December 2018

1. Long-Term Conditions December 2018 Report by Ipsos MORI for Framing Multiple Guy’s and St Thomas’ Charity

2. The importance of multiple long-term conditions The state of play Over 3 million people in the UK live with three or more long-term conditions(1). Multiple long-term conditions (MLTCs) have a significant impact on the lives of people who live with them, the carers that support them and health and social care services. Within the London boroughs of Lambeth and Southwark, the prevalence of multiple long-term conditions is estimated to be high. For example, for every five people in Lambeth and Southwark with diabetes, four will have (or develop) another condition, such as depression, heart failure or cancer. A common perception of multiple long-term conditions is that it is a phenomenon prevalent amongst older people. Whilst old age is a factor in predicting the prevalence, a broad range of ages and people are affected by multiple conditions. For example, in Lambeth, over a third of people estimated to be living with multiple long-term conditions are under the age of 65. Socioeconomic status is also a key determining factor. Those people who live in deprived areas are likely to develop multiple conditions up to 15 years earlier than those people living in more affluent areas. Ethnicity, deprivation and the management of risk factors play a key role in the prevalence of multiple long-term conditions.

3. Understanding multiple long-term conditions Framing the issue – what we know • The current framing of multiple long-term conditions is problematic: • The language used within the NHS is inconsistent and lacks a personal focus. There are a broad range of termsof similar meaning that are used by health professionals to describe people living with more than one health condition. Patients may often be described as having ‘co-morbidities’, ‘multi-morbidities’, ‘chronic conditions’, ‘complex conditions’, ‘complex needs’ and experiencing ‘frailty’. • People living with multiple long-term conditions tend to be defined by their individual conditions and are treated for a single condition. This can fail to address the cumulative impact of multiple long-term conditions on a person. • Multiple long-term conditions have a significant impact on the NHS, with a considerable amount of NHS resource being used in the treatment and management of people living with multiple long-term conditions. However, multiple long-term conditions are poorly understood outside the issue of frailty and an issue that relates to an ageing population. • Social factors play a major role in the variance within which multiple long-term conditions impact on the lives of the people who live with them. Health behaviours and lifestyle, ethnicity, housing and socioeconomic status all impact on the likelihood of developing multiple conditions but also in how people living with multiple long-term conditions experience them. The health system is poorly equipped to address these issues alone, without the involvement of other agencies. • The way multiple long-term conditions are perceived is heavily centred around the bio-medical frame and this frame tends to dominate the pathways through which patients interact with and access different aspects of the health service – focusing on a single disease or condition. 1The King’s Fund, 2010; 2 Guy’s and St Thomas’ Charity, 2018

4. Guy’s and St Thomas’ Charity's programme An overview • Guy’s and St Thomas’ Charity is an independent place-based foundation. We work in partnership with Guy's and St Thomas' NHS Foundation Trust and others to tackle the major health challenges affecting people living in urban, diverse and deprived areas. • The Charity is delivering a 10 year programme aiming to work with others to slow down the progression from one to many long-term conditions. The programme looks specifically at tackling the complex mix of factors influencing progression. • The programme’s main focus is on working-age people in Lambeth and Southwark and involves: • Helping people improve their physical and mental health as well as the management of their conditions. • Supporting people to make changes to the social factors that influence progression of their conditions. • Strengthening agency and building connections in communities to underpin efforts to tackle health and social factors. • To support this, the Charity has set out three communication objectives: • Engage key audiences in the programme. • Increase awareness amongst professionals of multiple long-term conditions as a major health challenge and social issue, requiring local and national action. • Share emerging insights from programme to influence policy and practice.

5. Purpose of the research Why was this research commissioned? • The research set out to: • Improve understanding around how multiple long-term conditions are talked about by different actors, such as academics, policymakers, health professionals and people living with multiple long-term conditions. • Support the development of a new shared language around multiple long-term conditions through which effective communication can work for all parties.

6. Research process Stakeholders: 15 telephone interviews with frontline professionals, academics, people working in policy roles. Familiarisation: Set-up meeting with the Charity’s steering group, key conversations, reading material. Discourse analysis: Robust and systematic analytical assessment of the data. FINISH START Document review: c.25 sources of mainly grey literature to build an understanding of the language used. People living with multiple long term conditions: 15 face-to-face interviews with a diverse group of people living with multiple long-term conditions. Report: The development of hypotheses to test and recommendations for communication with different groups.

