In this feature one of our methodologists, Dr Sara Pretorius, discusses our involvement in the ADMISSION research collaborative. This programme brought together clinicians, researchers, scientists and people living with Multiple Long-Term Conditions (MLTC) from across the UK. ADMISSION was awarded £4 million funding from UK Research and Innovation (UKRI) and the National Institute of Health and Care Research (NIHR).

Why is this research area important and what was the project looking to address?

The aim of ADMISSION was to improve hospital care for people living with MLTC. It is important because MLTC is very common among the population and it’s becoming increasingly prevalent. We focused on hospital care because we know that people with MLTC tend to have more adverse experiences in hospitals. They have more unplanned hospital admissions; longer hospital stays and generally less favorable outcomes. We also know hospitals and NHS staff face challenges when caring for people with MLTC as the system is generally not well-configured for multiple conditions. By getting a better understanding of what care looks like now, we can hopefully help to design a better system.

Can you share the HRC’s role in the project and the approaches and methodologies you used?

The project had a workstream dedicated to care pathway analysis which is an area of expertise for us. A large part of our work involved looking at care pathways from the perspective of the wide variety of people who work in different areas of the hospital. This included emergency departments and acute assessment units. We interviewed 40 NHS staff including consultants, nurses, allied health professionals, advanced clinical practitioners and managers. They covered various specialisms such as respiratory medicine and older people’s medicine. These interviews helped us to build a picture of current practice, how care pathways work and what factors influence the decision-making process when caring for people with MLTC. As part of the interview, we presented each participant with a clinical vignette describing a hypothetical case of a patient with MLTC in hospital. This approach was novel for the HRC, and I think it enabled us to get nuanced and realistic insights into how patients with MLTC are cared for during real-time scenarios. We know that clinical decision-making is influenced by recommendations from evidence based best practice guidelines. So, we also conducted a large review of 56 guidelines from the National Institute for Health and Care Excellence (NICE) to see if, and how, single-disease guidelines adapt for patients with MLTC.

What did you enjoy most about the project and were there any challenges?

This was the first time I had led such a large and complex project, but I really enjoyed it. The topic itself was interesting and eye-opening. I now fully appreciate the magnitude of MLTC, the problems that people living with multiple conditions experience and the challenges NHS staff face in this area. The multi-team aspect of the project was also excellent. We were just one team amongst others who were exploring areas such as genomics, proteomics and big data. It was interesting learning about their work and seeing how it all came together. We thought there would be a challenge recruiting and interviewing 40 people. However, we found that the topic really resonated with people, and they seemed to find it quite cathartic to share their experiences, which was very gratifying. We undertook a big piece of work to ensure that the guideline review built on previous high-profile reviews and met rigorous methodological standards. Yet, the dynamic within the HRC team was excellent and we all supported each other to meet the needs of the project.

Were patients and the public involved and if so, how did they add value?

At the outset, we met with our Insight Panel for Patients, Public and Carers who provided feedback on the design and resources for the project. The ADMISSION patient advisory group, which was made up of people living with MLTC, were also heavily involved in our guideline review. They shared their views on our findings and co-developed a set of recommendations for guideline developers. Collaborating with these groups really helped to ensure that our work was grounded in the perspectives of people living with MLTC and the wider public.

What have been the outputs so far?

At the beginning of the project, we conducted a scoping review to understand what previous work had been done in this area. The review was published in 2025 in BMJ Open and set the scene for our further work. Our findings from the guideline review, including the list of recommendations, have recently been published in BMJ Medicine alongside an editorial. I think this highlights the importance of the project.

Are there any next steps?

Our results from the interviews are being prepared for publication. Another team within the project have interviewed patients with MLTC to understand their perspective. We hope our manuscripts will be published simultaneously as both sets of interviews have highlighted some common themes. These include the tension between treating acute conditions while managing chronic conditions, the limited resources and structural inflexibility within a hospital environment and the single disease nature of existing clinical guidelines. I will present our findings, alongside other members of the ADMISSION collaborative, at the British Geriatric Society’s Spring meeting. It will be my first presentation to a large clinical group, so I am looking forward to that too.

Have there been any lessons learned during this project which might influence your future work or other people working in this area?

The biggest lesson is the importance of considering MLTC in all research and clinical practice. We realised during the project that a lot of existing clinical guidelines are informed by evidence from clinical studies which often exclude people with MLTC. The project lays the foundations for a whole range of future research in MLTC. Some aspects of our work will continue through our involvement in the recently established MLTC Cross-NIHR Collaboration. However, working on this project has led us to consider MLTC more in all the research we do.

Is there anything else you would like to share about this work, including its overall impact and the HRC impact on the project?

Our expertise in conducting robust reviews, care pathway analysis, and qualitative interviewing was a significant contribution to the project. We built capacity in this area through training two interns and one master’s student. They were involved in different aspects of the project including the groundwork for the guideline report, supporting the interviews and analysing the vignette data. One of the interns has now joined our HRC as a Technical Analyst, bringing the skills she developed as part of the project to our wider team. We believe the project will inform the design of care pathways, so they are efficient, less fragmented and more suited to people with MLTC. The recommendations within our guideline review should have an impact on policy and practice at a national and international level. Our findings also highlighted the need for more integrated, continuous and multidisciplinary care. So, the project could inform improvements to the structural organisation of healthcare services for people with MLTC too.

Read our review of clinical guidelines and recommendations

Find out about our involvement in ADMISSION

Learn more about this research