Multimorbidity - will it sink or swim general practice?
Dr Chris Salisbury GP
Chair of the RCGP Scientific Foundation Board
Professor of Primary Health Care at Bristol University
The topic of multimorbidity has gained much attention in the last few years. More and more of the patients who consult us in general practice come with multiple, complex and often long-standing problems. Trying to deal with all of these problems in a typical consultation can feel overwhelming for both the patient and their GP. Dealing with each individual problem 'properly' according to the relevant treatment guidance leads to patients receiving numerous prescriptions, tests and follow-up appointments. The population is getting older so the prevalence of chronic disease is increasing, and expectations for what GPs should do for each of these diseases are also increasing, and yet the time available remains as short as ever. So is general practice going to sink under the weight of workload demands and unrealistic expectations? Or could the issue of multimorbidity save rather than sink general practice?
Multimoribidity can be defined as the presence of two or more chronic conditions present in the same individual at one time. At least two-fifths of the population have multimorbidity, although estimates vary depending on which conditions are included. The issue of multimorbidity in the UK came to the fore because of the way in which the Quality and Outcomes Framework raised expectations and led to structured care for particular major chronic conditions. About 16% of the adult population have more than one of the chronic conditions included in the QOF framework but these people account for a third of all general practice consultations. Patients often come with list of problems to their GP - most consultations now involve discussion of at least two difference problems across different disease domains. Typical general consultations are not simple transactions leading to quick fix solutions for well-defined problems. They are complex interactions, demanding careful discussion about problems which might be managed but may never be solved. So it would be easy to conclude that general practice is going to sink under this rising tide of chronic disease and multimorbidity.
An alternative perspective is that recognition of the phenomenon of multimorbidity could instead save rather than sink general practice. General practice is not the problem - it is a key part of the potential solution. The NHS has to face up to the fact that as the population gets older, and the prevalence of multimorbidity goes up, and expectations for optimum care for chronic disease also increase, the health needs of the population and the potential demands on the NHS escalate. Without adequate investment in primary care, the pressure on Emergency Departments and hospitals will become much greater than it is now, which will not only cost much more but also lead to increasing public clamour and political fall-out.
How should the NHS respond to the issue of multimorbidity? What would good care look like? We have to get better at helping people to manage their own health, in a partnership which recognises that doctors support and advise patients who are experts in their own care. The key priorities are well summarised in the recent independent report on Patient Centred Care in the 21st Century commissioned by the RCGP. Patient centred care deals with people as a whole, rather than different specialist health professionals treating each of the patient's problems individually. It is personalised, and tailored to each individual's values, needs, capabilities and life situation. And it empowers patients through sharing decisions with them and helping them to take a more active role in looking after themselves. All of these things are promoted by a situation in which people have trusting relationships with professionals that they know.
Providing care for multimorbidity requires doctors who have generalist knowledge, who can co-ordinate and make judicious use of specialist, who think about the needs of people rather than just fulfilling the protocol for a disease, and who understand the importance of communication, relationships and continuity of care. These are what general practice does best and the very justification for why we have a strong primary care foundation to the NHS. The rising tide of multimorbidity means we need general practice more than ever - without a well-functioning primary care system, multmoribidity will sink the whole health care system, not just general practice.
To meet this challenge however, general practice needs to change. It is not possible to provide good care for complex problems in a system which is designed for treating simple acute problems in very short consultations. Meeting the needs of patients with multimorbidity has to involve investment in primary care, longer consultations, smaller caseloads and more doctors and nurses in the community. General practice has become increasingly disease centred, with consultations dictated by computerised templates and guidelines for individual diseases. We need to re-discover the importance of generalism and co-ordinating care so that we treat people as a whole. Continuity of care is rapidly declining, partly due to pressures to improve access and partly due to the part-time GP workforce, but unless we improve continuity and recognise the value of personal relationships with patients one of the key justifications for general practice will be lost. Although we need to ensure the consistency and quality of care for individual diseases, this needs to be balanced with attention to individual patient's priorities and needs, particularly for patients with multimorbidity where following all of the guidance may lead to burdensome treatment. Most importantly we need to re-discover the essential skill of good judgement - not everything that could be done for a patient with just one problem should be done for patients with lots of problems. With the right investment, and the willingness of the profession to innovate and adapt, general practice should thrive in an increasingly central role in the NHS, since managing multimorbidity is going to be the main function of the health system in the 21st century.