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NICE: GPs should develop individual care plans for patients with multimorbidity

GPs are to start systematically reviewing patients with multiple long-term conditions and giving them individualised care plans, under NICE’s long-awaited multimorbidity guidelines.

The draft guidelines have been discussed since 2012 in response to GP claims that multimorbidity guidance is more relevant than single-condition guidelines, which have led to potential harm for patients overburdened with treatments.

NICE’s proposals suggest GPs should carry out searches of electronic health records to identify patients who may benefit from having a more ‘tailored approach’ to their care – particularly the elderly and frail, and those taking fifteen or more medications.

In line with the current unplanned admissions DES, GPs should then agree on an ‘individualised management plan’ with these patients and make sure this is followed up by the lead clinician in charge of co-ordinating their care.

NICE tackles multimorbidity after criticisms of irrelevance and over-treatment

GPs have been waiting for NICE guidelines on multimorbidity for some years now, after NICE chiefs admitted that single-disease guidelines were not really helpful for GPs managing increasingly complex patients in their daily practice.

Leading GPs have warned existing guidelines may even be contributing to over-treatment of the elderly, while NICE advisors have admitted that it was too difficult for GPs to dig out the real benefits and harms of treatments from individual guidelines recommendations.

Current NICE chair Professor David Haslam - a former GP - has expressed his commitment to making guidelines more relevant to GPs, with the multimorbidity guidance a key step towards realising this aim.

As part of developing a plan, GPs are advised to discuss stopping any medications of limited benefit in controlling symptoms or extending life, or that carry a high risk of adverse events – such as falls, GI bleeding and kidney injury.

The guidelines also propose using a screening tool such as the STOPP/START tool for older people, to help pinpoint any drug safety concerns – as well as any potential medications that the patient is currently missing out on.

However, NICE experts have proposed only one specific recommendation for withdrawing a drug – which is to discuss stopping bisphosphonates after three years of treatment.

Chair of the guidelines development group Professor Bruce Guthrie, professor of primary care medicine at the University of Dundee, said: ‘Care for people with multiple conditions is often complicated. This is because the conditions themselves and their treatments interact in complex ways, and care can be fragmented across many different specialists and services.

‘General practice and other generalist services, like care of the elderly, have a crucial role in co-ordinating care through a person-centred rather than disease-focused perspective. The new draft guideline emphasises the importance of this perspective.’

Professor David Haslam, chair of NICE and a former GP, said: ‘When working with patients, healthcare professionals should use their judgement when deciding treatments or services appropriate to someone with more than one long-term health condition.

‘It is important to balance the evidence for benefit with the potential harm of treatment for the individual, and take into account the preferences and wishes of the person themselves.’

NICE - Multimorbidity: clinical assessment and management 

   NICE Multimorbidity guidance - Key points for GPs


Targeting patients for tailored care

GPs should identify people with multimorbidity (two or more long-term conditions) who may benefit from a ‘tailored approach’ to their care – such as patients with both long-term physical and mental health conditions, the frail, people prescribed multiple medications (especially those on 15 or more) and those who frequently seek unplanned or emergency care .

This can be done opportunistically, but should also involve proactively searching electronic health records – which may include use of a validated tool like the QAdmissions tool.


Tailored approach to care – principles

GPs should focus on reducing patients’ treatment burden, their risk of adverse events and unplanned care.

Take into account the persons individual needs and preferences, how their conditions and treatments interact and how this affects their quality of life.


Steps to delivering tailored approach

Agree an individualised management plan with the patient - including who is responsible for the co-ordination of their care, when their plan is to be reviewed and how to access urgent care – making sure this is communicated to all services involved.

Clarify with the patient at the outset whether and how they would like a partner, family member and/or carer involved in key decisions on their management.

Explain to the patient the aim is to find ways to reduce treatment burden and optimise their care. This may include identifying:

treatments that could be stopped because of limited benefit;

medicines with a higher risk of adverse events (eg, falls, fractures, confusion, GI bleeding, acute kidney injury);

non-pharmacological alternatives to some medicines; alternative arrangements for follow-up to coordinate or optimise the number of appointments.


Reviewing medications

Consider using a screening tool such as the STOPP/START tool in older people, to identify medicine-related safety concerns and any new medications the patient might actually benefit from.

Ask if treatments for symptom relief are helping or causing any harms, with a view to potentially reducing or stopping the treatment

Consider taking people off medicines that are supposed to offer prognostic benefit, especially if they have limited life expectancy or are frail

Explain to people taking bisphosphonates there is no consistent evidence of further benefit after three years and discuss stopping bisphosphonates after this.

Readers' comments (9)

  • Brilliant,
    after years of extolling niche specific and condition isolated guidance usually based on non comparable cohorts they now realise GPs need to take more than just a few words of the wise into account when caring for their patients.
    A welcome acknowledgement and sign of progress.
    Paul C

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  • Very laudable, but where are the resources for this? We can't even cope with the present demand for appts from patients with minor conditions. In fact should any health care professional be even consulting patients for minor URTIs etc? Perhaps if an extra fee was charged..?

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  • The Aussies have done this for years - and they get paid extra for doing them.

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  • If they are new work then yes gps should be 100% be paid for doing them separately, and this is only if they have the time to spare?
    Otherwise it is just a NICE idea.
    Also I cannot imagine any noctor being able to do this? Unless this was put in to get practices to employ a potential practice pharmacist to do???
    Anyway it is looked at it is an extra unnecesary burden for gps if it is not funded.

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  • Pie in the sky I'm afrain.

    In my locality, 1/4 of GP posts are unfilled. At our recent work force planning, we've discovered this will expand to a 1/3 unfilled at current projection by 2030. I'm currently working 11hrs/day and my colleagues are looking at me with ENVY as many do 12-13hrs/day.

    So exactly which part of our normal working day does the NICE/NHSE wish me to drop in order to service this laudable but time consuming work? That is assuming NICE has performed a cost effective analysis to prove it isn't just a good clinical idea but an idea which will make the difference in the real work of limited resources?

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  • Before NICE issues any more edicts that affect GP it should very publicly and boldly state exactly the number of GPs that are required to be able to adhere to all its guidance. Not doing this is cowardly and they should be ignored until they get this, the most basic of guidance, established.

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  • Fabulous idea. And as we are so fantastically underworked and super efficient we'll do this in our 10 minutes consultations at no extra funding. Maybe our care of the elderly consultants should step in, that was always meant to be their specialty field or?

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  • I wholeheartedly agree. We plan to reduce our appointment capacity as we move to 15-30mins per patient in the same working hours. The remainder will be directed to A&E/WIC. Best of luck NHSE.

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  • Usual delusions from these ivory tower impractical buffoons who would not last one day doing real work

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