Making clinical guidelines work for people with multiple long term conditions: analysis and recommendations from review of single condition guidelines

Objectives: To evaluate how UK guidelines for individual health conditions consider coexisting multiple long term conditions and to propose improvements to guideline development processes so that guidelines appropriately account for and consider coexisting multiple long term conditions.

Design: Analysis and recommendations from review of single condition guidelines.

Setting: Clinical guidelines developed by the National Institute for Health and Care Excellence (NICE), UK, 1 January 2013 to 31 December 2024. Population: 56 clinical guidelines developed by NICE covering a broad range of long term conditions.

Main outcome measures: The extent to which guideline recommendations consider multiple long term conditions and coexisting conditions, distinguishing between concordant conditions (those affecting the same organ system as the index condition) and discordant conditions (those affecting different systems).

Results: All but one of the NICE guidelines (n=55, 98%) included some advice on managing the index condition in the presence of coexisting conditions, and 50 (89%) guidelines offered general guidance on tailoring care. Only 11 (20%) guidelines, however, explicitly referred to multiple long term conditions, and none included a dedicated section on multiple long term conditions or how care should be adapted in this context. 19 (34%) guidelines featured sections looking at specific coexisting conditions or coexisting conditions generally. Coverage of coexisting conditions varied widely across categories of conditions, with mental health guidelines dealing with the most coexisting conditions (median 10, interquartile range (IQR) 4.5-14.75) in contrast with guidelines on cancer and eye disease covering the fewest conditions (median 3, 1-4.5; median 3, 2.25-2.75, respectively). Of the 397 possible concordant pairings, 120 (30%) were referenced, whereas of the 3859 possible discordant pairings, 259 (7%) were referenced, indicating greater coverage of same system combinations. Data on the composition of guideline committees showed wide variation in size, disciplinary diversity, inclusion of generalist clinicians (eg, general practitioners, general physicians, or others with no single specialty focus), and public contributors, although lived experience of multiple long term conditions was rarely specified.

Conclusions: Despite widespread acknowledgement of coexisting or multiple long term conditions, NICE guidelines are predominantly condition specific and offer limited tailored support for the care of multiple long term conditions. Recommendations rarely considered common condition clusters or the cumulative effect of multiple long term conditions. Structured improvements, such as clearer guidance on adapting care, broader cross condition referencing, and more transparent inclusion of lived experience could enhance the relevance and usability of guidelines for clinicians managing patients with multiple long term conditions.