7. Definition, variation and terminology Looking at how the term is used in more detail, it is clear that there is some variation in its definition. There is a lack of consensus around the number of conditions included within the definition. To some, the use of multiple is taken at face value (i.e. more than one), whereas others feel that having three or more conditions is where the complexity and difficulty in treatment becomes more apparent, and a persons’ lifestyle may start to be affected. The severity of the impact of the multiple conditions and their interactive, rather than an additive, effect on people’s lives has also been mentioned. The diseases considered to be ‘long-term’ also vary. For example some stakeholders believe that only conditions managed over time, like diabetes or arthritis, should be included. But other stakeholders believe the definition to be more broad, covering degenerative conditions and some forms of cancer. There are also a number related terms which are used interchangeably with multiple long-term conditions (all of which slightly differ in meaning depending on the context in which they are used). For instance: multi-morbidity, co-morbidity, poly-chronic conditions, polypharmacy, chronic conditions, complex conditions and complex needs. The term ‘multiple long-term conditions’ is commonly used by academics, policymakers and medical professionals and holds currency amongst these groups. But the understanding of its meaning and the definition given can vary. However, there is broad agreement on the general understanding of multiple long-term conditions – they are a group of chronic diseases which cannot be cured and need to be managed over time. The social determinants of multiple long-term conditions are also considered to be important in its definition – influenced in part, by factors such as education, income and diet, as well as old age. It might be an ongoing chronic thing that you have for the rest of your life that needs managing and may go through periods of stability and change. Multiple long-term conditions would be the experience of having more than one of those things. The problem with that is that they tend to interact and conflict, one influences the other and it can have a serious affect on lifestyle and they may face a lot of challenges.“ Frontline Staff, Lambeth and Southwark Diabetes, arthritis, nowadays maybe cancer is in there. Not all of them but some, it’s the really incurable conditions. Things like bipolar are essentially long-term conditions but then there are others like depression which aren't necessarily long-term but related.” Academic, Social Welfare If you had asked me this question three weeks ago, I would say a person with physical and mental health problems. But the social determinants are incredibly important. It’s about whole person care.” Policy Expert, Healthcare

8. So, why is framing useful? • All frames have built-in assumptions about the people using them. For multiple long-term conditions, this may include: • The medical services used • The nature of the disease • A person’s level of knowledge and understanding • And their role in the illness and treatment • But in all frames, actors are limited by the language and terms available to them to accurately describe their experiences. And this is particularly the case for people have multiple long-term conditions and those who work with them. • An investigation of the multiple long-term conditions frame can help identify language, concepts and terms which all stakeholders can share. A broader range of shared language for actors to draw on will lead to better communication about their experiences and ultimately bring about positive health outcomes. Understanding multiple long-term conditions through the lens of frame analysis will help to identify what language resonates with people, what concepts are retrievable and available and what holds significance to people, in particular among people with multiple long-term conditions.. The concept of a ‘frame’ and the broader idea of frame analysis is based on the work of Erving Goffman who defined a frame as: In other words, frames act as a blueprint for social conduct, providing a set of shared meanings for what is going on which is used by individuals, organisations and wider society. They allow us to claim an identity and influence the organisations we come into contact with. Essentially, they are shared definitions of a situation, and like all definitions they are continually being constructed, recreated and reaffirmed through social interaction. This means the understandings we hold personally, or the ones we share in our social circles and in wider society are malleable – they can be shifted and changed toward a certain purpose. A schemata of interpretation that enable individuals to locate, perceive, identify and label occurrences within their life space and the world at large. By rendering events or occurrence meaningful, frames function to organize experience and guide action whether individual or collective.” Erving Goffman. Frame Analysis: An Essay on the Organization of Experience (1974)

