Keeping in balance - managing the multimorbidity tightrope. A narrative analysis of older patients' experiences of managing multimorbidity.

Problem

The management of people with multimorbidity in the UK sits squarely with primary care. It is often guided by quality indicators (or targets) involving a range of measurable endpoints, designed to support patients in achieving balance across disease attributes and risk factors. The aim of this study is to explore how older people manage, flourish and achieve ‘balance’ in their lives in the context of multimorbidity.

Approach

Situated within an ethnographic study of multimorbidity and polypharmacy, we conducted 24 in-depth interviews, using the Biographical Narrative Interpretive Method. Participants were recruited from three GP practices in England, were aged between 65 and 94 years, and had been diagnosed with two or more chronic conditions for which they were prescribed ten or more medicines. We analysed the narratives using the Listening Guide – an established, voice centred, relational method for analysing qualitative data. Analysis involved three steps, or listenings: listening for narrative plot; listening for a participant’s subjective voice by creating I-poems based on the participant’s words; listening for the participant’s multiple voices and identifying where these voices interact and tussle. Our analysis was further informed by the work of Heath and Toon, on General Practitioners’ roles in witnessing and interpreting patient stories to facilitate a patient’s flourishing.

Findings

‘Keeping in balance’ was a recurring theme throughout our fieldwork in the wider project. General Practitioners talked about a reluctance to ‘upset the status quo’ and change a patient’s medication regimen if test results indicated that the patient was ‘in balance’. Through the Listening Guide analyses, we also heard our participants using the concept of balance to describe the work they had to do to manage their multimorbidity. The focus of this balancing act was more far-reaching. Participants understood the importance of their GP’s input into their care, but had to balance a ‘deontic voice’ (doing as they were told and living by the rules) with an ‘agentic voice’ (a desire for their own agency to live their life and manage their multimorbidity the way they wanted to). We draw on the metaphor of walking a tightrope to illustrate how patients negotiate a balance between resisting and accepting multimorbidity as they seek to live a flourishing life.

Consequences

Our research surfaces some of the ways in which patients with multiple long-term conditions both co-opt and resist biomedical framings of multimorbidity. Our analysis foregrounds the complex ways in which patients’ voices and values may be at odds with what is captured in chronic disease guidelines underpinning health care. This has implications for the organisation of primary care and the role of GPs in providing person-centred care to patients with multiple long-term conditions.