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The waiting game

Consider stopping treatment with 'limited benefit' in multimorbidity, advises NICE

GPs have been advised to to offer tailored care plans to people with two or more long-term conditions and consider stopping all treatments with 'limited benefit', by new NICE guidelines on multimorbidity published today.

The final guidance – largely unchanged from the draft version published at the end of March – urges GPs to draw up individual care plans for patients with two or more conditions – particularly elderly and frail people, and those taking 15 or more medications regularly.

The guidelines lay out how GPs should review medications and provide a 'database of treatment effects' to help weigh up the pros and cons of individual drugs.

The long-awaited guidelines are designed to help GPs manage patients with multimorbidity and have been under discussion since 2012, amid concerns that the plethora of single-condition guidance was unhelpful for busy GPs and was driving an epidemic of overtreatment.

GP experts welcomed the final publication – which has been in the pipeline for more than four years – but cautioned that GPs were not adequately resourced to carry out the extra work involved in developing individual plans and reviewing medications.

Professor Bruce Guthrie, professor of primary care medicine at the University of Dundee and chair of the group that developed the guidelines, said: ‘It’s not unusual for patients to be on lots of different medicines, to be taken at different times of the day for each of their conditions. The new guideline highlights the need for clinicians to discuss with their patients what the benefits and unwanted side-effects of drugs or treatments are.

‘A decision on what treatment is best for the patient, based on their wishes, can then be made – and this could lead to stopping treatment if appropriate.’

Dr Andrew Green, chair of the GPC clinical and prescribing subcommittee, said he was ‘delighted’ NICE had produced the guideline and that ‘hopefully, this will empower the more timid among us to adapt our treatments to our patient, and not force our patients into the guidelines’.

Dr John Cosgrove, RCGP council member and a GP in Cheshire, agreed, saying it ‘is good to see acknowledgment of the medical complexity of so many of our patients’ and that ‘GPs as expert medical generalists have the ideal skill set to manage multimorbidity in this way’.

However, he cautioned that this kind of approach ‘is increasingly difficult for us to fit into the available time’.

Dr Cosgrove added: ‘What is urgently needed is more resources into primary care to allow us more time for each patient.’

Dr Shaba Nabi, Avon LMC representative and a GP in Bristol, said the guidance was ‘a good document that is bread and butter for any good GP’ but that it was limited by the current lack of ‘capacity and GP continuity’.

Dr Nabi also cautioned that the guidelines make ‘no reference to exception reporting for QOF, which is essential to reduce the treatment burden in these patients’ and offered 'little to empower patients to direct their personal goals'.

The long journey to NICE multimorbidity guidelines

GPs have been waiting for NICE guidelines on multimorbidity for several years, after NICE chiefs admitted that single-disease guidelines were unhelpful to GPs managing increasingly complex patients in their daily practice.

Leading GPs have warned existing guidelines are partly to blame for an epidemic of over-treatment, and NICE advisors admitted that it is 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 repeatedly reassured GPs he is commited to making guidelines more relevant to GPs, with the multimorbidity guidance a key step towards realising this aim.

Readers' comments (22)

  • Where is the 30 mins per patient required for this work?Another example of wanting a rolls-royce service on second hand mini metro money!

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  • Dear All,
    putting aside all the work / money / time issues


    at last NICE has begun to understand the complexity of treating real patients in the real world.

    Roll on more reality checking.

    Paul C

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  • These guidelines are very welcome and long overdue. Yes, reviewing treatment plans, tailoring treatment plans and reducing treatments of limited benefit may take some initial extra time but the long-term payoff may come with reduced appointments from patients complaining of what are essentially drug side-effects or multi-drug interactions.

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  • While that is good, it is a bit late in the day. Perhaps they are finally waking up to the fact that in a year or so, there will not be any NHS gps left to dictate to!

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  • I think the main value of these guidelines is a back up for those occasions when we already want to reduce excess treatment-I am often held back from stopping polypharmacy because there is always the concern-if I stop this antiplatelt/antihypertensive or whatever on grounds of low benefit, a patient could potentially then have a hemiplegic stroke/arrhythmic collapse which might have happened anyway but there will always be a possibility that it was causative.Defensive medicine thinking competing with patient centred care maybe, but Nice not substitute for clinical judgment.

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  • Hopefully there will be a bit of detail coming with this guidance as to counts as a long term condition.
    Under my own definition this would mean 90% of the over 65's.
    We need funding and time to do this.

    And withdrawing treatment will be a medico legal risk I for one do not wish to take, as when something goes wrong we won't be supported.

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  • Four years to state the bleedin obvious

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  • agree with 11.51. thought it was just me, but having read through the guidelines, they do state the obvious and there are no real revelations

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  • Vinci Ho

    It is hard to have a guideline to tell you details about how you can categoretically stop certain drugs . The guidance was bound to be ambiguously worded instead of totally pragmatic , especially when NICE is not going to stop releasing single disease guidelines all the time. I agree that at least on the legal angle , this at least represents a sound argument giving some grounds for GPs to stand their feet in court should medical disputes arise about whether treatment(s) should be carried on or not .

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  • I'm completely sick of guidelines. This is the bread and butter of being a damned GP and I don't need a bunch of pen pushers telling me to manage multi-morbidity by drawing up bleedin individual care plans. This is what my brain is for. What complete and utter crap. Butt-out you interfering pointless resource wasting idiots.

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