Original Research
Care Team Continuity, Flexibility and Collaboration Benefits Whole-Person Care for Patients With Multiple Long-Term Conditions
Background: Research and policy have called for a shift toward whole-person primary care for people living with multimorbidity, defined as the presence of two or more chronic conditions. Researchers in the United Kingdom (UK) observed 25 general practitioner-patient consultations across five practices, and conducted six focus groups — four with 16 primary care staff members and two with eight patients and care staff members— to identify enablers and barriers to delivering tailored care.
What They Found: The researchers found that clinicians assess patients in context, allowing more time when possible, sometimes drawing on home visits or information from carers to understand how patients manage their conditions. Second, patients and caregivers develop management plans collaboratively, with both groups participating in decisions and coordinating across clinicians and services. Third, clinicians described developing new skills and confidence to move beyond disease-specific guidelines toward more holistic conversations about priorities and overall well-being. Clinicians said tailored care was easier when teams had continuity, flexibility and strong collaboration. Tailored care was harder when consultations were short, services were fragmented or care remained tightly structured around single-disease models.
Implications: The findings suggest that delivering whole-person care for patients with multimorbidity requires changes to how primary care is organized and practiced.
Person-Centred Multimorbidity Care in UK Primary Care: Identifying Changes to Practice
Molly Megson, MSc, et al
Hull York Medical School, University of Hull, Hull, United Kingdom
The Annals of Family Medicine
23-Mar-2026