Responding to the needs of

patients with multimorbidity

A vision for general practice
Executive summary
The provision of effective, person centred care to patients with
multimorbidity is a key part of creating a modern 21st century
NHS, and is a challenge in which general practice is very much
at the forefront.
The number of patients living with multiple long-term conditions
is increasing as a result of an ageing population, but also due
to multimorbidity occurring earlier in deprived areas.
Patients living with multiple long-term conditions often receive
a worse experience of the health and social care system. This
can include not having access to services when they are most
needed, consultations that are too short to discuss their multiple
conditions, and fragmented care as a result of the disjointed
approach of specialisms and services which are focused on
specific diseases.
This occurs alongside burden of illness, where patients have
to live with their conditions, often changing their lifestyle to
do so. Patients also must cope with burden of treatment, which
results from patients having to attend numerous appointments,
and medication burden from complex medication regimens.
General practice plays a vital role in caring for patients
with multiple long-term conditions. However, GPs are facing
barriers in providing care to this patient group including a lack
of research into multimorbidity, especially when physical and
mental conditions occur together, complexities of polypharmacy,
and incentives which are single disease focused. To address
these barriers, it is essential that action is taken at GP practice,
local health system and national level. This will support the
cultural, clinical, contractual and organisational changes needed
to improve outcomes for patients with multimorbidity.
 Royal College of General Practitioners 3

The multimorbidity challenge

Introduction Who and how many people are affected?

Multimorbidity is a major issue facing modern Estimates of the proportion of the population with multimorbidity
day general practice. Analysis conducted by the College vary according to the datasets used and how many different
has shown that by the year 2025 the number of people conditions these include. For example, in a retrospective
living with one or more serious long-term conditions in the study by Salisbury et al. (2011) of approximately 100,000 adult
UK will increase by nearly one million, rising from 8.2 million patients across 182 practices in England, 16% of patients had
to 9.1 million. Combined with the current ageing population, multimorbidity, defined as having two or more of the chronic
the increased prevalence of long-term conditions is having diseases in the Quality and Outcomes Framework, but 58%
a significant impact on health and social care, and could had multimorbidity when a wider list of 114 chronic conditions
cost general practice an extra £1.2 billion a year over the was considered1. In Scotland, Barnett et al. (2012) extracted
next decade. data on 40 morbidities from a database of approximately 1.75
million people and found that 23.2% of the population studied
While recognition of the challenges posed by multimorbidity were living with multiple long-term conditions2.
is gradually increasing, there is still a long way to go in
Despite the variation in definitions used, it is clear that the
ensuring that the health system responds adequately to the
prevalence of multimorbidity across the UK is rising, as are
needs of this growing patient group. This paper examines
the number of people surviving what would have previously
the experience of patients with multimorbidity and assesses
been terminal illnesses, and the number of people being
the barriers that currently exist to improving their care.
diagnosed. Analysis conducted by the College has shown
It outlines the actions that need to be taken by practitioners
that by the year 2025 the number of people living with one or
and policy makers to tackle these barriers, and highlights
more serious long-term conditions in the UK will increase by
the need for tools to be developed that support those in
nearly one million, rising from 8.2 million to 9.1 million.
general practice in providing care for patients living with
multiple long-term conditions. Research indicates that the likelihood of developing
multimorbidity is linked to the following factors:


nnAge. Salisbury et al. (2011) found a positive correlation
between age and both the percentage of people living with
Defining multimorbidity multimorbidity, and the number of conditions experienced3.
See Figure 1.
Multimorbidity is often defined as two or more long-term
conditions that coexist independently in the same individual. nnDeprivation. Evidence suggests that multimorbidity occurs
Whilst with comorbidity the focus is on an index condition in people 10-15 years earlier in more deprived areas than
(e.g. diabetes), multimorbidity does not imply any more affluent ones4.
one condition is more important than another. This is
particularly relevant in the general practice setting, as the
relative importance of different conditions can wax and
wane over time.
When defining multimorbidity, it is also important to
remember that multimorbidity itself is not a disease.
To each patient, different things matter and this makes
establishing the impact of multimorbidity, both on the
patient and their utilisation of the wider health care system,
difficult to measure.
4 Royal College of General Practitioners

Number
Figure of QoF
1: Number conditions
of QOF conditions -– percentage breakdowns
percentage breakdowns by age
by age group groups
(Salisbury et al. 2011)

100 5+
4
90
3
2
80
1
70

60

50

40

30

20

10

0
18-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

While older people are more likely to experience nnFragmented care resulting from a disjointed approach
multimorbidity, it is important to note that it is not just a across different specialisms and service areas, leading
problem amongst the elderly. For example, Barnett et al. to discontinuity;
(2012) found that of the 1.8 million people examined in their
nnNumerous, and often duplicated, tests;
study there were more individuals living with multiple long-
term conditions aged below 65 than above5. nnBeing more likely to have unplanned, potentially avoidable,
hospital admissions;
nnServices which are focused on specific diseases, making
How effectively does the current health it harder to receive holistic care;
system serve patients with multimorbidity?
nnConflicting advice from different doctors.

