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BACKGROUND: Around one in four people are living with multiple long-term conditions (MLTC). Integrated care to holistically manage both health and social needs could improve outcomes for people living with MLTC, including lower rates of hospitalisation and mortality. However, given the number of people with MLTC and increasing strain on health and social care, stratified approaches to identifying and addressing social care needs may be more efficient and cost-effective. We have developed data driven clusters that group people with similar health and social care needs, which could identify patients at the highest risk of poor outcomes related to social care need. AIM: To explore views about a future intervention based on these clusters. METHOD: We aim to plan a cluster-based intervention that engages people living with MLTC and health and social care professionals to consider social care needs (SCNs) when consulting in primary care. We have conducted 14 interviews with professionals to explore their priorities and concerns about care delivery by MLTC clusters and 19 remote interviews with people living with MLTC to find out how well they identify with the MLTC clusters we have defined. Data were analysed using reflexive thematic analysis. RESULTS: GPs are the 'starting point' for conversations about SCNs but need an efficient system to enable effective conversations. The cluster-based intervention could fill this gap. CONCLUSION: This research identifies key considerations needed for an intervention to engage people with MLTC and health and social care professionals to consider SCNs in primary care.

Original publication




Journal article


The British journal of general practice : the journal of the Royal College of General Practitioners

Publication Date