Area of capability: Managing complex and long-term care

Many aspects of care extend beyond addressing straightforward problems. Medical complexity includes a team-based approach to managing multimorbidity, acute and long-term conditions, as well as management of uncertainty and risk. It also encompasses appropriate referral, the planning, delivery and organising of complex care, and promoting rehabilitation and recovery. This may include providing palliative care in the end phases of a patient’s life. As a GP, you must be able to coordinate the patient care provided by other healthcare professionals, as well as by other agencies.

As a GP you need to simultaneously address multiple complaints and comorbidities in the patients you

care for. You will need to be able to encourage patient autonomy while co-ordinating all aspects of health promotion and disease prevention. This can be done opportunistically and as part of a structured approach, using other professionals in your primary care team where appropriate. It requires working with your patients in their rehabilitation and safe return to work using other occupational support services, bearing in mind the potential impact of a patient’s work on the progress of and recovery from a health condition.

When patients seek medical assistance, they are usually aware that they have become ill but may not be able to differentiate between the different conditions they may have and the significance of each on their quality of life. As a GP, the challenge of addressing the multiple health issues of each individual is important. It requires you to develop the skill of interpreting the issues and prioritising them in partnership with your patients.

Co-ordination of care also means that you must be skilled not only in managing disease and prevention, but also in caring for your patient. As a GP, you should use an evidence-based approach to the care of patients, including when the focus is the promotion of your patient’s health and general wellbeing. Reducing risk factors by promoting self-care and empowering patients is an important task of the GP. You should aim to minimise the impact of your patients’ symptoms on their wellbeing by considering personality, family, daily life, economic circumstances and physical and social surroundings.

Enable people living with long-term conditions to optimise their health

Learning outcomes:

• Maintain a positive attitude and use strategies to optimise the wellbeing of patients with long-term conditions, including:
  • encouraging and actively facilitating health promotion
  • supporting them in taking steps to increase their health resilience
  • reducing their treatment burden
  • supporting survivorship, that is, the ability to live with (or following) a serious condition
  • identifying relapse
  • managing their long-term decline.
• Identify the impact of a patient’s environment on their health, including home circumstances, education, occupation, employment and social and family situation. Offer support to the patient in addressing these factors.

Using a personalised approach to manage and monitor concurrent health problems for individual patients

Learning outcomes:

• Recognise how health conditions commonly coexist and interact.
• Demonstrate a person-centred approach to identify, clarify and prioritise the issues that matter to an individual with multiple problems.
• Demonstrate a reasoned approach to the review of patients with multiple problems, especially older adults, appreciating that multiple problems are often interconnected.
• Demonstrate an ability to establish partnerships with individuals and carers to prioritise investigations and treatments.
• Implement measures to minimise the overall individual treatment burden, such as polypharmacy and multiple interventions.

Managing risk and uncertainty while adopting safe and effective approaches for patients with complex needs

Learning outcomes:

• Recognise that patients often present with problems that cannot be readily labelled or clearly categorised. Evaluate how this uncertainty influences the diagnostic and therapeutic options available to patients.
• Recognise the risk of diagnostic overshadowing and clinical stereotyping when dealing with patients who have been labelled with complex diagnoses (such as learning disability).
• Recognise the limitations and challenges of applying existing clinical evidence and take a critical approach to the application of multiple clinical protocols while balancing risk and benefit.
• Recognise the limitations of protocol-driven ways of making decisions and explore ways of dealing with these situations with the patient and their carers, and consulting colleagues when appropriate.
• Manage the inevitable uncertainty in complex problem-solving through an enhanced use of risk assessment, surveillance, communication and ‘safety-netting’ techniques
• Communicate risk in an effective manner to patients with complex conditions and involve them in management of their condition, assisting them to tolerate diagnostic uncertainty when appropriate and to refocus on optimising their health and wellbeing.
• Recognise the importance of reflecting on your interaction with complex problems and on the outcomes of patient care to integrate this knowledge into your previous experience and improve your capability in providing effective care.

Co-ordinating and overseeing patient care across healthcare systems

Learning outcomes:

• Take responsibility for planning and co-ordinating all of an individual’s concurrent health needs.
• Provide continuity of care either personally or across teams and systems.
• Recognise the risk to patient’s health and the healthcare costs that arise when care is inappropriate, fragmented or uncoordinated.
• Demonstrate the ability to support patients in navigating along and between care pathways, enabling them to access appropriate team members and services in a timely and cost-effective manner.

Progression point descriptors – Medical complexity

Working effectively with other professionals is essential to good patient care. It includes sharing information with colleagues, acting as an effective service navigator and using the skills of the multiprofessional team optimally in both primary and non-primary care environments. Leadership, management and team working skills should be adapted and applied to real-life practice. GP education must promote learning that integrates different disciplines within the complex teams of the NHS and supports career development for yourself and colleagues.

Working as an effective member of multiprofessional and diverse teams

Learning outcomes:

• Meet your contractual obligations to be available for patient care, anticipating situations that might interfere with your availability and ensuring that patient care is not compromised.
• Seek advice from colleagues when encountering problems in following agreed protocols and policies for personal or professional reasons.
• Use skills such as active listening and problem solving to improve communication with colleagues.
• Optimise a positive attitude to the opportunities, assets and potential offered by diversity within a team.
• Enhance working relationships by demonstrating understanding, giving effective feedback and maintaining trust.
• Contribute to a team culture that encourages contributions, values co-operation and inclusiveness and commits to continuing improvement and preserving a patient-centred focus.
• Routinely prioritise, reprioritise and manage personal workload in an effective and efficient manner, delegating appropriately to other team members.
• Provide support to colleagues who are overburdened.

Leading and co-ordinating a team-based approach to patient care

Learning outcomes:

• Demonstrate the capability to lead and coordinate care at a team level and, when appropriate, at a service level. This includes, but is not limited to, team-based approaches to:
  • supporting patients to self-care
  • shared care planning with patients and carers
  • monitoring and surveillance of long-term conditions
  • recovery and rehabilitation after serious illness or injury
  • palliative and end-of-life care.
• Appropriately seek advice from other professionals and team members according to their roles and expertise.
• Anticipate and manage the problems that arise during transitions in care, especially at the interfaces between different healthcare professionals, services and organisations. Demonstrate the ability to work across these boundaries (for example, by actively sharing information and participating in processes for multi-agency review).
• Support the transition of responsibility for patient care between professionals and teams through structured planning, co-ordination and appropriate communication channels.
• Use the medical record and other communication systems to facilitate continuity of care via the transfer of information and care within multidisciplinary teams.

Progression point descriptors – Team working