As more people live longer, patients with multimorbidity are

accounting for an increasing proportion of the activity in the Burden of illness
health care system. Part of living with multiple long-term conditions is managing
the burden of illness. Patients often have to change
The Department of Health has estimated that in England
their behaviour to manage their illnesses and at times
long-term conditions account for 50% of all GP appointments,
have to influence the behaviour of others to fit in with the
64% of outpatient appointments and 70% of inpatient bed
lifestyle shaped by their conditions and treatment9. Where
days6. Research by Akker and Muth7 suggests that the
factors such as frailty, deteriorating manual dexterity, low
proportion of general practice appointments accounted for
health literacy and cognitive impairment occur alongside
by patients with multimorbidity could be even higher at 80%.
multimorbidity, the burden of illness is greater10. The
Overall, £7 out of every £108 of health and social care combination of physical and mental health conditions, as well
expenditure in England is spent on patients with long-term as issues such as alcohol dependency, can also exacerbate
conditions, with the spend per patient per year increasing issues further.
according to the number of long-term conditions they have.
Burden of treatment
Despite this, patients with multimorbidity often have a worse
The treatment of multiple long-term conditions takes up a
experience of the health and social care system. Problems
significant amount of effort and time for patients. They must
can include:
arrange their lives around attending clinical appointments
nnBeing unable to access health and social care services and often must take time off work to do so11. They have to
where and when they are most needed; navigate through specialised care, where at times specialists
don’t know what other specialists are doing. They also have
nnConsultations which are too short for patients to discuss
to collate clinical information on their health and input this
their multiple conditions;
 Royal College of General Practitioners 5

into administrative systems, attend appointments and learn

to understand their condition. All of this can have a very
Common clusters of conditions
real effect on patients’ quality of life and that of their families
Patients with multimorbidity have to live with the complex
and carers.
interactions of their conditions. There are, however, sets of
In addition, the current system is not designed to support conditions that are more common than others. Despite these
the lifestyles of patients living with long-term conditions, common combinations, there is little understanding of the
tending to prioritise measures to maximise clinical outcomes. impact the conditions that make them up have on each other
Often automatic notifications in the GP-patient consultation, in terms of clinical interactions, quality of life and service use.
reminding GPs to test different health level indicators, make
In order to make progress in delivering quality healthcare
it difficult for those in primary care to prioritise what matters
to patients with multiple long-term conditions, it makes
most to patients and their lifestyle.
sense to focus on further study of condition combinations
that are most common. Common clusters across the world
Medication burden have been reported to be cardiovascular/metabolic, anxiety/
As well as living with the burden of their illnesses, patients depression/psychological disease, and neuropsychiatric or
must live with the burden of taking medication. Whilst psychogeriatric conditions13. A systematic review by Violan
medications are intended to improve a patient’s health et al. (2014) also investigated patterns of multimorbidity
outcomes, they can have adverse side effects and affect a and identified the most common pair of conditions as being
patient’s quality of life. Evidence of this can be seen in one osteoarthritis plus a cardio-metabolic condition, such as
fifth of preventable hospital admissions being due to patients diabetes or hypertension14.
not adhering to their medication12. The more drugs a patient
is prescribed the more complex their medication regimen Figure 2 illustrates clusters of common conditions as reported
becomes and the less likely they are to follow it properly, in the study by Barnett et al. (2012). A secondary analysis of
with many patients not having the time to do so. Patients the same study found that only 10 conditions accounted for
also need to have high levels of numeracy and literacy, as the five most prevalent conditions at different ages in patients
well as practical skills, with some having to learn new skills, with multimorbidity across the life-course; in every ten-
such as being able to administer injections. year age group pain and depression featured in the top five
conditions (McLean et al., 2014)16.

Figure 2: Selected comorbidities in people with four common, important disorders

in the most affluent and most deprived deciles (Barnett et al. 2012)

Patients with this condition

Coronory heart disease (most affluent) 19 7 17 13 12 16 13 9 4

Coronory heart disease (most deprived) 23 19 16 14 10 32 21 13 3

Diabetes (most affluent) 21 4 6 9 6 14 13 7 2

Diabetes (most deprived) 24 11 6 10 5 28 21 10 2

COPD (most affluent) 15 9 6 8 6 15 14 10 3

COPD (most deprived) 24 13 6 9 5 31 23 15 2

Cancer (most affluent) 12 8 5 3 6 5 12 10 7 2

Cancer (most deprived) 17 12 13 4 7 5 29 19 12 3

Patients who also have ase es PD ilur

e TIA ion n ion iety ia
bet ke/ illat ditio ess Anx ent
this condition (%) rt dise Dia CO rt fa Stro fibr con epr Dem
hea Hea i a l f u l D
ry Atr Pai
n
ono
Cor
6 Royal College of General Practitioners

