Multi-morbidity – the case for change
David Paynton is a GP in an inner city surgery. He is also the Clinical Lead for Commissioning for the RCGP.
Generalists are the solution. For too long policy makers have ignored what clinicians on the front line have been telling them, people with multiple conditions not only exist but are the mainstream.
It is our failure to recognise this fact that has put pressure in the system as the NHS struggles to keep its head above water especially when one adds social factors, depression and mental health into the mix of complexity.
The RCGP “responding to the needs of patient with multi-morbidity” has created a powerful case for change with the need to substitute ever-increasing investment into super specialism by a call for the generalist to support those with multi-morbidity in the community.
Poly-pharmacy, multiple single disease specific clinics and individual QOF targets will have to be incrementally replaced by multidisciplinary team meetings (MDT), proactive care planning, changes in training and adaptation of IT systems. Evidence based medicine dominated by trials that remove confounding factors will need to be reset.
Continuity of care will be valued not just as a “nice to have” but crucial in supporting those with a combination of physical, social and mental health problems. Nowhere is this more important than in supporting older people in the community where frailty is being increasingly recognise as an entity in its own right and with GP systems automatically using algorithms to record frailty.
We need a new paradigm.
But what does this mean for those of us working in the community? Care and Support Planning for those with long term conditions, complexity and multi-morbidity will become the norm as we try to shift towards a more proactive approach. Wider teams based around neighbourhoods (circa 50,000 population) will support core general practice and the registered list. This will include enhanced community support team for older vulnerable patient with geriatricians, Allied Health Professionals, specialist nurses and social services.
GP surgeries and their respective MDT will remain the main unit of responsibility and accountability often supported by non-statutory agencies such as Age UK. Community geriatrician, who, as the generalist with an expertise in frailty, have been so valuable in helping us support more complex people in the community are already having to support those in their fifties, especially in the more deprived populations where mortality occurs ten years earlier.
Hospital care will have to become less precious about protecting clinical fiefdoms and become more streamlined as community geriatrics “reach into” the hospital rather than the other way round. Multi-morbidity is here to stay – the rest of the NHS needs to catch up.