The review represents a milestone in the process of generating Strategic Intentions for the Working Age population living with multiple long-term conditions. It outlines a set of Design Principles derived from insights gathered through local linked data, a literature review centered on multiple health needs, and discussions with experts, the public and key stakeholders. These Design Principles will guide the project into the next phase of generating plans through community-led design.
About Healthier Together 2040
Healthier Together 2040 is a strategic initiative aimed at enhancing the health of individuals residing in Bristol, North Somerset, and South Gloucestershire by the year 2040.
The plan first focuses upon the working-age population who are living with multiple long-term health conditions such as diabetes, chronic pain, and mental health issues, particularly those who are employed or providing care for others.
This group, along with those at risk of joining this demographic, is an indicator of the current and future health needs which the health and care system will need to respond to. Without substantial redesign in collaboration with the public, the system will be unable to meet the increasing demand, leading to a decline in overall wellbeing.
The approach includes the three national shifts moving healthcare closer to communities, using technology better, and focusing on prevention rather than just treatment.
About this population
There are about 5,300 people aged 20 to 64 in the area who have three or more long-term conditions from a short list of hypertension, diabetes, anxiety, depression, and chronic pain. This group is projected to grow by 50% in the next 15 years, under the assumptions of our local Dynamic Population Model.
Most people in this group live in deprived areas and their ability to manage their health is significantly impacted by their living and working conditions. In addition to this cohort, there are 38,000 people in wider risk groups where there is a prevention opportunity to delay or prevent further deterioration in health. This cohort is at a higher risk of emergency hospital visits and long-term care needs which is an indicator that our healthcare system as it is currently set up is not proactively supporting people.
Literature review summary
The literature review examined current research on how to improve the quality of life for people with multiple long-term conditions. It found that poor mental health, social and economic challenges, and fragmented healthcare services are major obstacles.
Addressing the wider and social determinants of health, such as poverty and job insecurity, is crucial to improving outcomes. Mental health problems, particularly anxiety and depression, are common among this group and make managing physical health more challenging.
Insights summary
People we spoke with reported feeling frustrated by the complexity of healthcare systems. They face challenges in accessing consistent, holistic care and often feel neglected or dismissed when trying to get help.
Community support and flexible, personalised care models are essential. Addressing mental health needs alongside physical care and involvement of community networks and organisations were recognised as important and valuable strategies. Employers can play a key role by offering support for mental wellbeing and flexibility at work.
Design principles
Bringing together the evidence and insights led to a set of ten Design Principles developed to ensure that ideas generated in the next phases are based on solid evidence and informed insights:
Recognise the Causes of the Causes: Solutions must address individuals’ life contexts holistically, considering the wider determinants of health to prevent exacerbating health inequalities.
Mental Wellbeing First: Enhancing mental health should be central to any care, as it plays a critical role in people’s overall wellbeing.
Physical Activity and Nutrition: Systematically focusing on physical activity and healthy dietary practices address key risk factors for this population cohort.
Community-Based Proactive Clinical Models: Develop community-based clinical models that integrate specialist support and are rooted in people’s holistic needs.
A Core Value of Whole-Person Wellbeing: A shift to redesigning services to enable professional interactions rooted in building trusted relationships and addressing the causes of the causes.
Supporting busy people, caring and working: Care models should recognise and respond to the unique needs of this population, including many multi-generational caregivers.
Addressing Self-Worth and Feelings of Guilt: Approaches to condition management should actively address guilt, shame, self-worth and the impacts trauma has on positive health behaviours.
Making VCSE Involvement Essential: Effective solutions should actively involve communities and Voluntary, Community, and Social Enterprise (VCSE) organisations as essential partners.
Sustainable Funding for Community Initiatives: Funding arrangements for community-based organisations addressing broader health determinants should prioritise long-term investment and incorporate outcome monitoring.
Workplaces are vital in health and keeping people in work: Workplaces can prevent poor physical and mental health, and some can be part of solutions.
Looking ahead
Over the summer of 2025, these Design Principles will be used as part of a co-design process to develop strategic intentions for this population cohort.
There will be a series of expert events, public focus groups, and an advisory group using design methodologies with the finalised strategic intentions are expected by early Autumn 2025.
This work will also inform future planning for three additional cohorts: preconception to 25 (with at-risk clusters to be identified), individuals living with multiple disadvantages (around 3,000 people facing complex needs), and older adults with multiple long-term health conditions (about 35,000 people over 75).