What barriers do GPs face in providing

care to people with multimorbidity?
GPs are the first point of call for patients and as a result are
paramount in delivering care to patients with multiple long-
term conditions. As expert medical generalists, GPs play a
vital role in overseeing and coordinating care for all patients,
but especially for those with complex needs. They facilitate
a patient’s transition between primary and secondary care,
and ensure that patients receive holistic, person-centred care,
where the patient is involved in the decision making process
as much as they wish to be.
Patients who receive relational, managerial and informational
continuity from their GP have better health outcomes, higher
satisfaction rates and the healthcare they receive is more
cost effective17. Relational continuity in particular, defined
as the extent to which a patient experiences an ongoing
relationship with a clinician, is essential for patients living with
multimorbidity, who will typically have numerous interactions
with the healthcare system over time.
However, general practice is facing unprecedented Lack of research into multimorbidity
challenges. The capacity of the service has not been able
to keep up with growing patient need, putting GPs under Multimorbidity is one of the greatest challenges in 21st
great strain and leaving them with little time to adapt and century healthcare. Despite this, research into patients with
innovate. While the need to invest more in general practice multiple long-term conditions, whether these be related to
is now being recognised, in particular in England through physical or mental health, is still very much in its early stages.
the GP Forward View, additional resources will take time to
flow through and will need to be used carefully to have the Patients with multiple long-term conditions are often excluded
maximum beneficial impact for patients with multimorbidity. from single disease clinical research, in order to ensure there
are no influencing external factors. This method of research
aims to understand how to treat an ‘average uncomplicated
patient’. As a result there is little evidence base for patients
Lack of time with multiple long-term conditions, yet it is often patients with
multimorbidity to whom the findings of this research are applied.
Current consultation lengths make it difficult for doctors to
deliver quality patient care for patients with one short term Whilst there has been slightly more research into
bout of illness, let alone those with multiple long-term and co-morbidity, it is often specialist-based and the findings are
complex conditions. not always applicable to patients with multimorbidity in the
primary care setting. A systematic review of US based studies
In England, in 2013/14 the average consultation length was
published between 2008 and 2014 showed that only 27 met
9.2 minutes which is insufficient to meet the needs of patients
the selection criteria of including those with multiple long-term
with multiple health problems18. Research undertaken in
conditions; addressing either improved clinical outcomes,
England into the content of GP consultations has estimated
efficiency of health care and spending or patient satisfaction
that in each consultation, on average, 2.5 different issues
and making comparisons to a baseline measurement22.
are discussed19. With many patients having in excess of five
conditions, the current system makes it difficult for those In addition to this, where research is conducted it is often
in general practice to care for patients who have chronic led by those with vested interests in the study outcomes.
conditions and only 8% of UK GPs feel that the current The drug and medical services industry plays a large role in
consultation length is long enough20. Whilst there is a lack clinical trials, and is often responsible for defining an illness
of research into the feasibility of offering extended and the levels of benefit at which a drug is deemed to be
consultations as standard to all patients with multimorbidity, successful23. This makes it difficult for clinicians to establish
it seems apparent that these patients will need longer if an intervention is suitable for an average patient, let alone
consultations to make their care most effective21. for patients with multimorbidity.
 Royal College of General Practitioners 7

implication with medicines currently costing the NHS more

than £10 billion a year30.
A broader view also needs to be developed as to what is
included when making judgements about drug effectiveness.
Whilst trials may show a drug to be successful, in patients
with multimorbidity there are more factors at play. Numbers
needed to treat and harm should be reviewed when
prescribing drugs for patients with long-term conditions,
and in elderly patients especially, the benefit of prescribing
drugs which increase life expectancy should be carefully
considered. The need for older patients to have support to
manage their medication should also be recognised, with
both health and social care services collaborating to ensure
that appropriate plans are in place.
More broadly there is a lack of research into the ways in
which professional practice can be developed and services
designed to provide the most effective care to patients Limitations of guidelines when treating
with multimorbidity. It is fundamental that more research is patients with multimorbidity
conducted into meeting the needs of patients with multiple
long-term conditions, alongside influencing factors such as Single disease guidelines offer limited assistance and can
socio-economic deprivation, condition severity, frailty and even be contradictory when providing care to patients with
vulnerability24. In addition, a better understanding is required multimorbidity. Current single disease focused guidelines do
of how clinicians and patients use research evidence, and acknowledge that co-morbidity should be considered when
how this feeds into clinical communication, diagnostic options developing a management plan31; however, little reference
and shared decision making25. is made to multimorbidity. As a result GPs face information
overload from numerous conditions guidelines; a lack of
clinical evidence on effectiveness of interventions for patients
Polypharmacy living with multimorbidity; and barely any evidence into the
most cost effective treatments.
Whilst patients may struggle to manage the numerous
The National Institute of Health and Care Excellence (NICE)
medicines prescribed for their multiple conditions, GPs also
has recently produced draft guidelines that set out broad
face challenges in prioritising medicines of patients with
principles on the care of patients living with multiple long-term
multmorbidity.
conditions. These cover topics including the need to develop
Current guidelines advise GPs on medicines to prescribe a tailored approach to patients’ care, how to deliver this
in order to treat a particular condition - not how to treat the approach, understanding the significance of frailty in patients
patient in the context of all their conditions. This can often who have multiple long-term conditions, and the importance
result in GPs being advised to prescribe numerous different of reviewing medication. The guidelines do not attempt to
medications. Sometimes polypharmacy is appropriate, make recommendations for every single possible combination
with patients experiencing significant benefit from being on of conditions or to cover the full range of circumstances that
multiple medications; however, often it is problematic26. One clinicians may encounter. However, they have the potential
study by Wallace et al. (2015) reported that approximately to act as a useful tool, provided that they are backed up by
20% of patients with two conditions were prescribed four to sufficient resources and the freedom for GPs to exercise
nine drugs, and 1% of patients were prescribed ten or more their professional judgement.
drugs. For patients with at least six long-term conditions this
increased to 48% and 42% respectively27. Additional research
into age and multimorbidity reported that around two thirds of
patients over the age of 70 take five or more medicines, with
one third of this group taking nine or more drugs a day28.
While GPs are expert generalists, it is extremely difficult
to know how drugs recommended for the considerable
number of combinations of single disease conditions
will interact. The more drugs a person is prescribed, the
greater the risk of human error or adverse drug reactions.
The implications of this are far reaching. Adverse drug
reactions account for 6.5% of hospitalisations, half of which
are preventable29. In addition there is a significant financial
8 Royal College of General Practitioners

