Professor Chris Salisbury is Emeritus Professor of Primary Health Care at the Centre for Academic Primary Care at the University of Bristol. Here he talks about how to provide more personalised care for people with multiple long-term conditions.
The new GP contract requires primary care networks to identify groups of patients who are most likely to benefit from continuity of care – those with multiple long-term conditions are an obvious example. We think providing an annual review for these patients instead of reviewing each condition separately is a good way to improve continuity, efficiency and patient care.
In most general practices, patients with diabetes get invited for an annual review of their condition. The same is true for patients with heart failure or with COPD. At each review, a practice nurse follows a computerised template (checklist) for the specific condition and ticks off various necessary checks.
But most people with a long-term health condition have other conditions as well. This is becoming an increasingly important issue as the population ages. In most general practices, people with multiple conditions get invited for a review of each condition separately, often seeing a different nurse for each condition. This leads to repeated consultations and very fragmented care. It is inconvenient for patients and inefficient for practices.
The computerised templates for each condition tend to focus on the specific activities measured by the Quality and Outcomes Framework (QOF), rather than taking a broader perspective and addressing the problems that most affect the patient’s health. Patients complain that the nurses and doctors are so busy taking their blood pressure or asking about smoking that they don’t get a chance to talk about the health care problems that matter to them most.
This old approach of different nurses reviewing each health condition in isolation simply doesn’t make sense. It isn’t sustainable, and it doesn’t promote high quality care that meets patients’ real needs.
We have developed and tested an approach which seeks to make care more personalised. This involves doing an annual ‘whole-person’ review, instead of several individual disease-focused reviews. Research, conducted as part of the Personalised Primary Care for Patients with Multimorbidity (PP4M) Study, indicates that this provides a better patient experience and is also more fulfilling for clinicians.
The annual review is supported by a ‘smart’ template which has a consistent and logical format to support a fluent consultation, but which includes sections that vary according to the individual patient’s age, sex, and health conditions. The template focuses on what matters most to patients and supports self-management. It encourages nurses and doctors to review the whole patient, including their mental health, quality of life, pain and social support, while also meeting QOF requirements.
We have recently published a set of practical tools and resources to help general practices move to this way of working. The guidance includes:
- An outline structure for the review
- How to plan for the change, including guidance about process mapping
- Details of a computerised template for Emis practices to support the review
- A search to enable Emis practices to Identify patients with three or more multiple long-term conditions who would benefit from review
- Guidance about staff training, including a curriculum to help staff self-assess their training needs
- A list of issues that practices face when changing to personalised annual reviews, and suggestions for how to address them.
Nurses, doctors and patients have a shared aim – to provide care which responds to patients’ individual needs leading to improvements in their health and well-being. We hope this new approach will help general practices to provide better, more personalised, care for people with multiple health conditions.
The tools and guidance were developed in close collaboration with patients and public contributors. The PP4M Study was led by Dr Rachel Johnson and Professor Chris Salisbury and funded by the National Institute for Health and Care Research (NIHR). A downloadable version of the guide and a video explaining the approach are available on the Centre for Academic Primary Care website.