From one to many
Exploring people's progression to multiple long-term conditions in an urban environment
At Guy's and St Thomas' Charity we focus on big health challenges that affect inner-city areas. Multiple long-term conditions are key amongst these. As a result, we're in the early stages of our ten-year programme to address the issue in our local boroughs of Lambeth and Southwark.
Our latest research looks in detail at the progression to complexity for people living with long-term health conditions, combining analysis of local health data alongside people's experiences.
Scroll down for a snapshot of our research and people's stories or
download the full report
"I'm not ruled by my conditions. I'm me, I'm in charge."
Lynda, 61, Brixton Hill
61-year-old Lynda lives in Brixton Hill in Lambeth. A Londoner all her life, Lynda began to develop health issues in her early 30s. Lynda has since been treated for cancer, depression and also manages diabetes, all of which have affected her mobility and ability to work.
Lynda's story is not unusual among people with multiple long-term conditions in our boroughs: health issues that start early in life and progress to a combination of conditions which can become life-altering.
This work takes a detailed look at the data available Lambeth and Southwark, layering on top the experiences of people like Lynda, to paint a clearer picture of how multiple long-term conditions unfold in an inner-city area.
Over 15 million people in England live with one long-term health condition. Around 3 million have three or more.
As a place-based health foundation, we focus on major health issues affecting people living in urban, diverse and deprived areas. When we look at multiple long-term conditions, we believe that these factors impact on some people's ability to keep healthy for longer.
We partnered with King's College London to take look at multiple long-term conditions in our boroughs to understand better what contributes to developing them, and what solutions can help us slow down progression and improve people’s quality of life.
We have looked at data from Lambeth and Southwark, including GP records, across a portfolio of the most common long-term conditions and their associated risks factors, such as smoking or high blood pressure. We also interviewed local people living with multiple long-term conditions.
Scroll down to explore our key findings, or download our full report.
This is not just a problem of old age
The current understanding around multiple long-term conditions is that it is the inevitable result of getting older.
Whilst age is a major factor, this view misses where the ‘journey’ from single to multiple conditions begins, the role of risk factors and the impact of ethnicity, gender and social context.
In Lambeth, around a third of people with multiple long-term conditions are diagnosed under the age of 65.
Locally, we are seeing the most prevalent long-term
conditions in Lambeth diagnosed in younger people. Serious mental illness and depression are diagnosed in people with an average age of 37 and 38, and diabetes is diagnosed at an average age of 53.
In fact, the four most prevalent long-term conditions in Lambeth have an average age of onset between 37 and 53 years of age.
As notable as the rates of younger people developing multiple long-term conditions is that people living in deprived local areas are more likely to develop multiple long-term conditions on average 13 years earlier than people living in the most affluent areas.
"I was in my twenties when my stomach problems started. I was diagnosed with diverticular disease and soon after with osteoarthritis."
There are a number of commonly associated risk factors with multiple long-term conditions. When looking at these risk factors – such as smoking, high blood pressure or obesity – we see that whilst each individual risk factors increases the likelihood of specific long-term conditions, a combination of each raises the overall risk of acquiring multiple conditions.
Rates of multiple long-term conditions in our local population are higher among men below the age of 60.
This changes above the age of 60, when women represent a higher proportion of the patient group. This is an area for further investigation as our data do not show detailed reasons for this discrepancy.
Mario came to the UK from his native Portugal pursuing a better life for his family. A former semi-professional footballer, he developed health issues early in life which have affected his mobility and ability to work. He finds strength in his loved ones and his passion for cooking.
When I was a child I had asthma and bronchitis. My next health problem was in 1998, in my early thirties, a sarcoidosis problem in the lung. I now have a problem with my lungs, my bones, my pancreas, diabetes.
I started taking cortisone as a treatment for my lungs after an operation in 2002. I took this for eight years and it was after that my other problems started. That was when I had my problems with my bones, the avascular necrosis of the head of the femur.
I was 12 or 13 years old when I started work. To stop the activity as a man makes me feel very, very bad. And financially too, it makes a huge impact on me. Emotionally as well.
A single disease focus may miss the combined impact on the person
By better understanding the diseases that people develop over time or people’s ‘journey’ to multiple health conditions, we may begin to understand some of the complexity and impact on quality of life.
Our exploration showed that people don’t tend to identify themselves by individual conditions. They view some of their symptoms as a result of single conditions and others as a result of having multiple. This affects their view of their health and in turn, how they manage their conditions.
Understanding the patterns
Part of why a single disease focus may miss the reality of a person's lived experience with multiple long-term conditions is the development of additional conditions over time often follows diagnosis patterns. Looking at people's progression from one long-term condition to many may help us consider why certain groups of conditions occur and suggest possible opportunities for intervening early.
For people living with multiple long-term conditions in Lambeth, the most prevalent co-existing conditions are diabetes (62.3%), chronic pain (42.2%) and chronic kidney disease (41.3%).
