A peer-level look at how FP/GPs manage chronic disease when day-to-day responsibility, patient behaviour, multimorbidity, and specialist access all converge inside primary care.
Total responses: 660
Countries: 6
– Hero finding
Quick Read — Key Findings
Includes section-wise interpretation, clinical meaning, design implications, and exact backend-ready data tables.
Chronic disease care often enters primary care through a diagnosis, a prescription, or a target. But in everyday FP/GP practice, the harder work begins after that point: maintaining follow-up, adapting treatment in multimorbidity, managing adherence, and deciding when to escalate without losing continuity.
MDForLives reviewed responses from 660 FP/GP chronic disease survey participants, including 507 complete responses and 153 partial responses. Question-level denominators vary from n=529 to n=516 depending on completion depth.
85.2% of respondents say chronic disease management is either the core or a major part of their day-to-day work. This matters because the rest of the survey shows the burden is not only clinical knowledge. It is longitudinal execution.
FP/GPs are most stretched by tasks that require continuity, coordination, and longitudinal tracking, not simply treatment initiation.
Managing follow-up consistently (26.1%) and coordinating care across providers (23.3%) together account for 49.3% of responses. Add preventing deterioration in complex patients, and the downstream burden rises to 65.8%. The insight is that chronic care pressure lives in the gap between knowing what should happen and making sure it keeps happening.
In multimorbid patients, 73.0% routinely or often adjust treatment plans without specialist input.
This suggests primary care is not simply a holding zone before specialist referral. FP/GPs are making active treatment decisions. But the survey also shows why autonomy can become a burden when follow-up systems, patient behaviour, access, and multimorbidity complexity do not move with the same speed.
The most common next step is not immediate intensification or referral. It is reassessing adherence and lifestyle first.
The 42.0% who reassess adherence and lifestyle first are not necessarily delaying care. They are checking whether the treatment plan is actually executable. This is a critical insight: for FP/GPs, escalation is often a clinical decision filtered through patient behaviour, treatment feasibility, and continuity.
The barriers to sustained control are spread across behavioural and structural factors, which means the solution cannot be a medication adjustment alone.
Adherence over time leads at 42.4%, followed by limited lifestyle-change success (36.4%), financial or access barriers (35.3%), and multimorbidity complexity (30.2%). The pattern shows that chronic disease control is rarely lost for one reason. It erodes when patient capacity, system access, and disease complexity stack up.
The top challenge in multimorbid care is managing polypharmacy safely, cited by 31.2% of respondents.
This reframes the FP/GP role. In complex chronic disease, the task is not only to treat more. It is to decide what can be intensified safely, what needs simplification, what may conflict with another condition, and what the patient can realistically follow.
75.0% are highly or moderately confident in influencing long-term patient behaviour. The important detail is that most of this confidence is moderate.
101 highly confident and 286 moderately confident respondents, out of n=516.
Moderate confidence is the largest category, suggesting capability exists but remains conditional.
Only 19.6% report high confidence. This matters because adherence and lifestyle barriers lead the sustained-control problem. If long-term behaviour change is central to outcomes, then primary care needs more than advice-giving time. It needs structured behaviour support, follow-up prompts, patient education tools, and practical escalation pathways.
The complete export shows the strongest system failure is limited consultation time, selected by 47.1% of respondents, followed closely by weak follow-up and continuity systems at 42.8%.
This changes the interpretation of the earlier findings. The pressure is not only that FP/GPs carry chronic disease work. It is that the system asks them to manage longitudinal risk inside short visits, weak recall systems, and inconsistent specialist coordination. The result is a setting where care quality depends heavily on individual clinician effort rather than designed continuity.
49.2% describe specialist coordination as generally functional with occasional gaps, while 39.6% describe it as inconsistent, delayed, fragmented, or minimal unless the case becomes severe.
This is a fragile-middle pattern. Most respondents are not saying specialist coordination is absent. They are saying it works until complexity increases, timing matters, or a case needs more than routine handoff. In chronic disease, that fragility can shape escalation timing, medication adjustment, and patient confidence.
Looking ahead, 47.1% select more time for complex consultations as an improvement priority, while 39.4% want stronger coordination with specialists.
This finding is important because it makes the solution practical. FP/GPs are not asking only for more clinical knowledge. They are asking for the operating conditions that allow chronic care to be done properly: time, coordination, team-based support, recall systems, and tools that help patients stay engaged after the visit.
Visible open-text responses repeatedly point to time, communication, reimbursement, approval friction, specialist access, and staffing as the gap between what GPs are expected to do and what settings allow.
Time constraints and multiple metrics inside short visits
Because Q13 is open text, these are qualitative themes from the visible responses rather than quantified survey percentages. They reinforce the same story seen in Q10 and Q12: the gap is not clinical intent. It is the infrastructure around chronic care delivery.
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