9. Framing in action There are some examples of how the reframing of a specific health issue can have an impact on the language, perceptions and understanding of individuals and wider society. HIV The Smoking Ban The Sugar Tax • Over the past 30 years perceptions of HIV have changed considerably. In the early 80s HIV was seen as an issue primarily affecting gay men, with much fear, paranoia and stigma around the disease. • The first change in the HIV frame can be seen in the move toward a new, more accurate term – Auto Immune Deficiency Syndrome (AIDS). • But real change began as patient activists were able to shift the way HIV was perceived and understood, through social action such as protests and engagement in politics. • Patients also became experts in both medical language, and political mobilisation. This created a shared understanding between health professionals and patients, where political and medical input came from people who were directly concerned with the disease. • Just over 10 years ago, the UK banned smoking in enclosed spaces, marking a shift in the nation’s attitude. • Before the ban was enacted, charities and campaigners were working to make the issue of smoking a public health issue. This also coincided with preventative work on cancer. • Initially an unpopular piece of legislation, with some decrying the rise of the ‘Nanny State’, public opinion has now changed, with most of the public supporting the smoking ban. People have now adopted the frame first put forward in the name of prevention and good health. • Since the smoking ban, there has been a decline in the number of teen smokers (2) and a drop in the number of adults taking up smoking (3). • The level of sugar in food is another area of public health concern where the frame has shifted over time. • Sugar has become viewed as one of the major health issues of the last ten years. Slowly, opposition from charities and health organisations led to a change in understanding of the types of food we eat and consume. • The issue of ‘hidden sugars’ has become linked with children's health, obesity, Type 2 diabetes and the future health and economic well-being of the nation. • High profile campaigns by celebrities – particularly chef Jamie Olivier – have also helped to shift the frame in relation to sugar. • The changing of the frame has led to a tax on some sugary foods and calls for further restrictions on the marketing of foods and reformulation of food products.

10. Explaining the language of multiple conditions Academics i i i i The language model The model describes the kinds of frames different stakeholders use to discuss multiple long-term conditions. There is some bio-medical language used throughout each of the stakeholders’ frames. The model shows the inverse relationship between the utility of the term ‘multiple long-term conditions’ and the impact it has on the stakeholder, even while the concept itself is clearly important. The language is most familiar at the top of the model and least at the bottom. People with multiple conditionshave the least ability to make the impact of multiple long-term conditions felt without the necessary language. Other stakeholders are charged with needing to translate the concept to multiple audiences. Navigation: To navigate through the model, click or use the arrows on your keyword, or use the ‘i’ icons when you are in slide show mode. The summary associated with each stakeholder is provided on the subsequent slides. Policy Experts MLTC understanding Frontline Staff People with multiple long-term conditions

11. Explaining the language of multiple conditions Academics i i i i • Academics • Public Health – Scientific Code Academics are very familiar with the term ‘multiple long-term conditions’ and there is a growing amount of literature on this topic. Even while academics recognise the needs of people with multiple conditions, and a person-centred approach, their language demonstrates a distance from people’s daily lives when speaking about multiple long-term conditions in terms of its definition, incidence, associated data and need for more research. • Examples of key terms used:- Risk factors • Impairments • Social participation • Co-morbidities • Multi-morbidity • Pathways Policy Experts MLTC understanding Frontline Staff People with multiple long-term conditions

12. Explaining the language of multiple conditions Academics i i i i • Policy Experts • Political economic – bureaucratic/administrative codingTo some degree, policy experts must engage with all stakeholders and understand multiple audiences and problems to create impactful social policy, and their language reflects this; it varies depending upon the specific need or audience. They feel the limitations of the single-disease model structuring the discussion around multiple long-term conditions as they are focused on contextual drivers of the situation, such as socio-economic deprivation and system reconfiguration. Focused on contextual factors, they are also concerned with wider issues impacting on the affected population. • Examples of key terms used:- System reconfiguration • Streamlining • Strategy • Commissioning plans • Deprivation Policy Experts MLTC understanding Frontline Staff People with multiple long-term conditions

13. Explaining the language of multiple conditions Academics i i i i • Frontline Staff • Biomedical – medical codingFrontline staff, such as doctors, have been professionalised into a particular way of understanding the body, patients and illness. Their engagement in patient interaction is not only about treating patients, but also about developing rapportand empathy to the degree that it facilitates treatment of the person. Part of this process is about understanding how to translate their knowledge into more generalised terms in order to treat patients, but the concept of the patient as expert and partner is limited by a number of factors, including the single-disease model around which their knowledge, approach and the medical system is based. • Examples of key terms used:- Disease trajectory • Patient activation • Co-morbidities Policy Experts MLTC understanding Frontline Staff People with multiple long-term conditions

14. Explaining the language of multiple conditions Academics i i i i • People with multiple long-term conditions • Socio-medical – common languageThe language individuals with multiple long-term conditions use is a reflection of the ways in which their medical conditions and their lives intersect with the healthcare system but also more broadly how their medical conditions affect their lives, socially and organisationally. What seems central to their language is their personal capability and capacity in the world and how it is altered with respect to their medical conditions, and their relationships with people around them, both within and outside of the medical context. • Examples of key terms used: • Persistent • Frustrating • Debilitating • Independence and management Policy Experts MLTC understanding Frontline Staff People with multiple long-term conditions