Diabetes is the starting point for the majority of the most common journeys and chronic pain is a common feature in more than half recorded journeys.
"One of the by-products of the granulomatosis is Type 2 diabetes. It was just a reaction to the vast amounts of steroids that I had to take."
When we consider the many possible combinations of long-term conditions, compounding impact, counter effects of medicines as well as an individual’s own characteristics and risk factors – every person with multiple long-term conditions is unique.
Rather than managing many sets of individual symptoms, data from Lambeth and Southwark supports moving from a ‘one-size fits all approach’ to a person-centred and holistic approach. This may help to address the causal factors and likely subsequent conditions on an individual basis.
“I’ve got chronic pains. I was going to the pain clinic thinking that I would finally find a cure for it. No, they don’t have a cure for pain. I said to her, I said, ‘Well, what do I do?’ She said, ‘You just have to learn to manage it and use things to manage it.’”
Smoking, high cholesterol and obesity are the dominant risk factors across the population of Lambeth.
These risk factors not only point to potential health conditions in the future, but often need managing and dealing with in their own right and highlight the complexity of people’s experiences.
Impact of treatment and care
Whilst individual conditions have their own complexities, these are compounded when a second or third condition is acquired.
"The worst year I had for appointments – 52 weeks in a year and I had 68 appointments. Different departments, different checkups. That was doctors, GP, hospital, diabetes check, eye checks and everything else. I had to give up work because of it."
Elephant and Castle
Lindsay has struggled with mental health his whole life. A diagnosis of depression was followed by granulomatosis – a rare condition of the blood vessels – and diabetes Type 2. He volunteers as a gardener and is looking to get back into work.
The first time I got unwell, the first time I was diagnosed, was with depression, in about 1996 or 1997. It had probably been going on for quite a while. I’d probably had the condition for many years, since my late teens, early twenties, and it wasn't until I was 35 or 36 when it was diagnosed.
I used to binge drink, I suppose it was my way of coping with the depression.
One of the by-products of my granulomatosis is Type 2 diabetes. Not that it caused the diabetes, it was just a reaction to the vast amounts of steroids that I had to take.
I’ve had a great deal of help from the NHS. I’m very lucky. I have a very fine GP, so I’ve been quite switched on to all my conditions.
People's background and social context play an important role
Lambeth and Southwark are examples of dense, urban environments with a broad ethnic mix and high levels of inequality. A deeper look at local data highlights the impact a person's background and social context has on their experience of multiple long-term conditions.
London is a multicultural city and Lambeth and Southwark are prime examples of urban environments with a complex social mix and high levels of inequality.
“When I had the stroke, I said, I’ll do a bit of physio to help myself, help to move my arms and things a bit better. Since I went to the Dragon Café, to the Tai Chi, to the reflexologist, the massage I took, the dancing, the singing, the artwork I do, it relaxes you and you try to make the brain remember things and all of that. It helps.”
People from black and Asian communities in Lambeth are experiencing a greater burden of long term conditions than people from white ethnic groups.
There is a higher prevalence of people living with three of more long-term conditions in black and Asian ethnic groups and people from these communities are often diagnosed years earlier than their white neighbours.
Levels of deprivation also seem to play a crucial role on the burden of multiple long-term conditions experienced by a community. People living in our most deprived wards are diagnosed with multiple long-term conditions earlier than their more affluent neighbours.
"I've always suffered from bronchitis, every winter. I've lived in damp accommodation and I mean damp."
A neighbourhood look at ethnicity and deprivation
Drilling down to data at the neighbourhood level provides helpful insights into the prevalence and distribution of multiple long-term conditions.
For example, a neighbourhood in Knight's Hill has over twice the prevalence rates of people with three or more long-term conditions than a neighbourhood in Clapham Town. The former has more than double the proportion of Black, Asian and Minority Ethnic (BAME) population, and is more deprived.
Whilst the correlation and insights can be debated in detail and require further investigation, our data may suggest that ethnicity, age and deprivation seem to play an interlinked role in the development and progression of multiple long-term conditions.
Clapham Park Estate, Lambeth
Londoner Sue has multiple long-term health conditions including diabetes and vascular disease. Sue has struggled financially and, as an adult, combined studies with work to ensure a better life for herself and her children. She has received an MBE for her services to the community.
Diabetes is in the family, high blood pressure is in the family. I've got it, my brothers and sisters had it, my mother had it and it just won't seem to go away.
When consultants and doctors turn around and say to me I should give up smoking I turn around and say, "Don't go down that road". I've been smoking since I was 15. A cup of tea and a fag has got me through many, many crises.
I worked and studied simultaneously, because when you're destitute, and I mean really destitute, there's only one way to go and that's up. And I thought that was through education.
Eventually I became part of the New Deal for Communities government scheme to improve housing. Having gone through bad accommodation myself I wanted something good for my neighbours. I got a civic award as well as I felt really proud, actually.