Physical and mental multi-morbidities Incentives which treat illnesses, not patients

The combination of long-term physical and mental health Contractual mechanisms such as the Quality and Outcomes
conditions is very common. The King’s Fund has reported Framework (QOF) have not historically tended to incentivise
that 30% of people with a long-term condition also have a a holistic approach to treating patients with multiple
mental health condition and 46% of people with a mental morbidities, focusing instead on single diseases. QOF is
health problem have a long-term physical illness32. The effect part of the General Medical Services contract, and rewards
of mental health on physical illness is estimated to cost the practices for treating individual long-term illness, for example
NHS between £8 and £13 billion a year in England33. Despite asthma or diabetes. However, this framework makes no
this there are few studies that review the effects of physical attempts to review, and reward, how well practices treat
and mental health conditions on each other. patients with multiple long-term conditions.
The interaction of long-term physical conditions and long-term Under QOF large numbers of patients with multimorbidity
mental health conditions poses particular challenges for the are excluded, with individuals with ‘high dependency and
health care system. Whilst a patient may develop depression long-term conditions’ accounting for 11.2% of exemptions
as a result of living with a long-term physical illness, depression in England and patients with ‘mental health and neurology’
itself can reduce a patient’s ability to manage a physical accounting for 14.5%37. While this at least avoids penalising
condition. Research has demonstrated that 23% of patients practices for tailoring their approach to meet the needs of
with one chronic condition reported depression, compared to patients with multimorbidity, it also skews care and attention
40% of those with five or more conditions34. away from them.
It is therefore paramount that mental health is recognised Despite the intention of QOF being to reward practices for
as being of equal importance to physical health when the quality of care, it does not always reflect the needs of
treating multimorbidity. Research by Coventry et al. (2015) patients. There is evidence to suggest that non-disease related
demonstrates where depression and a long-term physical outcomes may provide a more accurate indication of care
condition were treated collaboratively, rates of depression quality. For example, relationship quality, self-management
were 0.23 SCL–D13 points lower than when they were treated and consistency have been reported to predict mortality more
separately35. The association between mental and physical accurately than biomedical measures of disease progression.
health problems is also socially determined, with patients This implies that focusing purely on disease related outcomes
living in deprived areas having a much higher prevalence of may not be the best way to treat, or measure, the quality of
mental health problems for a given number of physical health care patients with multimorbidity receive.
conditions (Barnett et al., 2017, to be published). In addition,
the ageing population means more people are living with
dementia. Dementia can make management of a physical
condition especially challenging due to forgetfulness or
confusion, and if medication is not taken a patient’s physical
condition may decline.
Stigma around mental health issues is also a challenge when
managing multimorbidity. Patients with physical conditions
may choose not to disclose their mental health conditions,
which can make treating their illnesses difficult for a GP. For
example, at times it can be difficult for a GP to differentiate
the signs of depression and signs of ageing36.
 Royal College of General Practitioners 9

Actions to improve outcomes

for people with multimorbidity

Collaborative care and support planning

Collaborative care planning between a patient and their GP

is widely recognised as being crucial to ensuring that patients
with multimorbidity receive quality health and social care. The
College has already developed a Care and Support Planning
Programme43, and the collaborative care and support
planning approach has been recommended by the National
Institute for Health and Care Excellence. Key components of
this approach include:
nnShared decision making between patients and clinicians;

nnProactive goal setting that reflects what is most

important to the patient;

The increasing number of patients living with multimorbidity nnUse of multidisciplinary teams that draw on the expertise
is a profound challenge for the NHS, and it is essential that of a range of health and social care professionals as part
measures are taken which harness the potential of general of a coordinated approach;
practice to improve outcomes for these patients. Alongside nnLonger consultations; and
additional resources, action is still needed to better enable
professionals to provide this patient group with truly whole nnContinuity of care with a named professional.
person care. This will require cultural, clinical, contractual In Scotland, a five-year programme of research (2009-
and organisational changes at the GP practice, local health 2014) called ‘Living Well with Multimorbidity’ resulted in the
system and national level. development of a whole-system intervention (CARE Plus)
for patients with multimorbidity in very deprived areas.
This involved substantially longer consultations for targeted
Consultation length patients living with multimorbidity, relational continuity with
their GP, a structured care plan based on the patients’ own
A longer consultation length for patients with multiple goals, and support and training for GPs44. A feasibility cluster
long-term conditions is an approach that would enable randomised controlled trial in Glasgow showed preliminary
these patients to have more time to discuss their complex evidence of benefits in terms of quality of life
conditions with their GP. and cost-effectiveness45.
A study by Mercer et al. (2007) in Scotland found that patients
in the most deprived areas had more problems to discuss
(especially psychosocial), yet clinical encounter length was
generally shorter – at 8.2 minutes on average compared
to 8.6 minutes in more affluent areas39. Further research in
Scotland that looked into the impact of longer consultations
in deprived areas found that an increase in consultation
length for patients with complex needs to an average
of 15 minutes was associated with enhanced levels of
patient enablement40. The study recommends that 15
minute consultations should be standard for patients with
multimorbidity, and suggests that more integrated working
would free up time to allow this to happen41.
The Deep End Project in Glasgow has taken these insights
and supported practices to apply them by exploring a range of
approaches to increase face-to-face clinical time with patients
in deprived areas including offering longer consultations42.
10 Royal College of General Practitioners

