Better management of patients with multimorbidity

In a recent BMJ article, Charlotte Paddison and I argue that we need a new approach to patients with multimorbidity. Or not so much a new approach as rediscovering some old values. First, we argue that we need to put more value on clinical judgement. Guidelines are generally developed for people with single conditions and often don’t take account of patients’ other problems, or indeed their general frailty. Doctors fear they will be criticised if they don’t follow guidelines, and this can lead to inappropriate or even unsafe care. We need to value clinical experience and judgement in deciding what treatments patients need.

Second, we argue for more focus on continuity of care. This is partly because most patients want to see a doctor they know. This is especially important for older people, but recent surveys suggest that this is true across all ages. However, patients often don’t realise how important it is for doctors to see patients that they know. It’s almost impossible to provide good care for someone with ten chronic conditions in a 10 minute general practice consultation if you’ve never met them before. We suggest a number ways on which practices can organise themselves to provide better continuity of care, including:

  • Help people to understand that it’s easier for doctors to provide good care if they’re seeing patients they know.

  • Change receptionists’ behaviour and prompts on booking systems so that the patient’s “own doctor” becomes the default choice

  • Organise large practices or clinics into small teams of two or three doctors who see each other’s patients when one is unavailable. Make sure that patients know about these arrangements and know when junior doctors are going to be changing

  • Identify patients with particularly complex problems who should be seen by a restricted number of doctors and adjust the appointment system to ensure this happens. Explain to patients that they may have to wait longer but will get better care

For our full list, see the free full text in the BMJ.

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