A Patient-Led Roadmap for Change: Policy Action to Transform Care for People Living with Multiple Interconnected Chronic Conditions

Background: Cardiovascular disease is not an isolated condition, but part of a growing crisis of multiple interconnected chronic conditions (MICC) that include stroke, diabetes, chronic kidney disease, liver disease and obesity. These diseases are deeply interlinked – sharing risk factors, influencing disease progression and contributing to the development of new or aggravated conditions – yet most health systems remain ill-equipped to provide the coordinated, holistic care that patients need. Patients are left to navigate complex care pathways and bear the burden of disjointed treatment, leading to worsening health outcomes and a higher burden on the healthcare system.

 

Approach: Global Heart Hub (GHH) designed and delivered a two-day, patient-led Unite Summit to co-create priorities on MICC. The Summit convened 165 delegates, including 65 patient organisations alongside policymakers, clinicians, researchers and industry representatives. To ensure broad representation across the MICC landscape, GHH collaborated with the International Diabetes Federation, the European Coalition for People Living with Obesity, the Global Patient Alliance for Kidney Health, the European Liver Patients’ Association, and the European Kidney Patients’ Federation. The Summit combined plenary sessions, a live survey of all delegates to capture collective perspectives, and structured breakout discussions to facilitate dialogue, gather feedback and identify priority opportunities and solutions.

 

Results: The collective feedback from the Summit delegates was synthesised to highlight key challenges hindering progress for people living with or affected by MICC. Barriers included the continued dominance of siloed and uncoordinated care, pervasive issues in timely diagnosis, lack of innovation and prevention strategies, and persistent inequities across gender, ethnicity, geography and socio-economic status.

 

These challenges are pervasive, yet progress is possible through structural, systemic reform. Summit delegates co-created five key joint policy asks for change: 1) multidisciplinary care and navigation for people with lived experience, 2) scale up early detection and community-based screening programmes, 3) accelerate access to innovation and digital health solutions, 4) guarantee equity in cardiovascular and multimorbidity care across gender, geography, ethnic and socioeconomic groups, and 5) prevention, empowerment and mental health integration for people with lived experience.

Under these five policy asks, delegates proposed a variety of innovative and patient-led solutions to reimagine health systems. For example, participants drew focus to the value of integrated, specialist-led teams supported by patient navigators, underscoring the importance of coordinated care pathways that reflect the realities of multimorbidity. Screening and early detection were also seen as opportunities to move care closer to communities, with expanded access to diagnostics in primary care and embedded mental health assessments.

Delegates further highlighted the transformative potential of digital health and innovation, from AI-driven diagnostics to telehealth and precision medicine. Equity featured prominently, with calls to embed gender-sensitive protocols, invest in underserved communities and ensure diverse patient representation in research and policymaking.

 

Implications: The Summit showed the value of patient-led collaboration in shaping health policy across interconnected conditions. A global report, launched from the findings, provides an advocacy tool to drive widespread change. International delegates can adapt these shared priorities to advance equity, integration and innovation in health systems worldwide.