The 3D study is another example of how providing holistic

care can improve the health outcomes of those with multiple
long-term conditions. The research assesses the Dimensions
of health, Drugs and Depression, with a view to addressing the
issues of illness burden, treatment burden and lack of patient
centred care. Interventions conducted to produce better health
care outcomes of patients with multimorbidity were:
nnIdentification and prioritisation of patients with
multimorbidity;
nnImproving continuity by having a named GP;

nnLonger consultation times;

nnPerson centred assessments every 6 months, as opposed

to reviewing conditions on an individual basis, using an
interactive template;
nnFocusing on 3Ds; Dimensions of health (quality of life
as well as disease outcomes); Depression and Drugs There are, however, barriers to medication reviews. Patients
(addressing polypharmacy and medication adherence); may feel that certain medication is a necessity or hope it will
lead to improvements in the future, and patients can fear
nnWritten care plans taking account of individuals’ priorities
stopping medication if they have had negative experiences
and needs;
when stopping before, such as withdrawal effects48.
nnIntegration with a physician who is available to provide over Additionally, GPs fear that they will be blamed for their actions
the phone advice and co-ordinate hospital care; and in regard to deprescribing and more guidance is needed to
assist GPs when ceasing to prescribe medication. Close
nnDevelopment of a sophisticated interactive computer
collaboration between pharmacists and doctors regarding
template for patients with multimorbidity, removing the need
prescribing and medication reviews is also essential.
to use a series of individual disease focused templates for
these patients and steering clinicians to focus on patients'
individual needs.
Multi-disciplinary teams

As we continue to develop new ways of working, multi-

Medication review disciplinary teams are proving essential in delivering care
for patients with multimorbidity.
Medication reviews are a good way for GPs to establish
how what a person is prescribed compares with what is Multi-disciplinary teams enable GPs to manage the care of
recommended, and are an opportunity for clinicians to reduce those living with multiple long-term conditions more effectively
polypharmacy when possible. They are essential in informing by ensuring all aspects of a patient’s care are accounted
patients about the purpose of their medication, identifying for. While GPs have a knowledge and understanding of
any side effects, and ensuring they are involved in decision numerous illnesses, and have undertaken extensive training
making regarding their care. Often medication reviews can to care for patients with complex needs, when caring for
form part of the GP-patient consultation; however, patients patients with multiple long-term conditions coordination with
with multiple long-term conditions would especially benefit other professionals, particularly specialists, is paramount.
from a dedicated medicine review consultation. Those working as part of a multi-disciplinary team take into
consideration co-morbidities a patient may have and the GP
As GPs are currently facing unpreceded pressures, utilising
is made aware of medication prescribed by other professionals,
the skills of clinical pharmacists may be an option for
reducing the risk of any adverse drug reactions.
conducting medication reviews where prescribing is more
complex. The College has previously welcomed the inclusion The Roland Commission identifies the opportunity to make
of pharmacists as part of the general practice team stating use of a broader range of skills and roles in delivering care to
that pharmacists could work with GPs and other colleagues patients with multimorbidity, including specialists, allied health
to resolve day to day medication issues and would be of professionals such as physiotherapists, and pharmacists
particular benefit to those taking multiple medications. Whilst working in GP practices and from premises in the community.
there is conflicting research on the benefits of pharmacists It highlights the potential to roll out new roles such as
conducting medication reviews, Holland et al. (2007)47 found medical assistants and calls for better access to training for
that there was a slight decrease in the number of drugs practice nurses and improved integration between general
patients were prescribed when medication reviews were practice and those working in community health services.
conducted by pharmacists. It also advocates consultant-run email and telephone
 Royal College of General Practitioners 11

