Efficient Multimorbidity Management

Multimorbidity encapsulates the challenges of generalist care. This project aims to understand barriers and opportunities for offering holistic chronic disease care and to showcase examples of effective practice. This will include assessing ways to streamline chronic disease care and how work can be shared across the multidisciplinary primary care team.

The RCGP has a fundamental translational role in championing new ways of working as outlined in RCGP 2022 Vision: multimorbidity is increasingly relevant due to our ageing population and the complexities arising from improved standards of care for chronic long-term conditions. It is now common for patients to accrue an array of chronic diseases because of shared underlying lifestyle risk factors, such as obesity, malnutrition, smoking, loneliness, poverty, poor dentition, inactivity and excess alcohol. Maximising efficient care for patients with several co-morbidities will benefit individuals but also is crucial if primary care is to cope with the changing prevalence, demands and pharmacological complexities of non-communicable diseases.

Multimorbidity is relevant to and will collaboratively support existing RCGP clinical priority work streams, in particular the Cancer, Physical Activity and Lifestyle and Liver Disease projects, because it intertwines with many of the central themes relevant to these areas.

Aims of the project

1. To understand barriers to offering holistic chronic disease care (compared to single disease QOF-led care) 
2. To showcase examples of effective practice, including assessing ways for blood test monitoring to be streamlined and how work can be shared across the multidisciplinary primary care team.
3. To broadcast the importance of managing multimorbidity efficiently and trigger awareness of the need to tackle underlying shared chronic disease risk factors, thus evolving from existing silo disease models of care

Key outputs 

A report of the RCGP survey of current attitudes to providing multimorbidity care has been developed by the Clinical Champion of the project, Dr Rachel Pryke. Download the report.

Exploration of how template development has been used to support holistic co-morbidity management that focuses on patient priorities and underlying shared risk factors, rather than just QOF boxes. 

Resource development including a set of short ‘Clinical Conversation Cases’ teaching and dissemination tools for publication in InnovAiT to support training in multimorbidity conversations and a list of good practice examples through the RCGP’s quality improvement platform and RCGP Web Index. This will highlight varied examples of how multimorbidity management can be individualised for patients with several co-existing conditions, such as how malnutrition management can improve COPD care or improve outcomes during cancer treatment, or how physical activity approaches can feel feasible for those with complex health problems). Download the summary. 

Linking and supporting the 3D Bristol study.

Linking with the NICE Implementation Team to identify tangible collaborative steps to promote the NICE 2016 Multimorbidity guidance (NG56). 

Clinical team

 Dr Rachel Pryke MBBS MRCGP FRCP is a GP and trainer in Worcestershire. She is RCGP Clinical Advisor on obesity and multimorbidity and held a NICE Fellowship from 2015-18. She is an author of many obesity resources including two books and runs primary care obesity and malnutrition training courses throughout the UK. She collaborated with WHO on a European primary care obesity training package. 

Dr Pryke is a member of the National Child Measuring Programme Board, PHE Obesity Priority Programme Board and sits on World Obesity Clinical Care Committee. She is currently a commissioner on the Lancet/EASL Commission on Liver Disease across Europe.

General introduction and models of care

• NICE Multimorbidity: clinical assessment and management. This guideline covers optimising care for adults with multimorbidity (multiple long-term conditions) by reducing treatment burden (polypharmacy and multiple appointments) and unplanned care.
• NHS England General Practice Forward View April 2016
• Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith SM. Managing patients with multimorbidity in primary care. BMJ. 2015;350:h176. An overarching introduction to multimorbidity published in the BMJ in 2015. An introduction to community-based frailty care.
• Frailty Care in a community based clinic: maximising the potential of integration. Rickenbach M, et al 
• Book: ABC of Multimorbidity. Mercer SW, Salisbury C, Fortin M. John Wiley & Sons Ltd; 2014. PProvides primary care practitioners with a practical approach to the complex issues of treating and managing patients with more than one morbidity.
• The Richmond group of charities Taskforce on Multiple Conditions. The taskforce, a partnership between the Richmond Group of Charities, the RCGP and Guy's and St Thomas' Charity has so far produced the report “Just one thing after another” Living with multiple conditions.

Social prescribing

• NHS England Social Prescribing 2018. This guide provides primary care practitioners with a practical approach to the complex issues of treating and managing patients with more than one morbidity.
• Marmot M, Wilkinson R. Social determinants of health: the solid facts. 2nd edition. This publication outlines important aspects of social determinants of health and relates to areas of public policy.
• Making sense of social prescribing. This guide contains essential concepts of social prescribing, illustrates different models, and makes the case for the implementation of different schemes in the community.

 Polypharmacy and treatment burden

• NICE Multimorbidity and polypharmacy KTT18. This guideline supports healthcare professionals who are reviewing people with polypharmacy to help guide decision making about the appropriateness of prescribing and deprescribing. 
• Scottish Polypharmacy Guidance for practical and case-based advice on common polypharmacy issues, e.g. anticholinergic side effects, constipation, benzodiazepines and z-drugs.
• A patient centred approach to polypharmacy developed by the NHS Specialist Pharmacy Service.

Motivational interviewing and communication skills

• BMJ introductory module. Short module about Motivational interviewing in brief consultations.
• Motivational interviewing and behaviour change: Stephen Rollnick - Psychologist/Author and co-founder of Motivational interviewing; his own courses and publications.

Nutritional aspects

• NHS England need to recognise the role dietitians can play in primary care.
• Patient information. Food and nutrition advice for patients. 
• The NHS Eat Well guide to nutrient reference ranges, fat sugar salt. 

Malnutrition

• The Patients Association Nutrition Checklist: for general use but primarily intended for those aged over 65 and living in the community. 
• BAPEN patient and carer ‘self-screening’ tool for use by patients and carers.
• Managing Adult Malnutrition in the Community patient information leaflets: free to download here. Separate leaflets are available for patients at high, medium and low risk of malnutrition, plus advice on fortifying foods and incorporating ONS into the diet.
• Guidance on oral nutritional supplements: rationale, indication, type and duration.

Obesity

Find many links to different resources relating to obesity at the RCGP A to Z Obesity webpage.

Physical activity

• The RCGP Physical Activity and lifestyle toolkit was designed to arm GPs with the knowledge to confidently discuss PA with their patients, as well as to guide GPs, other health professionals and practice staff concerned about their own activity levels.
• NHS England physical activity guidance for older adults. 
• Prescribing Movement. The ultimate step-to-step guide to conversations with patients about physical activity.

Research and policy

• The 3D trial: Improving the management of multimorbidity in general practice using the 3D approach: a randomised controlled trial.
• The 3D approach: Improving whole person care for patients with multimorbidity. 
• Publication: The Solid Facts of Social determinants of health
• Managing Multimorbidity: Scottish School of Primary Care Briefing Paper 3. Mercer S
• The Govan SHIP Project is funded by the Scottish Government to improve integrated care for patients living in a very deprived area.

 Training material

• Practice Based Small Group Learning (PBSGL) is part of CPD Connect, an NHS Education for Scotland (NES) initiative. Registration is required to access material.