15. Stakeholders

16. Academics How they talk about multiple long-term conditions varies depending on who academics speak to. When communicating with peers or other professionals, they may talk about the issue in explicit terms. However, they would not talk in this way in a patient context, nor with members of the public. Instead, academics talk in lay terms about issues that directly relate to the patient’s experiences and challenges faced in managing daily life. It is recognised that the frame for multiple long-term conditions lacks clarity: Whilst conceptually easy to understand, there are some difficulties with the practicalities and benefits of engaging patients with the current frame. • Academics specialising in the area of long-term conditions talk about multiple long-term conditions with familiarity and a common understanding. For them, the frame has developed and expanded over the last five years as research into long-term conditions and people with complex needs has focused on gaining a deeper understanding about the growing number of people presenting with multiple health needs and health conditions – for which the single-disease model is inadequate. • Academics use a scientific code to talk about multiple long-term conditions. They talk about the issue of multiple long-term conditions interchangeably with other issues with a similar focus, such as co-morbidity, multi-morbidity, chronic conditions and frailty. • While research into multiple long-term conditions has progressed, discussions around patients’ health with colleagues and peers is limited by the dominance of a single-disease model. There still remains a lack of evidence and data on the issue of multiple long-term conditions to facilitate these conversations across the variety of stakeholders (and thus a more generalised approach to the issue). MLTCs is a different way of thinking. It’s about recognising that categorising [patients] by a single health condition doesn’t work. We need to have a people focused approach, rather than a disease focused one, and that requires thinking about doing healthcare differently.” Academic, University How do you define MLTCs? I think we need some criteria to define a commonly accepted definition. A definition which the public would accept, which healthcare professionals would accept, because even when you have an agreed set of conditions...there are gradations of severity. We need some kind of weighting system that tells you these aren't just background conditions. We need to have some threshold for each condition, before it can get included in a basket of multi-morbidities.” Academic, University • Do I find it useful? No not really. I think the problem is that it doesn’t really lead to a change in the treatment of the patient or in their care. We just say ‘thank you very much, here's a patient with multiple conditions’. And yet the patient will still get seen just for a single problem with their liver or kidney.” • Academic, University

17. Policy experts The convention of using a single-disease model presents challenges for most stakeholders, including policy experts. It dominates the policy agenda and forms the frame through which public understanding of health issues is structured. However, policy experts themselves acknowledge that this is not an effective way through which to manage people living with multiple conditions. There is a lack of consistency among policy experts in how they frame the issue. Some focus solely on bureaucratic/administrative methods to define the issue (e.g. identifying a patient with multiple long-term conditions through medical records). Others question the necessity (and feasibility) of having a strict set of conditions or parameters. Instead, they focus on the variable impact different combinations of conditions may have on people depending on a range of factors (e.g. combination of diseases, lifestyle, housing, finances, ethnicity). When communicating with doctors, we’d say multi-morbidity, we'd say frailty, we'd say multidisciplinary teams (because people often need more than one person to look after them). This language is transferrable across most healthcare professionals.” Policy Expert, Professional Health Body • Policy experts working in the area of health and social care talk about multiple long-term conditions in a similar way to academics. They too acknowledge that the issue has evolved from previous ways of categorising people with multiple conditions (e.g. chronic conditions) which have become less popular due to negative connotations. • Policy experts draw on a broader range of language which reflects the various actors that are part of the discussion around multiple long-term conditions – but the code is mainly bureaucratic/administrative. This largely reflects their need to communicate with a range of audiences and involves: • Picking up on emerging academic ideas and theories about how society works; • Processing these ideas into policy (to transform systems); and, • Commissioning health professionals to deliver services for patients. Back in the day we used to call it chronic conditions, which is very negative. If you have something chronic it was really bad. So over time this has changed to long-term conditions. We also have this multiple morbidity which I think is a dreadful term. So multiple long-term conditions I think is better.” Policy Expert, Health Charity When language can get quite disparaging, it’s when doctors are single [disease focused] - almost turned off by people with 15 or so medical problems. disease interventionists, who can do radical things for people, and can often help young people, is higher up the hierarchy than doctors who just help people to live with complex multiple problems. It's not as glamorous.” Policy Expert, Health Organisation

