Summary of recommendations from major reports 1 National Guideline Centre. Multimorbidity: clinical assessment and management. London: National Institute for Health and Care Excellence; 2016. Think carefully about the risks and benefits, for people with multimorbidity, of individual treatments recommended in guidance for single health conditions. Discuss this with the patient alongside their preferences for care and treatment.1 Local health care provider level 1. Identify patients with multimorbidity or other complex health needs and prioritise them for pro-active, co-ordinated care. 2. Arrange regular comprehensive review of patients’ problems according to their individual circumstances. 3. Focus disease management on quality of life and function as well as disease control. 4. Tailor treatment recommendations to each individual’s priorities and situation. 5. Balance risks and benefits of treatment while seeking to reduce treatment burden (particularly from taking too many prescribed drugs). 6. Promote patient self-management: engage patients in decisions about their care; agree an individualised care plan and provide patients with support to follow it. 7. Provide better support for care givers. Regional or national level 8. Coordinate services to be delivered by a multidisciplinary team in the community, but with one clearly identified professional who has responsibility for coordinating care. This is likely to be the GP or another member of the primary health care team. 9. Develop clinical information systems which provide decision support and facilitate communication between care providers based on shared record systems . 10. Integrate health and social care services and physical and mental health care. 11. Train more generalists and organise systems around generalist primary care services rather than structuring services around specialisms and sub-specialisms. 12. Reform payment systems to encourage collaboration between providers and adequately compensate for complexity; remove systems which lead to inappropriate treatment or fragmentation of care. 13. Reprioritise research funding. There are major gaps in knowledge about the causes and determinants of multimorbidity, how to manage individual patients with multimorbidity and how to organise care for them. These are priorities for research. PolicyBristol – influencing policy through world-class research Policy Report 39: October 2018 Evidence has been summarised in a Cochrane systematic review1 , NICE guidelines on multimorbidity2 , and a recent report from the Academy of Medical Sciences3 . All of these reports acknowledge that there are major gaps in our knowledge about how best to manage people with multimorbidity. Multimorbidity refers to the existence of multiple medical conditions in a single individual. The issue is a growing global health concern but the available evidence on its causes, impact, and treatment is currently inadequate.3 Cochrane Review • Explored the evidence on the effectiveness of interventions to improve the management of multimorbidity in primary care and community settings • Most recent version (2016) included 18 high quality randomised controlled trials • Found no consistent evidence about interventions that improved clinical outcomes or reduced costs NICE Guidelines • Several recommendations made about identification and management of multimorbidity and frailty, including about the kind of care which should be provided • Strength of evidence to support most of these recommendations was low to moderate • Specific recommendation made that research was needed to examine different ways of organising general practice to better serve the needs of people with multimorbidity Academy of Medical Sciences • Takes a global perspective • Identified inconsistency in definitions of multimorbidity and recommended a consensus definition • Highlighted the need for more research into the causes and burden of multimorbidity; determinants and patterns of multimorbidity (including the most common clusters of conditions, their causes and effects); how to improve treatment for patients; and how to organise health care systems to address multimorbidity Given this limited evidence, we conducted the 3D trial, the largest evaluation to date of an approach to managing multimorbidity. The findings from the 3D trial were published in the Lancet in June 2018. 1 National Guideline Centre. Multimorbidity: clinical assessment and management. London: National Institute for Health and Care Excellence; 2016. 2 Smith SM, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews. 2016(3). DOI: 10.1002/14651858.CD006560.pub3 3 The Academy of Medical Sciences. Multimorbidity: a priority for global health research. London; 2018 April 2018. PolicyBristol – influencing policy through world-class research Policy Report 39: October 2018 The 3D approach: designed to reflect the international consensus that care for multimorbidity should be patient-centred, focus on quality-of-life, and promote self-management towards agreed goals.1 One named responsible GP Each patient was allocated one GP to be responsible for their care and was encouraged to see the same GP whenever possible Patients offered six-monthly comprehensive “3D” reviews, each consisting of two appointments which were longer than usual First appointment (nurse): agenda setting • Nurse asks patient about the health problems that bother them most • particularly asking about pain, function, quality of life • screening for depression and dementia • providing disease-specific care required, according to the individual patient’s combination of diseases • findings shared as a printed ‘agenda’ for the patient to discuss with their GP Regular ‘whole person’ review Second appointment (GP): agreeing a plan • GP considers the nurse and pharmacist reviews • discusses how well patient is getting on with their current treatment • discusses the patient’s needs and goals • agrees a collaborative health plan, which specifies how the patient and clinicians will address the agreed goals over the next six months • patient given a printed copy of the plan, including results of tests Pharmacist review of medication • Pharmacist reviews the patient’s medical records 1 Salisbury C, Man MS, Bower P, Guthrie B, Chaplin K, Gaunt DM, et al. Management of multimorbidity using a patient-centred care model: a pragmatic clusterrandomised trial of the 3D approach. Lancet. 