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25 January 2022
Professor Chris Salisbury is ARC West’s Theme Lead for Integrated and Optimal Care. He is also Professor of Primary Health Care at the Centre for Academic Primary Care at the University of Bristol, a GP and an NIHR Senior Investigator. Here Chris describes the origins of our new project on improving review appointments for people with long-term conditions (PP4M).
The Quality and Outcomes Framework (QOF) was introduced to improve the quality of care in general practice for people with long-term health conditions such as diabetes. It has been successful at ensuring that key aspects of care are delivered consistently. But like all schemes based on targets and incentives it has an important downside – the targets become ends in themselves rather than indicators of quality, and aspects of care that are not specifically incentivised get neglected.
This is particularly true for people who have multiple long-term health conditions. We now realise that this is not a rare problem – a high proportion of adults have multiple long-term conditions, including most people aged over 65. General practices offer regular review appointments for patients with the limited range of conditions covered by the QOF. People with, say, diabetes, asthma and heart disease can get invited to separate reviews for each of their conditions on different days, often seeing different nurses or doctors for each condition. These clinicians conduct the review using different computerised checklists, or templates, for each condition. These templates are designed to collect the biomedical data required by the QOF for that condition.
For people with multiple health conditions, this approach leads to fragmented care. They might receive multiple review appointments and end up with a collection of disease-specific treatment plans which can be confusing and even give conflicting advice. Most importantly, this approach means little attention is given to health conditions that are not included in the QOF. Patients complain that the nurses and doctors are so busy taking their blood pressure or asking about smoking that the patient doesn’t get a chance to talk about the health care problems that matter most to them.
Some practices have replaced separate disease-focused reviews with a combined annual review consultation for people with multiple health conditions, and this can improve co-ordination and efficiency. But when patients attend these reviews, the nurse or doctor uses a series of disease-specific templates which contain a lot of duplication and questions which are irrelevant to the individual patient concerned. Trying to pay attention to the patient while chopping and changing between multiple checklists makes it very difficult to run a fluent consultation. And this approach still doesn’t solve the problem of how to ensure that nurses and doctors provide care that is ‘person-centred’ rather than ‘QOF-centred’. A review that ticks boxes but does not address the patient’s main problems from their point of view is never going to be very useful or effective.
A priority in the NHS Long-Term Plan is that care should be more personalised.
“Personalised care is based on ‘what matters’ to people and their individual strengths and needs.”
NHS Comprehensive Model for Personalised Care
Key pillars in the NHS Personalised Care model include the importance of patient choice and shared decision-making, supporting self-management, community support through social prescribing and offering patients an individualised care and support plan.
How can general practice offer care which is both flexible and personalised, while at the same time meeting the highly standardised requirements of the QOF? We recognise that templates can be useful to ensure that nothing important is missed, but they can also encourage a tick-box mentality which isn’t responsive to patient’s priorities and needs. A promising way forward is to use a ‘smart’ template which has a consistent and logical format to support a fluent consultation, but which includes sections that vary according to the individual patient’s age, sex, and health conditions. The template provides a structure to the consultation that focuses on what matters most to patients and supports self-management. It encourages nurses and doctors to review the whole patient, including their mental health, quality of life and social support, while also meeting QOF requirements.
In the Personalised Primary care for Patients with Multimorbidity (or PP4M) project we are evaluating the implementation of a smart template in general practice. We have worked with Ardens, a commercial supplier of templates, to adapt a template already developed for multimorbidity to make it more personalised. Working with healthcare commissioners and NHS networks in three areas we will make the new template widely available to general practices, supported with training and other tools such as patient recall systems and patient reported outcome measures. Using a range of methods, we will study the opportunities and challenges which arise, and how to overcome any difficulties with implementation.
Nurses, doctors and patients have a shared aim – to provide care which responds to patients’ individual needs leading to improvements in their health and well-being. Through this project we hope to find out how to help general practices provide care which is more personalised for people with multiple health conditions.
If you are from a general practice interested in using the new multimorbidity template and possibly taking part in the evaluation, please contact the PP4M project on pp4m-project@bristol.ac.uk.
Professor Chris Salisbury and Dr Rachel Johnson explain more about the PP4M study.