18. Frontline staff Frontline staff tend to use different terminology and language depending on who they are speaking to. This is often based on efficiency and the level of connection with a specific audience. With colleagues, they often use medical language (e.g. neuropathy) as a shorthand for communicating specific issues relating to a patient’s condition. In contrast, they never explicitly talk about multiple long-term conditions with patients. Instead, they focus on the particular symptoms, concerns and experiences being presented to them by the patient and how these link to other conditions or issues the patient may have. Frontline staff also acknowledge that the status-quo of the single-disease model still dominates how the health service operates and manages patients. They sense that more needs to be done to encourage frontline staff to break out of working in silos and to communicate and engage with each other in addressing and understanding the experiences and needs of people living with multiple long-term conditions. • Caring for people living with multiple conditions is very much at the forefront of what frontline staff do, and it is something that they come across on a daily basis. • Frontline staff (i.e. health and social care professionals) are easily able to understand the term multiple long-term conditions, but tend not to talk about the issue explicitly in these terms (in discussions with colleagues or patients). Instead, they are talked about through an implicit process whereby frontline staff discuss (with a patient) the impact and implications of having several conditions at one time and how these conditions may interact and affect the person’s health and quality of life. • Despite the time invested in working with people living with multiple conditions, there is little frontline information explicitly focused on communication about multiple long-term conditions, to inform, advise or support frontline staff or patients about the issue. I am a chair of the community multidisciplinary team…We meet once a month and we have consultants in social health, geriatric health, social workers, rehabilitation physios, pharmacy all coming together with the GPs to talk about patients who, for the majority have multiple long-term conditions.“ Frontline Staff, GP Practice I use different terminology depending on who I'm talking to. With the patients you have to make sure that [the terms you use] are digestible and understandable so that they can then feel they are participating in their care and not just being ‘done to’. If they can understand what's going on and involve them in the big picture they are more likely to take on the lifestyle management things that will be just as important as any medical intervention.” Frontline Staff, Local Government

19. People living with multiple long-term conditions

20. People with multiple long-term conditions Aspeople access health services designed around the single-disease model, they draw in language to express certain medical and symptomatic features of their experience. But people’s lived experience of disease is shaped in how their social lives are affected by physical incapacity or because of extensive time in symptom management, and capacity to deal with such issues by frontline professionals is limited. People may communicate about their conditions separately, but this does not mean that they do not perceive them as interlinked. Peoplemay or may not see the connection between their diseases depending upon time between diagnoses or the dominance of one disease over another, but they tend not to link this back to socio-economic deprivation. People living with multiple conditions also perceive the language around multiple long-term conditions as negative and discouraging. Independence and management of health conditions is important to people and is a key part of the socio-medical frame. They want to feel positive about the future and live a life that is as free as possible. At the moment the bio-medical frame of multiple long-term conditions only partially captures this idea through the concept of self-care. • Most people would not talk about their health in terms of living with multiple long-term conditions, and it is not a label they immediately identify with nor have a practical use for. When talking about their health conditions collectively, patients speak in terms of impact and emotion using words like ‘persistent’, ‘strain’ and ‘intensity’. • They are also most likely to talk about their main health condition. This is determined by the condition which impacts their life the most or in some cases, the condition which has the strongest, and most recognised social identity attached to it. • In this way,peoplediscuss their experience within a socio-medical frame. They draw upon bio-medical terms as used by health professionals but their language differs in that it is far less technical. If I’m honest it’s a strain, I don’t like the constraints it puts on me. Like not being able to go for a long walk or carry anything heavy. It limits what I can do.” 48-year-old male, Southwark Well I would just tell people that I have back problems. I’ve had back problems since I was young and that’s what really impacts me on a daily basis. My anxiety is relatively new although it feels like a long time. 30-year-old female, Southwark I’d say that I have diabetes, but I wouldn’t tell them [a friend] about the rest of it. My diabetes affects me more than anything else, so I see that as my main condition.” 52-year-old male, Southwark

