How can we improve the management of
multimorbidity in general practice?
I'm Professor Chris Salisbury, a GP and
Professor of primary health care at the
University of Bristol. More and more
people are living with long-term chronic
health conditions like diabetes, asthma
and arthritis and for each of these
diseases there's a care pathway through
There are published guidelines for treatment,
specialist nurses who try to manage
their conditions and electronic
templates and checklists that doctors
and nurses use to try to make sure that
nothing gets missed. This would all make perfect
sense if patients only had one
disease at a time. But many people have
got several chronic conditions at once,
or multimorbidity, and then this
disease-focused approach might not work so well.
People with multimorbidity often have
poor quality of life. They also often get
depressed and anxious. Their conditions
can be painful and stop them
doing things in life that they want to
do. We call this the burden of illness.
Having multimorbidity often means
having to take lots of different tablets,
attend numerous different clinics, maybe
being expected to change your diet or do
more exercise. We call this the burden of
treatment. And because care is so structured
around checklists and disease pathways,
people with multimorbidity often feel
that no-one really treats them as a
whole person. They see lots of different
doctors and nurses and it's not clear
who is joining the dots. So people with
multimorbidity complain about lack
of holistic patient-centred care.
So we designed the 3D approach as an
attempt to address all of these problems
in general practice. First we used special
software to identify patients who had
three or more long-term conditions that
otherwise would need separate disease-
focused reviews, and flag their records.
We sent the patients a '3D' card, which
tells them their named responsible GP and
effectively says "we want to offer you a
different kind of care, so feel free to
ask". Then we developed strategies to improve
continuity of care. The 3D card tells
patients to ask to see their named GP or
nurse whenever possible and to ask for a
longer appointment if they've got several
things they need to discuss. Whenever
they make an appointment a pop-up on
the practice computer reminds the
receptionist to try to book them with
their named doctor and to offer them more
time if necessary. In many practices
patients with several long-term
conditions get called up repeatedly to
have reviews for each of their
conditions one by one. Instead, in the 3D
approach, each patient's invited for a
'whole person' 3d review every six months
in which all of their problems are
addressed at once. If a GP wants advice
about a patient with multimorbidity, it's
difficult to know which specialist to
ask and it's not easy to get quick
accessible advice. So each 3D practice
has a named general physician in a local
hospital who they can phone or email for
advice and expect to get a response
within 2 working days. At the heart of
the 3D approach is the combined 6-monthly
review and these have got a different
focus from a conventional chronic
disease review. In particular, it focuses
on dimensions of health (paying attention to
quality of life and patients' priorities,
not just disease control), identifying and
treating depression, which is often
under-recognised, and drugs - trying to
simplify drug treatments. The 3D review is
made possible using a special
interactive computerised template. The
computer already knows which conditions
the patient's got and the template only
pops up questions which are relevant to
the particular combination of conditions
that the patient's got. The template also
helps to focus the attention of the
doctor and nurse on the patient-centred
aspects of the 3D approach.
Before the 3D review a pharmacist looks at
the patient's medication list. The aim is
to try and simplify the drug regime. The
pharmacist logs in remotely and records up
to four recommendations in the template
in the patient's record. So each review
consists of two appointments. The first, with a
nurse, starts by asking the patient what their
biggest problems are at the moment and what
they most want to discuss. Then the nurse
asks about issues relating to quality of
life, such as pain, function and ability to
do usual activities. Only after this do
they pay attention to the aspects of
disease management which are usually the
focus of traditional reviews. The nurse
also does any blood tests that the patient
needs. The computer tells them which tests
are needed. At the end of the appointment
the nurse gives the patient a printed
3D agenda which summarises what they've
discussed and forms an agenda for the
next appointment,
about two weeks later, with the patient's
usual GP. The role of the GP is to review
all the information collected by the
nurse, the pharmacist's recommendations and
the blood test results, and to agree an
action plan with the patient. For each
problem they agree what the doctor can
do to help and what the patient can do
to help themselves. Then the patient is
given their printed 3D health plan which
sets out what actions have been agreed
and also shares with them the other results
from their 3D review, such as their blood
test results. So that describes the 3D
approach. But we know that it's easy to have
any number of good ideas, but making them
happen in real life is very difficult. So
we've used a range of strategies which
have been shown to reinforce quality
improvements in healthcare. We train all
the relevant staff in each practice in two half-day
sessions. Separately, we train
receptionists because having them on
board is key.
We appoint a GP champion in each
practice who's responsible for making sure
that change actually happens, and the
champions in local practices meet every
few months to share problems and
solutions. We provide each practice with
monthly feedback on how well they're
doing and we pay practices a small
financial incentive for each patient in
which they do a 3D review. Does this 3D
approach actually lead to benefits? That's
the million-dollar question.
We're doing an evaluation based on a
randomised controlled trial in 32
practices to discover the answer.
You can find out more about the
evaluation by watching the next video in
this series, or looking at the 3D
website or reading the published
protocol.
I'm Chris Salibsury, thanks for watching.
For more infomation >> Cristo Corona - Just For You [Videoclip] - Duration: 3:14. 
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