2018;392(10141):41-50. DOI: 10.1016/S0140-6736(18)31308-4 PolicyBristol – influencing policy through world-class research Policy Report 39: October 2018 The 3D Trial Based on the existing evidence and international consensus on ‘best practice’, we believed that the patient-centred “3D” approach for patients with multimorbidity had the potential to improve patients’ quality of life, make their care more patient-centred and reduce their burden of illness and treatment compared with usual care. The aim of the 3D trial was to test whether these outcomes were actually improved. Trial methods: The 3D approach was evaluated in a randomised controlled trial in general practices in England and Scotland 16 practices provided the 3D approach while 17 practices continued usual care. 1,546 adult patients, each suffering from three or more different types of major long-term health conditions, took part. Measures of success included patients’ quality-oflife, experience of patient-centred care, illness burden and treatment burden. We also assessed use of health care services, including continuity of care, and costeffectiveness. We interviewed patients and staff to understand how 3D worked, and how it could be improved. Findings: At the outset of the trial, patients had poor quality of life with a third of them experiencing depression as well as multiple physical health problems. Many also reported problems with the organisation of their care. After 15 months follow-up there was no significant difference on average between patients in the practices providing the 3D approach or usual care in terms of quality-of-life, illness burden or treatment burden. However, patients in practices providing the 3D approach reported significant improvements in patientcentred care. They felt more able to discuss the problems that were most important to them, their care was better co-ordinated, and they were more satisfied with their overall health care. The cost of providing the 3D approach was not significantly higher than the cost of usual care. “So the great thing about this is that they’re looking at you as a whole being and taking everything into account and that is very new” [3D trial participant]1 Interpretation: The 3D approach improved patients’ experience of patient-centred care but not their health outcomes. It is arguable that improved patient-centred care is itself sufficient reason to roll out the 3D approach more widely, given that it is not significantly more expensive. From the interviews with patients and staff it was clear that most patients preferred the 3D approach, but it took time for practices to adapt to the new way of working particularly in a system that was organised and incentivised through the GP payment system to provide ‘disease-focused’ care. The effectiveness of the 3D approach might improve over time and if it became normal practice. Funding: National Institute for Health Research. The views and opinions expressed in this report are those of the authors and do not necessarily reflect those of the NIHR, the NHS or the Department of Health. 1 Salisbury C, Man MS, Bower P, Guthrie B, Chaplin K, Gaunt DM, et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet. 2018;392(10141):41-50. DOI: 10.1016/S0140-6736(18)31308-4 PolicyBristol – influencing policy through world-class research Policy Report 39: October 2018 Implications for health policy The challenge for health care More people in the UK are living with multimorbidity. This impacts on the health and well-being of patients, and places great pressure on the NHS. Current models of care, largely focused on the care of individual diseases such as diabetes or heart disease, are becoming increasingly expensive and yet are failing to meet patients’ needs for whole person, patient-centred care. Does research point to a solution? The problems caused by multimorbidity are clear, but the solutions less so. There are many gaps in current knowledge, highlighted in several recent national and international reports. Even though the volume of evidence from high quality research is limited, based on the 3D trial and previous studies it seems unlikely that currently proposed models to improve care for multimorbidity will lead to rapid improvements in patients’ quality of life or health outcomes.1,2 The difficulty of improving quality of life in people with multimorbidity This may be because the problems that most affect the quality of life of patients with multimorbidity are complex and deep-seated. Quality of life, including health, is affected by factors such as income, employment, housing and education as well as health care. Solving the patient’s problems may require actions beyond the current remit or vision for the health service, for example requiring social care (although health services may have a role in referring patients to this). There are few new approaches to providing health care for long-term conditions which have been shown to improve quality of life even for patients with single conditions, never mind in people with complex multimorbidity. For example, many innovations which are currently widely promoted (such as in the field of digital health) have not been shown to improve patient’s quality of life in randomised controlled