If we want to take prevention of multiple long term conditions seriously, then we need to know what we mean by that

Primary prevention

For most people with multiple long term conditions, the accrual of long term conditions happens across their lives. So prevention could be aimed at the “sentinel condition” (defined as the first long term condition which occurs in the process of developing multiple long term conditions) 7 by tackling its risk factors. This could be considered true primary prevention as it aims to stop the accrual of long term conditions right at the beginning.

However, the wide range of sentinel conditions makes this a little problematic. Some of them can be precursors for others e.g., hypertension and cerebrovascular disease, and some are not preventable in the traditional sense e.g., genetic disorders. So even if we could prevent that first condition, it would not eliminate all multiple long term conditions.

Secondary prevention

The early detection of sentinel conditions or one or more of the components of multiple long term conditions e.g. through screening programmes or primary care health checks can be considered secondary prevention. This approach can help mitigate some of the impact, as well as providing opportunities for reducing the risk of further long term conditions.

But if what we mean by “prevention” is not being in the situation of having multiple long term conditions, then “primary prevention” of multiple long term conditions could encompass anything that leads to having more than one long term condition, so would include all secondary prevention activities for any sentinel long term condition.

Similarly, prevention of adverse outcomes of multiple long term conditions could be considered secondary prevention, but cannot be pinned down to one set of actions given the high number of potential combinations of long term conditions and outcomes. A strategy based on this will be too vague and we might get confused with tertiary prevention depending on the type of health outcomes considered.

Tertiary prevention

If we focus on prevention of the impact or ongoing “burden” to individuals of living with multiple long term conditions, this could be considered tertiary prevention. However, the nature of the impact varies widely by the condition combination experienced by an individual, and it could even be considered primary prevention of the state of being “burdened.”8

Primordial prevention

Prevention tackling the wider social, economic, and environmental modifiable determinants of health, including “the determinants of the determinants” can be considered primordial prevention.9 This includes activity across the lifecourse, but particularly in early life, at population level, to reduce life chances of developing any long term condition and therefore multiple long term conditions.

What next?

We clearly need a better language or framework for the prevention of multiple long term conditions to know where our priorities should lie, particularly in the context of limited resources and overwhelmed health systems.10

As Geoffrey Rose recognised in his 1981 article on strategies of prevention there is a paradox in taking just a “high risk” approach to health care. You may think you are doing the right thing, and be striving hard to achieve it, but “a large number of people exposed to a low risk is likely to produce more cases than a small number of people exposed to a high risk.”11

Taking a “high-risk” approach to the prevention of multiple long term conditions might focus all our endeavours on “secondary and tertiary prevention” i.e. screening for the first long term condition and reducing the risk of subsequent long term conditions and of adverse outcomes. While vitally important activities, these will not stop the ever-increasing population of people developing multiple long term conditions and the consequent impact on individuals and health systems.

The risk of developing long term conditions starts early in life and prevention policies and strategies need to adequately reflect that in both their focus and scale of endeavour through primary and primordial whole-population prevention approaches.

For example, a long term strategy to prevent the multiple long term condition combination of chronic kidney disease, hypertension, type 2 diabetes, depression and obesity should not only consider mid or later life pathways such as those from obesity to diabetes and hypertension, and from diabetes to chronic kidney disease and depression, but also early lifecourse determinants and risk factors for childhood obesity, adolescent mental health problems, and early-onset hypertension.

However, as people’s lives are lengthened by better living conditions and health care, we also need more attention given to tackling the impact of living with multiple long term conditions where quality of life is prioritised and the “workload” of living with multiple long term conditions is reduced as much and for as long as possible.8

According to Head and colleagues “the focus on multimorbidity must shift from solely management of high-risk older individuals to include integrated population-level prevention strategies throughout the life-course to address the drivers of multimorbidity.”2 We agree with this. But we also argue for an urgent need to be more specific when talking about the prevention of multiple long term conditions.

Our call for action is to:

a) achieve consensus among experts and those with lived experience towards a widely adopted and easily understood multiple long term conditions prevention framework

b) incorporate the whole lifecourse when considering prevention of multiple long term conditions

c) integrate all types of prevention (primordial, primary, secondary and tertiary) within such lifecourse framework.