Abstract
Multimorbidity is a major issue facing modern-day general practice (RCGP, 2016). The National Institute for Health and Care Excellence (NICE) defines it as the presence of two or more long-term health conditions (NICE, 2016) and published guidelines on assessment and management of multimorbidity in 2016.
Care and support planning (CSP) is a systematic way to carry out annual reviews in general practice to ensure the discussion between the patient and doctor is based on what is important to the person living with long-term conditions (LTCs). It moves away from a tick box approach and replaces it with a genuinely patient-centred conversation. Issues previously discussed in separate appointments are combined in a single review process, no matter the number of LTCs with which they live.
Year of Care (YOC) Partnerships is an NHS-based organisation dedicated to driving improvement for people with LTCs using CSP to provide person-centred care (YOC, 2018). This article describes implementing multimorbidity annual reviews using the YOC model of CSP (Fig. 1) across a Clinical Commissioning Group (CCG). Our aim was to change the delivery of care for people in Gateshead living with LTCs to a more personalised approach focussed on what is important to the patient. This also aligns with NHS England’s new Comprehensive Model for Personalised Care (NHS England, 2019).
The care and support planning process.
Implementing the YOC model of CSP in Gateshead
Background
Gateshead has lower life expectancy than the England average, and a high prevalence of LTCs. In 2013, Gateshead CCG developed its LTC Strategy, recognising the multimorbidity burden in its population. In 2014 Gateshead CCG became one of five UK sites selected to take part in the British Heart Foundation House of Care project (British Heart Foundation (BHF) (2018a)), and implement CSP for people with cardiovascular disease within a multimorbidity context, using the YOC model (YOC, 2018).
CCG support
The CCG provided funding for GPs and other clinical staff to complete YOC training in CSP. They enabled training across a range of conditions via education sessions and locally developed masterclasses, to support multimorbidity approaches. A reference group of patients living with LTCs in Gateshead provided an invaluable advisory role, developing resources, and championing roll-out to other practices.
Standardised documents for call/recall and care planning were produced, and an ‘intelligent’ template developed for EMIS (the electronic patient record system). This ensured relevant tests and tasks are identified and collected during information-gathering appointments, and flags relevant Quality and Outcomes Framework and CSP sections for the second consultation. CCG funding required practices to target patients with two or more LTCs, which included diabetes, cardiovascular disease, peripheral vascular disease, cerebrovascular disease, atrial fibrillation, asthma and chronic obstructive pulmonary disease.
Practice examples
Glenpark Medical Centre and Whickham Practice are two of seven early adopter Gateshead practices who have embedded CSP for patients with multiple LTCs. Patients are invited to two appointments. The first is an information-gathering appointment with a healthcare assistant or nurse to carry out tests (e.g. blood or urine tests) and checks (e.g. weight, foot examinations, smoking status). Its length depends on the combination of conditions. Recall is in the birthday month, making it easy to remember when it is due. The information-sharing document is explained to the patient and sometimes literacy issues are disclosed, helping with future communications.
A triage process ensures the second CSP appointment is with someone appropriately trained to review the whole person (usually practice nurse, nurse practitioner or GP), and that enough time is allocated. This step depends on the skill mix at individual practices and involves looking at the patient’s usual/ preferred healthcare professional, their conditions, results and medications.
Patients are sent an invitation letter, which includes information to help patients prepare for the second appointment. There is space to write what is important to them, with prompts that include social issues such as money, work, and relationships. Test results are also included, alongside previous results with a brief explanation, and depression screening questions. Receiving information in advance provides an opportunity to reflect on results and general wellbeing, and to prepare for the conversation. Information can be discussed with friends, family or carers.
The consultation is based around the patient’s priorities as identified before the appointment, and encompasses all conditions including mental health and frailty, focusing on what is important to the patient. A summary of the conversation is recorded along with goal setting and action planning if relevant. Conversations are often less medically focused, and outcomes may include community or voluntary sector support.
Evaluation
Clinicians have consistently noted the conversation changes when a person has prepared for their appointment. One patient said: ‘It’s talking about something you know about, rather than something you’re kept in the dark about’ (BHF, 2018b). People often attend with a plan, or ideas about what they want to focus on, and seem to find it easier to discuss previously undisclosed issues.
A survey of 188 patients (BHF, 2018b) showed that:
95% remembered getting a letter with test results before their conversation 81% were able to understand their conditions ‘better’ or ‘much more’ after their CSP conversation; 75% were able to cope with their conditions ‘better’ or ‘much more’ 71% felt they could help themselves ‘better’ or ‘much more’ 87% rated overall experience of the CSP conversation as ‘very good’ or “excellent”
Over the 3 years, blood pressure control and recording improved by 10.9% and 11%, respectively, although it is difficult to directly attribute this to CSP (BHF, 2018b). Clinicians reported improved personal skill set and capability dealing with all conditions and improved job satisfaction. One doctor described that it ‘has changed the conversation with every patient, not just those with LTCs- it’s a new way of consulting’ (BHF, 2018b). Analysis at Glenpark showed changing to multimorbidity clinics saved administration and consulting time and cost less over a 12-month period.
KEY POINTS
CSP for people with multimorbidity involves a change in philosophy to focus on what is important for the patient and support self-management A ‘whole practice team’ approach is required for successful implementation Process mapping a patient journey from individual disease clinics to multimorbidity clinics is useful in showing how burden of care for patients can be improved and practice procedures streamlined Involve patients from the start; for individual practices, patient participation groups could be involved in a similar way to our reference group Practice nurses may experience a significant change in their way of working - multimorbidity reviews require training, support and sufficient time for appointments Robust links with local social prescribing services help support self-management First steps for practices considering multimorbidity review clinics could include mapping current review systems for people with multiple LTCs and reviewing skill mix to ensure clinicians feel confident seeing people with a range of LTCs