trials. What could be done to make a difference? The lack of evidence from research for benefit in terms of improved quality of life does not necessarily undermine the consensus recommendations. These recommendations have wide support. To really make a difference to the health and wellbeing of patients with multimorbidity, interventions will probably need to be more intensive and provided over a longer period than any of the evaluations which have been conducted so far. They will also probably have to be introduced at a whole system level, since meaningful change is likely to involve changes in the ways in which general practice, hospitals and social care work together. There is also likely to be an increasingly important role for voluntary and community services. Moving towards a health care system designed to meet the needs of large numbers of people with multimorbidity will require radical re-organisation involving a rebalancing of resources towards high quality health and social care provided in the community, with a greater role for specialists in advising, supporting and monitoring care provided outside hospitals. These are major changes which will take time. In the meantime, the 3D approach represents a fairly simple, low cost intervention which demonstrably improves the care of patients whose needs are not being met by current services. Although improving quality of life and health outcomes for patients with multimorbidity is clearly challenging, there is good evidence from the recent 3D trial1 as well as from earlier studies2 that new approaches can lead to improvements in the way in which care is provided and patients with multimorbidity experience their health care. Providing a patient-centred rather than diseasefocused approach leads to care which is more joined up, respects patients’ wishes and priorities, and is more attuned to their perceived needs. This may be a worthwhile end in itself. 1 Salisbury C, Man MS, Bower P, Guthrie B, Chaplin K, Gaunt DM, et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet. 2018;392(10141):41-50. DOI: 10.1016/S0140-6736(18)31308-4 2 Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings BMJ 2012; 345 :e5205. DOI: 10.1136/bmj.e5205 PolicyBristol – influencing policy through world-class research Policy Report 39: October 2018 Policy recommendations • Promote patient-centred approaches to the management of multimorbidity in primary care, such as the 3D model. This will require training, support and changes in incentives. • Develop and evaluate new approaches to managing patients with multimorbidity within hospitals. • Explore new models of integration of primary and community care, hospital care and social care which enable better co-ordination and support for people with multimorbidity. This is likely to require substantial changes in commissioning and funding mechanisms, and a rebalancing of resources. These aims are being pursued by ‘sustainability and transformation partnerships’ and in some areas by ‘integrated care systems’.1 These should give high priority to improving care for patients with multimorbidity, and it will be important to learn lessons from the experience of pilot sites. • Better integration of primary, secondary and social care will not come about through organisational change alone – it will also require major cultural change for care providers and managers. This is likely to require changes to professional education, training and regulation. • Improving care for the large and increasing number of people with multimorbidity will require a stepchange in engaging people and enabling them to manage their own health and long-term conditions. This will require co-ordinated action across many aspects of government and public life, including not only health policy but also education, welfare, transport, and policies which impact on public health issues such as healthy eating, exercise, smoking and alcohol consumption. • Several of the major chronic diseases affecting people with multimorbidity have common risk factors, such as smoking, obesity and lack of physical activity. The benefits of addressing these lifestyle problems will be magnified through preventing many different diseases. 1 Ham C, Making sense of integrated care systems, integrated care partnerships and accountable care organisations in the NHS in England. King’s Fund. PolicyBristol – influencing policy through world-class research Policy Report 39: October 2018 Further reading 1. Salisbury C, Man MS, Bower P, Guthrie B, Chaplin K, Gaunt DM, et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet. 2018. 392:41-50. DOI: 10.1016/S0140-6736(18)31308-4 2. The Academy of Medical Sciences. Multimorbidity: a priority for global health research. London; 2018 April 2018. 3. The Commonwealth Fund International Experts Working Group on Patients with Complex Needs. Designing a High-Performing Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers. New York; 2017 September 2017. 4. Smith SM, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews. 2016(3). DOI: 10.1002/14651858.CD006560.pub3 5. National Guideline Centre. Multimorbidity: clinical assessment and management. London: National Institute for Health and Care Excellence; 2016. 6. Baker MJ, Jeffers H. Responding to the needs of patients with multimorbidity. A vision for general practice. London, England: Royal College of General Practitioners; 2016. 7. Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith SM. Managing patients with multimorbidity in primary care. BMJ. 2015;350:h176. DOI: 10.1136/bmj.h176 8. Mercer SW, Salisbury C, Fortin M. ABC of Multimorbidity. Chichester: John Wiley & Sons Ltd, 2014. 50 p. ISBN: 978-1-118-38388-9 9. U.S. Department of Health and Human Services. Multiple Chronic Conditions—A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. Washington, DC.; 2010.