liver Disease across Europe.


General introduction and models of care

Social prescribing

 Polypharmacy and treatment burden

Motivational interviewing and communication skills

Nutritional aspects



Find many links to different resources relating to obesity at the RCGP A to Z Obesity webpage.

Physical activity

Research and policy

 Training material


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