helplines providing advice for GPs and other primary care

professionals, and greater specialist participation in multi-
The primary/secondary care interface
disciplinary team meetings.
Improvements in the interface between primary and secondary
It is vital that the development of multi-disciplinary teams care offer the potential to deliver real gains in the quality of care
is done carefully and that professionals work together to received by those living with multiple long-term conditions.
ensure that continuity is not lost. Care must be taken that
As patients transition between primary and secondary care,
GPs are not deskilled by the development of multi-disciplinary
and different sectors of the healthcare system, information
teams. Access to comprehensive medical records is also
can be lost and healthcare professionals may not be aware
an essential prerequisite for effective multi-disciplinary team
of the actions and decisions taken by those from other parts
working. Hospitals, GP out of hours services, emergency
of the system.
services, GP practices and clinicians conducting home visits
all need to be able to share information in a timely fashion on An enhanced role for general practice in conducting more ‘in
aspects of care such as repeat medication, acute medication, reach’ could assist in bridging the gap between primary and
laboratory results and discharge and outpatient letters. secondary services, and in ensuring that patients are not
treated in hospital unnecessarily. This consists of primary and
secondary healthcare professionals collaborating to assess
patients and plan their care in the secondary care setting,
Co-morbidity clinic in Grosvenor and is likely to be especially beneficial in providing continuity
Surgery, Belfast for patients with multiple long-term conditions. GPs working
in this role could conduct geriatric assessments, which have
In Northern Ireland, Grosvenor Surgery trialled a been proven to reduce admission to residential care from
co-morbidity clinic to provide holistic care for patients hospital, and conduct individual discharge planning from the
with multiple long-term conditions.
moment a patient is admitted to hospital.
The practice recognised that many patients were on
different chronic disease registers and were attending the Electronic health record systems have the potential to
practice multiple times for various clinics. They wanted develop and shape new ways of clinical working at the
to reduce the number of occasions patients had to attend interface between primary and secondary care. Advanced
the practice and increase patient satisfaction as a result,
as well as improving health attitudes, perceptions and health record systems could search for previous changes
self management. in medication, alert GPs and specialists to potential adverse
In reviewing their patient lists the practice identified
medical interactions and also calculate risks versus benefits
patients who had either diabetes, Chronic Obstructive for certain patient interventions49. In Northern Ireland, the
Pulmonary Disease (COPD) or Ischaemic Heart Disease Health and Social Care Board is developing IT systems for risk
(IHD), combined with 3 other long-term conditions. This stratification that will interrogate patient records and identify
produced a list of 55 patients. patients with multimorbidity, polypharmacy and their statistics.
The practice reviewed the medical notes of each of these Northern Irish GPs, hospitals and out of hours services also
patients and produced a timeline covering the care they already have access to Electronic Health Care records. This
would need in the future, including any potential secondary
allows them to view patient demographics, repeat and recent
care they might need and also how they could receive care
from other aspects of the community. acute medication, allergy records, blood and radiological
results and hospital discharge and clinic letters.
Patients were asked to attend the surgery for a week
before the clinic for blood tests and an ECG, the results
of which were reviewed at the clinic a week later.
The clinic itself consisted of the patient having a one hour
appointment. The first 20 minutes of the appointment
were spent with a nurse, followed by 40 minutes with the
GP, with the option to have a medication review with the
practice pharmacist. To deliver continuity, the same GPs
would take part in the clinic each week.
Feedback from patients was that the clinic was successful
and they valued having longer consultation times. GPs
stated the clinic was onerous but worthwhile as it allowed
them to discuss issues in greater detail with patients.
12 Royal College of General Practitioners

Leeds interface geriatrician service Commissioning Enhanced Care

Pathways in Wandsworth – integrated
At Leeds Teaching Hospitals NHS Trust and Leeds
Community Healthcare Trust interface geriatricians are care for frail older people
working to improve the care of patients living with multiple
long-term conditions. Wandsworth is taking a proactive approach to identifying
patients that will especially benefit from integrated care.
They attend integrated health and social care team GPs, community services and social care are working
meetings on a monthly basis, working alongside district together to identify an initial cohort of 500 frail older people
nurses, GPs, social workers, occupational therapists and that are at highest risk of unplanned hospital admissions
physiotherapists to deliver whole patient care. They make who will receive support via an enhanced care pathway.
home visits and attend to intermediate care patients, as
well as educating others on caring for patients with multiple Geriatricians will conduct single assessments to ensure
long-term conditions. patient care is holistic, taking into account medical, social,
functional and mental health needs and care plans, with
Additionally, the service consists of a nurse-led patient clear measurable outcomes.
care advice Line that gives GPs and community staff
access to speciality beds and advice from geriatricians Patients with urgent care needs will benefit from a
working at the interface. rapid response service and where clinically appropriate
enhanced care will be provided at home to prevent
unnecessary hospital admissions. Where patients live in
care homes, GPs will provide proactive care supported by
a community geriatrician.
Commissioning for patients with When patients are admitted to hospital community
complex health needs services, GPs and social care will adopt integrated
discharge planning to reduce the amount of time
The current system of designing care pathways around single medically fit patients stay in hospital. This will consist of
identifying patients’ ongoing care needs within their home
diseases simply does not work for patients with multiple
environment and ensuring they make optimum use of
conditions. When commissioning care, more emphasis needs available support services.
to be placed on the fact that a large proportion of patients now
have multiple long-term conditions, and this will continue to rise
in years to come. Future systems of commissioning healthcare
should support the integration of services, acknowledging that Education and Training
current budgets are fragmented, in order to meet the needs of
patients. One means of doing this being rolled out in England In addition to recruiting more doctors and nurses to general
is through primary care co-commissioning. practice, those in training need to gain more experience of
caring for patients with multimorbidity, and this needs to start
from undergraduate medical training onwards. Education
needs to move away from the current approach of focusing
on single diseases and move towards holistic care, preferably
in the patient’s own setting and context, with a focus on
influencing factors such as frailty. Training should ensure
health care professionals recognise that the needs of the
patient are the priority and not the illness itself, alongside
ensuring that the patient is involved in making shared
decisions which enable them to self-manage.
Elements of the multimorbidity educational curriculum
should include research-led evidence-based findings from
studies into multimorbidity, development of new clinical
guidelines that look at clinical care for patients with more
than one medical problem, and a greater emphasis on the
effectiveness of medications and their interactions when
patients are faced with needing to take many drugs. Trainees
also need more practice in negotiating management and
treatment plans with patients, better understanding of
the issues affecting compliance and how to rationalise
medication regimens to ensure optimum uptake and reduce
over medicalisation.
 Royal College of General Practitioners 13

