Jonathan Stokes, working for the UK-SELFIE team, successfully defended his PhD thesis “Multimorbidity and integrated care”

Below you can read the abstract of the thesis. Interested in the full thesis? Click here to go to the electronic version.


Health systems internationally face a common set of challenges: ageing populations,increasing numbers of patients suffering from multiple long-term conditions (multimorbidity) and severe pressure on health and care budgets. ‘Integrated care’ is pitched as the solution to current health system challenges. But, in the literature, what integrated care actually involves is complex and contested.

1. What does ‘integrated care’ currently look like in practice in the NHS?
2. What is the effectiveness of current models of ‘integrated care’?
3. To what extent are there differential effects of ‘integrated care’ for different types of multimorbidity?

The thesis utilises routinely collected data, systematic review and meta-analysis,combined with quasi-experimental methods (difference-in-differences, and subgroup analysis, difference-in-difference-in-differences).

The current implementation of the concept of integrated care is predominantly carriedout through multidisciplinary team (MDT) case management of ‘at risk’ (usually of secondary-care admissions) patients in primary care. This approach, however, has not proven capable of meeting health outcome and utilisation/cost aims. Patient satisfaction, though, is consistently improved by the approach. There might also be positive spill-over effects of increased team-working through MDTs for the wider practice population. There does not appear to be a multimorbidity subgroup which benefits significantly more than others in terms of secondary-care utilisation or cost. However, patients at the end of life and/or those with only primary-care sensitive conditions might benefit slightly more than others.

Integrated care, in its current manifestation, is not a silver bullet that will enable health systems to simultaneously accomplish better health outcomes for those with long-term conditions and multimorbidity while increasing their satisfaction with services and reducing costs. The current financial climate might mean that other means of achieving prioritised aims are required in the short-term, with comprehensive primary care and population health strategies employed to better prevent/compress the negative effects of lifestyle-associated conditions in the longer-term.



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