NHS long-term planning: Six steps to improve care for people with multiple conditions

1. Supporting those with multiple conditions to live well

People with multiple conditions are prescribed an average of 20 medications, and to manage their health may need to frequently attend GP appointments (over once a month in our analysis) and outpatient appointments (over four times a year). Daily life with multiple conditions can mean an overwhelming focus on symptom management and health care tasks.

A substantial proportion of people with complex health problems need support to manage their care. Over a quarter of people with multiple long-term conditions (and a third of those with multiple mental health conditions) report being overwhelmed by the requirements of managing their health, and these people are also least able to manage their health conditions. Of people with multiple conditions, those least able to manage their health are 17% more likely to attend a GP appointment, 32% more likely to attend an emergency department, and 38% more likely to have an emergency admission than those most able.,

There are many approaches, such as health coaching or peer support, to help people develop the knowledge, skills and confidence to manage their health conditions. Using tools that measure these abilities would show policymakers that patients vary widely in capacity and confidence, and track changes over time. It would also allow clinicians to identify those who could benefit most from extra support. While some areas are implementing health coaching and goal-setting with patients with health conditions, and NHS England is encouraging more areas to do this, the NHS could also do more to encourage patients to access peer support, including via online platforms.

As it is more common for people living in more-deprived areas to have multiple conditions, their clinical needs may be compounded by social factors. They might not have access to the financial support or community services that others in more affluent areas may have. Social prescribing – referring patients to non-medical, community-based sources of support – might be particularly valuable in more-deprived areas (if properly resourced). Examples of social prescribing include advice on finances, navigating access to local community groups to reduce isolation, and prescribing exercise to improve wellbeing and mobility. However, further investigation and evaluation of the effectiveness of social prescribing for people with multiple conditions is needed to identify which interventions should be prioritised.

Although initiatives such as social prescribing are important, a person’s health is the result of many factors, including their quality of housing, where they live, good quality work and affordable food. Therefore, urgent and cross-government action is needed to tackle the underlying causes of health conditions, along with investment in public services that affect people’s health. Furthermore, social prescribing is reliant on services and support being available in the community. These are often delivered by the voluntary or local government sector, which are both underfunded and not always available in the deprived areas where they are most needed. Therefore, social prescribing cannot be a substitute for continued efforts to address the underlying social determinants of health, and this is particularly relevant for those with multiple conditions who are more likely to live in deprived areas.

2. Developing new models of NHS care for those with multiple conditions

Meeting the needs of people with multiple conditions, at the same time as the NHS is treating more patients than ever, will require continued investment in developing new models of care. These models should be person-centred (ie their care should be focused on the needs of the person rather than on the needs of the service) and coordinated across primary, secondary, community and social care. Fragmented care poses a risk to quality and safety; for example, if care is duplicated or omitted, or if the trade-offs that can be inherent in managing multiple conditions are not properly recognised. Integrating care can reduce this risk. Integrating care also allows the needs of patients (not just clinical needs but social care needs, such as assistance with daily tasks or extra support on discharge from hospital) to be effectively coordinated by health and social care providers.

Integrated care is a feature of many of the vanguards in the New Models of Care Programme. For example, the Fylde Coast vanguard is aiming to provide an ‘extensive care’ service to people with multiple conditions (based on the CareMore model from the US). Following an assessment with the patient to identify their needs, a dedicated extensive care hub team takes over full clinical responsibility, providing all primary and secondary care. The patient is discharged back into the care of their GP when they are unlikely to further benefit from the extensive care scheme. An independent evaluation of this new model by the Improvement Analytics Unit (IAU), a partnership between NHS England and the Health Foundation, is underway.

Multidisciplinary care teams consist of practitioners who meet regularly to discuss the needs of their most complex patients and coordinate their care between them. They work together to manage complex situations and the needs of the patients. A recent evaluation by the IAU of multidisciplinary care teams in North East Hampshire and Farnham showed that they did not lead to lower emergency admissions for their patients, at least in the short term. However, these teams have the potential to reduce fragmentation in care and improve the patients’ experience of care.

3. Resourcing the vital role of primary care

Whatever new models are developed, the most important service for people with multiple conditions is still likely to be general practice. People with multiple conditions attend general practice more than any other NHS service and rely on GPs to coordinate their care. This role has been recognised by policymakers – improving the workforce, skills and infrastructure of general practice has been a priority since the publication of the Five year forward view for the NHS in England, while better coordination between general practice and other services, including social care and hospitals, has been an explicit aim of the New Models of Care Programme launched at the same time.

The General practice forward view, published in 2016, promised an additional 5,000 GPs by 2020/21. However, the latest data from NHS Digital suggests that far from this target being met, more GPs are leaving than joining. In March 2018, there were 33,686 full-time equivalent GPs: 235 fewer than in March 2017.

