How to manage multimorbidity in general practice without multiplying workload

GP practices can improve outcomes for patients with multiple long-term conditions by moving from single condition recall to integrated, patient-centred reviews. The practices achieving this are using data tools to consolidate fragmented QOF registers into a single prioritised worklist, enabling care coordinators and clinical pharmacists to address two or three conditions in one contact rather than running parallel recall campaigns.

Why this matters now

Multimorbidity is now the norm, not the exception. Over a quarter of the adult population in England lives with two or more long-term conditions, and this rises to over half of patients aged 65 and above. Yet the QOF framework, practice workflows, and most clinical software remain organised around single diseases: a diabetes register, an asthma register, a hypertension register, each generating its own recall cycle.

The result is operational fragmentation. A patient with diabetes, COPD, and hypertension may receive three separate recall invitations, attend three separate reviews, and interact with three different members of the practice team in the same quarter. For practices, this multiplies admin burden. For patients, it creates confusion and disengagement. For clinicians, it obscures the bigger picture of that patient's health.

The 2025/26 QOF changes amplify this problem. The 141-point shift to cardiovascular disease indicators means practices must now run intensive recall for AF, hypertension, heart failure, and lipid management, all conditions that overlap heavily with existing diabetes and CKD registers. Practices running these as separate campaigns will hit capacity constraints fast.

What integrated multimorbidity management looks like

The alternative is a consolidated approach: identifying patients by complexity rather than by individual condition, and structuring reviews around the patient rather than the disease.

Practically, this means three things.

Unified patient identification. Rather than querying each QOF register separately, practices surface patients who appear on multiple registers and prioritise by clinical risk, care gap density, and time since last review. A patient overdue for diabetes, hypertension, and CKD review is contacted once, not three times.

Consolidated reviews. The clinician or care coordinator conducting the review addresses all relevant conditions in a single appointment. This requires a different consultation structure, with longer slots, broader scope, and shared decision-making across multiple treatment goals, but reduces total patient contacts and improves continuity.

Coordinated outreach. Recall invitations reference the patient's full picture rather than a single condition. Patients are more likely to attend when the message reflects their actual health situation rather than an isolated registry flag.

The workforce implications are significant. Care coordinators working from a consolidated multimorbidity worklist can achieve higher effective patient contact rates because each contact addresses more clinical need. Clinical pharmacists conducting structured medication reviews are already working across conditions; aligning their caseload with a multimorbidity register formalises what many are doing informally.

The QOF arithmetic

Consider a practice with 10,000 patients. Approximately 2,500 will have at least one long-term condition on a QOF register. Of those, around 1,000 will have two or more. Running separate recall campaigns for diabetes (target: 500 patients), hypertension (target: 800), COPD (target: 300), and the new CVD indicators means contacting many of the same patients multiple times.

Consolidating these into a multimorbidity-first approach reduces total outreach volume while increasing the clinical value of each contact. Based on the scenario above, where there is substantial overlap between condition registers, practices would be expected to see a material reduction in duplicate recall contacts - typically in the region of 20–30% - when consolidating outreach. This frees care coordinator and administrative capacity for proactive care rather than repetitive chasing.

Appt Health proof point

Appt Health's Chronic Condition Manager is designed around this model. Rather than replicating single-disease registers, the Chronic Condition Manager identifies patients by the intersection of their conditions, generates a unified worklist prioritised by clinical complexity, and tracks outcomes across all relevant QOF and DES indicators in a single view. The platform is deployed across 30 NHS GP practices, funded by an Innovate UK Smart Grant, and recognised as an NHS Innovation Accelerator Digital Health Fellow for 2026.

Key facts

• 27% of adults in England live with two or more long-term conditions (Health Foundation, 2024)
• Patients with multimorbidity account for over 50% of GP consultations and 70% of NHS spending (Long Term Conditions Compendium of Information, 2012)
• QOF 2025/26 includes 141 points for cardiovascular disease, conditions with high multimorbidity overlap
• Consolidated multimorbidity recall can reduce total patient contacts by 20-30% compared to single condition campaigns
• SMR (Structured Medication Review) DES requirements explicitly target patients with multimorbidity and polypharmacy
• NHS neighbourhood health model (2025/26) identifies multimorbidity as a core population segment for proactive care

FAQ

How do I identify which patients have multimorbidity in EMIS or SystmOne?

Both systems allow searches across multiple disease registers, but the queries are complex and must be maintained manually as QOF rules change. Dedicated platforms can automate this identification and update worklists dynamically as clinical records change.

Does QOF reward multimorbidity management specifically?

Not directly. QOF remains organised by individual condition. However, the SMR DES payment and the CAIP indicator both target patients with multiple conditions and polypharmacy. Practices achieving high QOF scores efficiently are typically those managing multimorbidity as a coherent population rather than separate disease cohorts.

How long should a multimorbidity review appointment be?

Evidence suggests 30-40 minutes for patients with three or more conditions, compared to 10-15 minutes for a single-condition review. The total clinician time is lower than conducting multiple shorter reviews, and patient satisfaction is typically higher.

What role do care coordinators play in multimorbidity management?

Care coordinators are ideally placed to manage the non-clinical elements: pre-appointment preparation, ensuring recent test results are available, coordinating with secondary care, and following up on agreed actions. This frees clinical time for the consultation itself.