National bodies responsible for education across the UK

have an important role to play in reviewing existing curricula
for the training of professionals who will be caring for those
with multimorbidity, and making changes where necessary.
All foundation doctors should spend a period in general
practice to encourage awareness in all specialties of
multimorbidity and its management. The RCGP has also
argued for an extension in the length of postgraduate GP
training from three to four years, to enable GPs to gain
greater experience of aspects of healthcare such as child
health, mental health and caring for patients with multiple
long-term conditions. In the meantime the MRCGP curriculum
will also need to be kept under review to ensure it continues
to align with current UK patient needs and consulting
behaviour, including the use of IT in the consultation and the
facilitation of multi-disciplinary teams in managing patients.
GPs will also need to gain a greater understanding of patient Improved information systems and
demography and multimorbidity, and of polypharmacy.
decision making tools
More sophisticated information and guidance needs to
Research tailored to patients living be developed to ensure patients with multimorbidity receive
with multimorbidity adequate care. This needs to be clearer on the benefits
and risk of interventions for patients with numerous
In order for the health system to tailor care for patients living conditions, and be accompanied by decision-making tools
multiple long-term conditions more research is needed. that enable the doctor and patient to tailor care to the
Research to establish a definition of multimorbidity that individual’s preferences.
encompasses all aspects of a patient’s symptoms, both in The introduction of the forthcoming NICE guidance will
terms of illnesses and psychological impacts, is needed provide clinicians with a broad set of overarching principles for
to understand the varying quality of life these patients can treating patients with multimorbidity. The draft guidelines also
experience. The current lack of a widely accepted definition is discuss the importance of frailty being assessed alongside
acting as a barrier to consistent, holistic care for all patients. multimorbidity and the need for GPs to explain the potential
Understanding factors that influence a person’s likelihood of benefits and side effects of treatments, as well as offering
living with multimorbidity or impact the quality of care they non-pharmacological solutions. It may also be possible
receive is also necessary. Whilst research into the prevalence to develop more detailed guidelines that address some of
of multimorbidity in elderly patients and areas of high the most common combinations of disease, or synthesise
deprivation is more established, research into the experience relevant advice based around presenting symptoms in a
of certain ethnic groups, those with poor social support and similar fashion to NICE’s recent cancer guidelines. However,
those with drug or alcohol problems is still in its infancy50. realistically there will never be a guideline that is tailored to
Understanding these influencing factors in greater detail will every patient and set of circumstances.
enable the health care system to be tailored to the increasing
number of patients living with multiple long-term conditions. Technological developments could also support doctors
when prescribing multiple medications by highlighting
As well as analysing the causes and effects of multi- potential risks51. Online systems recording numbers to treat,
morbidity, more research into the interventions that are most duration for which medication should be taken, or a hierarchy
effective in improving outcomes for patients with multi- to show the most important medications could ensure
morbidity is urgently needed. This should encompass both that patients have the greatest chance of positive health
drug effectiveness and service delivery and design, focussing outcomes. NICE recommends the use of decision support
in particular on what can be done to improve treatment for the software such as STOP START can assist in improving
most common clusters of conditions. patient outcomes52.
Furthermore, the NHS England programme Patient Online
could support patients living with multiple long-term conditions.
Patient Online offers more online services to patients such as
access to coded information records, appointment booking
and ordering repeat prescriptions, all of which would support
patients in playing an active role in their care.
14 Royal College of General Practitioners

Already in Scotland the QOF contractual requirement has

been dropped. From April 2016 practices will form 'Quality
NHS Scotland Polypharmacy Clusters’ to deliver a model of quality that is peer based and
Guidance App has professional values and patient outcomes at its core. It is
intended that the process of quality improvement will be better
In Scotland, the NHS and the Scottish Government have suited to the complex needs of people with multimorbidity. In
developed a decision making tool designed to aid those
caring for patients with multiple long-term conditions. addition, replacement of QOF has also been trialled in some
parts of England - see below for more detail.
The app identifies seven steps to provide a clear structure
for the medicine review process. These are focused on
the needs of the patient and encourage communication
between doctor and patient to identify non-pharmacological
solutions in addition to medicine related ones. Somerset Practice Quality Scheme
The app is intended to increase knowledge and
NHS Somerset CCG has already trialled a replacement
understanding of patients and doctors, and includes case
to QOF in the form of the Somerset Practice Quality
studies to demonstrate the importance of holistic care.
Scheme (SPQS). The scheme developed as practices felt
Whilst the app is still in its early stages it is these types of that QOF did not incentivise best practice. Practitioners
tools that will support GPs to make informed decisions and reported that due to being single disease focused, QOF
will simplify the complex care delivered to patients living impinged on person centred care for patients with multiple
with multiple long-term conditions. long-term conditions. As 25% of those over 80 years old in
Somerset have three or more long term conditions, this was
something that Somerset CCG wanted to tackle, with 55 out
of 75 practices choosing to take up the offer to leave QOF.
Appropriate incentives The removal of QOF reporting allowed practices to
innovate, for integration to improve and for organisational
change to begin to develop. The SPQS practices
While the evidence is mixed regarding the impact of QOF in conducted longer consultations for patients living with
improving patient outcomes, it is essential that, to the extent multiple long-term conditions. These consultations were
that general practice is subject to financial incentives, these focused on the needs of the individual and aimed to reduce
are geared to ensuring that the needs of patients living with the number of appointments patients needed, as well as
multiple long-term conditions are prioritised. Changes to the reducing the amount of letters they received regarding
each of their conditions. Practices also adopted multi-
current QOF indicators are essential in caring for those living disciplinary team working to provide holistic care, which
with multimorbidity. These alternatives should not penalise improved coordination within and across sectors.
clinicians for tailoring care towards individual patients but Patients reported that they had positive experiences in
support them in using their professional judgement, and relation to continuity and that their ability to self manage
should easily enable development and innovation, as well their conditions had increased as a result of the Somerset
as collaboration with the patient themselves. The table Practice Quality Scheme. Practitioners felt they were
below outlines three potential approaches together with their providing more holistic care to their patients and highlighted
that one of the main barriers to caring for people with
possible advantages and disadvantages: multiple long-term conditions was communication issues
hampered by lack of effective IT systems.
No financial Removal of current Removal of current
incentives QOF indicators and QOF indicators and
the introduction of the introduction
new process based of new outcomes
financial incentives based financial
incentives

