Multimorbidity: time to deliver the Emperor’s clothes

Bruce Guthrie05_resizeBruce Guthrie is Professor of Primary Care Medicine at the University of Dundee in Scotland. He is a keynote speaker at this week's Society for Academic Primary Care annual conference in Oxford.

 

Multimorbidity is usually defined as present when people have two or more chronic conditions. It’s an idea that appeals to medical generalists because it makes clear that specialist care that only focuses on one of those conditions may sometimes be too narrow, particularly when someone has very many conditions or when the conditions they have are very different. Physical and mental health conditions are the exemplar of the latter, with many countries having separate services for each that rarely communicate or consider the interaction between mind and body. In the last few years, interest in multimorbidity has rapidly increased across the research, practitioner and policy communities, with many epidemiological studies ‘discovering’ that multimorbidity is common, that it increases with age and socioeconomic deprivation, and that it is associated with a range of poorer outcomes including higher mortality, lower quality of life, higher health service use and greater experience of treatment burden and fragmentation of care. As a UK general practitioner (family physician), such interest in stepping outside the single disease model that dominates healthcare organisation, medical education and research is gratifying, but as Martin Roland indicated eloquently in 2014 we have been much better at identifying why multimorbidity is a problem than at identifying what to do about it. He said,

“So here’s a real challenge to the academic primary care community. We’ve exposed many of the weaknesses of single disease guidelines and quality indicators. But we haven’t put anything adequate in their place. We’ve opened up an intellectual space, but we haven’t filled it. No-one else is going to lead the way on this. It’s up to us, or the single disease paradigm will continue to dominate.”

Or as my 14 year old daughter rather more assertively put it when I attempted to explain what I did for a living – “Wow! Sicker people see the doctor more. They pay you for this?”

One of the problems that multimorbidity poses to researchers and policymakers is that it is a fantastically appealing idea that highlights many of the problems with current health services, but it’s too big and heterogeneous to do much with. There isn’t a big bang solution to it. We do need an appropriate balance of generalism and specialism in our healthcare systems, but we also need to better define what those generalists will be doing. In the UK and elsewhere there is ongoing research which has begun to address this, including trials of complex primary care organisational interventions that seek to change what GPs do to people with complicated or high-burden multimorbidity (such as Stewart Mercer’s CARE Plus intervention, and Chris Salisbury’s 3D intervention), and these trials may (or may not) change how we do things. (I’m peripherally involved in both of them but am in pretty perfect equipoise.)

Guideline developers have also woken up to the limitations of single disease guidelines blithely making recommendations - for all people with a condition - that is based on evidence from younger, less comorbid and less co-prescribed people with that condition. David Haslam, the current chair of the National Institute for Health and Care Excellence (NICE), has made it his mission to change the way that NICE create guidelines and NICE are developing a new clinical guideline on multimorbidity which will complete next year.

Multimorbidity isn’t a new paradigm. But the epidemiology adds substance to things that most of us already knew in a rather vaguer sense and it has been persuasive to policymakers and research funders at least. Still, researchers have a lot of work to do to deliver the Emperor his promised splendid garments cut from the cloth of evidence.

SAPCASM2015The 44th #sapcasm runs from Wednesday 8th to Friday 10th July 2015

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