As we noted earlier, people are more likely to have multiple conditions if they live in socioeconomically deprived areas. Primary care practitioners, especially those working in more-deprived areas, need additional resources to provide the best care for their population. For many years, practices in more-deprived parts of the UK have had too few doctors relative to the health needs of their population.,, This fact is well recognised, and efforts to improve the distribution of the primary care workforce across different socioeconomic areas may be having some success. But challenges remain for professionals providing care and for people managing their conditions in the face of socioeconomic deprivation.

There are several ways in which primary care might better meet the needs of people with multiple conditions. Boosting continuity of care (eg seeing the same primary care practitioner over time) can improve patients’ experience of care and reduce emergency admissions. However, further research and improvement activity is needed to establish models of service delivery that achieve these gains. A ‘3D’ approach to care (based on dimensions of health, depression and drugs) that aimed to improve the continuity, coordination and efficiency of patients’ care by implementing practice-level changes was recently trialled. Significant improvements were seen in patients’ experience of well-designed, patient-centred care, but there was no measurable impact on quality of life or service use in the short term.

Further work is needed to develop primary care models that can improve outcomes for people with multiple conditions. The Royal College of General Practitioners has identified the importance of longer consultation time, continuity of care, medication reviews, multi-disciplinary teams, better collaboration with secondary care, better training, and a better-developed evidence base to provide tools and resources for GPs and patients. Our analysis shows that patients with multiple conditions have more consultations but not necessarily longer ones. More flexible appointment schedules, allowing for longer consultations at times, might benefit patients with multiple conditions, particularly in more-deprived areas.

The current shortage of GPs makes it hard to deliver a sustainable model of primary care, let alone develop and implement the sort of person-centred care that people with multiple conditions need. Proposed solutions must be mindful of the realities in general practice. The Health Foundation is currently working with five primary care teams to test approaches to improving continuity of care.

4. Designing secondary care around those with multiple conditions

Our analysis shows that having additional conditions is the norm for people with cancer, cardiovascular disease, respiratory disease, or a mental health condition. Specialists in secondary care services need to effectively organise and coordinate services for patients with multiple conditions. Traditionally, specialist advice is accessed in outpatient hospital departments, which are organised by clinical area. This disease-focused approach means that a patient with multiple conditions may be under the care of several specialists and may not receive person-centred care. There are examples of flourishing clinical alliances between different outpatient specialties and between outpatient specialists and primary care practitioners., Such models could be spread more widely and adapted for a wider range of patients.

Initiatives to reduce the treatment load for patients are also being tested. These include virtual clinics and co-located services (services located in the same physical location) so that patients don’t have to visit multiple outpatient departments. A workforce that is trained to care for patients with multiple conditions is also key for the NHS. The Royal College of Physicians has emphasised the need for generalism to be valued in medical training and medical careers. It has also highlighted the need to improve transitions between primary and secondary care. Collaborative planning for what is needed in secondary care and better sharing of information should improve continuity of care.

5. Using data and sharing information to improve care for those with multiple conditions

Sharing information within and across care providers is essential for integrated care models and to offer better joined-up care for patients. Sharing electronic records and other patient information should reduce the need for people to repeat their medical histories and care goals and reduce unnecessary, repeated tests. Sharing information should help those providing care to better understand the patient’s condition and context.

Incompatible information systems and lack of clarity on information governance are often barriers to timely information-sharing. The Local Health and Care Record Exemplars programme is supporting local areas to adopt best practice in collecting, protecting and sharing patient information to improve patient care. The Global Digital Exemplars programme is supporting digitally advanced providers to spread best practice and innovation in using information and technology. It aims to improve services by giving clinicians timely access to accurate information and patients access to their own records.

Linking data across health care and social care will allow the NHS to better plan services and track outcomes for people with multiple conditions. At present, it is difficult to understand how care in one part of the system depends on care in another part. Modelling can be used to predict future demand based on population projections or to test alternative scenarios where new initiatives are being considered. A system-wide view of the effects of service changes would be invaluable. To achieve this, greater investment in analytical capability is needed so that the NHS and its partners can turn data into insights.

6. Robustly evaluating what works

There are many unanswered questions about how to best care for people with multiple conditions. The challenge of caring for the rising number of people with multiple conditions is well known to practitioners and health system leaders, but there is not yet clear evidence on what works.

Encouragingly, research efforts are underway. A recent systematic review summarised the evidence from interventions in primary and community care. However, trials and other evaluations have so far only been able to report on short-term outcomes. Even if recent trials of new approaches have shown mixed results to date,, we need investment in the design and delivery of excellent health care services for people with multiple conditions. These models must be carefully evaluated in a timely and rigorous way.

An innovative partnership between NHS England and the Health Foundation is providing quantitative evaluation to show whether local change initiatives, implemented as part of major NHS programmes, are improving care and efficiency. The NIHR Applied Research Collaborations have signalled multimorbidity as a key challenge to be tackled. Learning from other health systems in international studies is also providing us with more evidence on what might work to improve care for people with multiple conditions (eg the Selfie Project and ICARE4EU)., Promising models must be identified and spread throughout the NHS.

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