21. People with multiple long-term conditions Although all people with multiple long-term conditions discussed the burden multiple long-term conditions places on their social life, younger people spoke with particular emphasis on this point. They described having to put more energy and effort into maintaining relationships with friends and felt a struggle to keep up with their friends’ lifestyles. In terms of independence and management, younger people also take a moreproactive approach to self-care. Younger people tended to be more engaged in researching their health conditions but would also express a more critical or mixed view of their medical professionals. I definitely think it’s affected my career. I feel like I missed out on a lot of opportunities because I was basically in rehab for a year. I've had to adjust my expectations and ambitions, and that’s taken me a long time to admit and that’s been a massive grief. I see people from university achieving things that I think I could of.” 36-year-old male, Lambeth • Although there are common themes which run across all people with multiple conditions, when we look at the different ages of people involved in the research, we can see there are some important nuances in the way they talk about and frame multiple long-term conditions. • Among the group of working age people, which were the focus of this research, we identified differences in younger people (18-37) and older people (42-65). • Most younger people see their multiple conditions as the result of bad luck. They use words and phrases like ‘different’, ‘misfortunate’ or see themselves as ‘unlike other people’. They often talk about their health conditions in comparison to other peers of a similar age without multiple conditions. • This emerges in discussions of personal relationships as well as educational and career achievements in life. I just think at my age, or anyone of my age it’s just bad luck to have multiple health problems. I don’t know anyone else who has problems like me.” 30-year-old female, Southwark Things have been going well lately but it takes a lot of focus to live a decent quality of life, to see my friends and to keep up with normal life. I’m just quiet active in self-care and my research. I try to read reliable sources.“ 35-year-old male, Lambeth

22. People with multiple long-term conditions • The older group of people on the other hand, generally framed multiple long-term conditions as a part of the process of ageing. They could talk to, and knew about, other friends who had similar problems and felt that having a number of health issues was to be expected as they got older. They talked about being ‘slower’, ‘tired’ or ‘knackered’. • However, although this is seen as a natural process, this did not mean that multiple long-term conditions are viewed positively, or indifferently. Older people often spoke about their worry for the future and their ability to manage their health conditions in later life. • For older people, the socio-medical frame also included concerns about frailty (though this wasn’t a term used by people), and becoming a ‘burden’ to family and friends in later life. For participants who had lost some of their independence already, this was a particular concern. My immediate thought is that I'm just getting old. When I'm not feeling quite so happy or not in a good mood, I tend to think this is just the beginning. I've thought I don’t want to live another 10 years because my conditions are only going to get worse.” 58-year-old female, Lambeth I feel like they view me as a burden at times and as I get older, I worry I’ll have to rely on them more. My son and my sisters come to see me every other day. I don’t know what I’d do without them.” 64-year-old male, Southwark

23. Communication going forward Conclusions

24. Conclusions from this research Currently, this disparity between health professionals and patients shows the top down nature of the language around multiple long-term conditions. The term is highly conceptual and at the moment at least, cannot be used to engage with patients who have these conditions, as there is a great amount of variation in the definition and meaning of the language. However, from this research we can identify a need for creating a frame which can be accessed by both experts and people with multiple long-term conditions. People with multiple conditions need a frame, and shared language, which can be used to communicate about the collective burden of having, and living with, multiple long-term conditions. They feel that the complexity of multiple conditions creates needs and experiences which are not currently addressed or articulated through the single disease model and bio-medical frame. • Overall, this research has found that there isn’t currently a shared frame which is used by experts and people with multiple conditions to communicate about the experiences of people who live with multiple long-term conditions. • Multiple long-term conditions holds some currency with academics, policy experts and frontline staff. It is a term used to identify a variable group of patients to research, treat, or to accommodate when thinking about health system re-configuration. • However, it holds limited relevance in the day-to-day interactions between frontline staff and people with multiple conditions. At the moment, they have little use for the concept of multiple long-term conditions as it does not affect their treatment and has limited utility in their definition-of-self or their self care. • People view ‘multiple long-term conditions’, and other associated language, such as ‘chronic conditions’ and ‘co-morbidities’, as negative and discouraging. People who have multiple conditions want to feel positive and encouraged toward better management of their health and strive for increased independence. I think whatever you’re suffering from you need to have something or a phrase that isn't negative. It needs to be positive. The positive attitudes help, so positive words would help.” 58 year old women, Lambeth

25. Split into two groups: • Draw on the data for patients with multiple long term conditions • Assumptions about other patient groups Next steps Place holder slide

26. References (1) The King’s Fund, 2010; 2 Guy’s and St Thomas’ Charity, 2018 (2) The Smoking Drinking and Drug Use survey https://files.digital.nhs.uk/07/49FE46/sdd-2016-rep-cor.pdf (3) The Annual Population Survey https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2017 1The King’s Fund, 2010; 2 Guy’s and St Thomas’ Charity, 2018

27. Monique Centrone Semiotics Lead monique.centrone@ipsos.com Reuben Balfour Research Manager reuben.balfour@ipsos.com Michelle Mackie Research Director michelle.mackie@ipsos.com Suzanne Hall Research Director suzanne.hall@ipsos.com Freddie Gregory Research Executive freddie.gregory@ipsos.com