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GPs go forth

NICE multimorbidity guidance - key recommendations

Five-minute summary of the new guideline

Identifying 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.


Delivering a tailored approach

Agree an individualised management plan with the patient, including:

· goals and plans for future care

· who is responsible for coordination of care

· how the plan is communicated to everyone involved in patients’ care.

Explain that the purpose is to improve their quality of life 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

Use the database of treatment effects to find information on:

· effectiveness of treatments

· duration of treatment trials

· populations included in treatment trials.

Consider using a screening tool such as the STOPP/START tool in older people, to identify drug-related safety concerns and medicines the person might benefit from starting.

Ask if treatments for symptom relief are helping or causing any harms.

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

Discuss stopping bisphosphonates after three years, including patient choice, fracture risk and life expectancy in the discussion.

Source: NICE NG56 – Multimorbidity: clinical assessment and management

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Readers' comments (4)

  • Common sense pioneered by the college for decades. No time to do it though ... the current NHS structure depends on GPs moving at 10 minute intervals all day. Pinning hopes on " Transformation Groups " showering us with physicians' assistants and residential home pharmacists. Takes cash a lot of cash. Need to change mono- disease ( BP) guidelines too to unfreeze nervous prescribers.

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  • fine if there's a protocol to remove protocols from specialists and a supply of adequately experienced GPs to apply common sense without fear of retribution when they are next admitted.

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  • What has gone wrong with these patients? I am aged 70, and being treated by my GP for mild to moderate hypertension, a large hiatus hernia with marked reflux and and slightly raised HDL Cholesterol level. And yet I am still walking miles, attending concerts, films and plays with my friends and visiting a 90 year old lady friend in a care home who would test the best because her memory is either very confused or simply missing and this presents a major challenge to understanding her.

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  • A very relevant point that any such process involves adequate investment of resources - time / staff which unfortunately are not existent at the moment in the primary care team to deliver such services

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