+ Bureaucracy + Aspects of care − This could become

and box ticking such as care another box ticking
processes will be planning will be exercise
removed prioritised
− Measurable
− Practices may not − This could become outcome based
be incentivised to another box ticking indicators that
prioritise the needs exercise reflect general
of patients living practice care
with multiple long- + How well a patient may be difficult to
term conditions feels their care develop
enables them to
live a better life − Outcomes may not
will be prioritised be wholly within
GPs’ control e.g.
environmental
factors
 Royal College of General Practitioners 15

Resourcing implications

In order to provide quality care for the increasing number

of patients living with multiple long-term conditions, more
needs to be done to address the resourcing implications for
general practice. General practice is currently facing a lack
of GPs, with the College currently calling for 10,000 more
GPs to be recruited across the whole of the UK. These GPs
are desperately needed to provide care for patients with
more complex needs. If fully implemented, the GP Forward
View in England will go a long way towards meeting this
aim; however, as the general practice workforce increases,
it will be important to ensure that it is deployed in ways that
will improve care for patients with multi-morbidity. As well
as being more clinically effective, this will also lead to better
financial outcomes for the NHS in the long-term, and this
needs to be reflected in decision making frameworks for
resource allocation within the NHS.
16 Royal College of General Practitioners

Recommendations
The following recommendations aim to prioritise the
care of patients living with multiple long-term conditions
and should be implemented by general practice and the
wider health service:

Recognise the importance of GPs as the lead physicians providing generalist care
to patients with multiple conditions in the community.

Prioritise longer consultations for those with multimorbidity to provide them with more
time to discuss the complexities of their multiple conditions.

 ive patients living with multiple long-term conditions the opportunity to form on-going
G
relationships with those providing their care in general practice. Practices should monitor
the proportion of patients with multiple long-term conditions receiving continuity of care
and take steps to improve this when necessary.

 mbed care planning for those living with multimorbidity and support greater collaboration
E
between the range of professionals involved, aiming for coordinated holistic care.

 evelop multidisciplinary teams around general practice to ensure that GPs are able
D
to gain rapid access to the care that patients with multimorbidity need e.g. mental health
services, district nursing and support for social care needs.

Improve communication at the interface of primary and secondary care to ensure patients
do not receive fragmented care e.g. through use of in-reach teams and advice lines for
GPs and other primary care staff.
 Royal College of General Practitioners 17

Improve the interoperability of IT systems throughout the whole health and social care sector
to facilitate easier collaboration between different professionals and across different settings.

 dopt face to face dedicated medicine reviews for all patients with multimorbidity –
A
ideally incorporating the skills of both GPs and practice based pharmacists.

 nsure that those in foundation training gain more experience in caring for patients living
E
with multiple long-term conditions by spending time in general practice. The MRCGP
curriculum should also be updated to reflect the needs of patients living with multimorbidity
and the length of GP training extended.

 evelop tools for GPs and patients with multiple long-term conditions to enable them to make
D
informed decisions, such as apps or improved guidance e.g. guidance on deprescribing.

 eview performance related payments which relate to disease specific targets, and develop
R
alternatives that encourage a whole person approach to care and measure outcomes that
are important to patients.

 ecognise that multimorbidity occurs earlier in areas of high deprivation and ensure that the
R
NHS channels funding to areas that most need services for those with multimorbidity, not only
to areas of greatest population size.

 ecognise the importance of mental and physical health interactions in patients living with
R
multiple long-term conditions, and conduct research to understand the combination of these
types of conditions in more detail in order to provide resources to support both GPs and patients.

Increase funding to provide the resources and capacity for independent research into
multimorbidity including common clusters of conditions, drug effectiveness, deprescribing
and physical and mental multimorbidities.
18 Royal College of General Practitioners

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Authors
Professor Maureen Baker
Holly Jeffers

Endorsed by RCGP Council

Royal College of General Practitioners

30 Euston Square
London NW1 2FB, UK
T +44 (0)20 3188 7400
F +44 (0)20 3188 7401
E [email protected]

www.rcgp.org.uk

Royal College of General Practitioners is a registered charity in England and Wales

(Number 223106) and Scotland (Number SC040430)