NICE guidance and the importance of considering multimorbidity

Amit Arora is a consultant physician in care of older people and Chair of the England Council of the BGS. EmergencyAvoidance

Finally, multi-morbidity may be recognized- is this wishful thinking or a BGS victory for our patients?

Whatever it is, it is time for action!

NICE is committed to developing more relevant guidance for GPs that takes into account the complexity of patients they see in daily practice with multiple long-term conditions, the chief executive of NICE told delegates at Pulse Live.

Opening the first day of the conference in London on 29th April 2014, Professor David Haslam said NICE recognized current single-condition guidance was impractical for GPs dealing with patients with multimorbidity. ‘Single long-term conditions – which is the way NHS is organized generally apart from primary care – is the rarity.’ This of course is a cause close to the hearts and minds of many geriatricians. I have myself written about this on this blog and in some submissions to the health agencies in past.

Prof Haslam said, ‘What I know for certain is taking the NICE guidelines for each [single] condition and adding them together is no way to deliver quality care for that person.’ ‘It’s absolutely clear we have to find a way of addressing the whole complex issue of multimorbidity and that’s something NICE is absolutely up for.’

The BGS has been advocating this for some time now. More recently this has been highlighted in year of care project submissions and has been discussed at various Clinical Advisory Panel meetings of the Payment by Results section of the Department of Health before this project moved on to NHS England and Monitor.  In a recent pilot project on ‘Year of Care’ funding model;  and the ‘Recovery, Rehabilitation and Re-ablement’ project, the North Staffordshire Early Implementer Team had suggested in its submission that multi-morbidity should be recognized and frailty be considered as a new entrant to existing long term conditions. This was acknowledged by the DH and we wait further developments in this regard.

I would suggest that most BGS members agree that single organ long term conditions only exist in a minority of older people and often the challenge for GPs is to optimize medication for multi-morbidity. This was once again highlighted by Martin McShane, NHS England’s Director for people with Long term Conditions, in his Webex on the 8th May for the Staffordshire Digital Programme Stakeholders attended by key people from the local CCGs  in the area including myself.

The point here is, finally the NHS is starting to realize that multi-morbidity really exists and is important to address. This is not easy and takes a lot of training, experience and skills and geriatricians are well placed to do this.

However, the lack of clinical trials in older people does not make multi morbidity guidance any easier. BGS has been calling for more research in older people for some time.

As practicing geriatricians we are only too well aware of the unintentional effects of polypharmacy where treatment of one condition can cause worsening of another one. Treatment with anti-hypertensives in a patient with heart failure or stroke who has postural hypotension can lead to multiple falls; treatment with warfarin leading to harm in a patient at risk of falls is a story familiar to many geriatricians.

Professor Haslam also added, ‘What we don’t believe in is massive polypharmacy, with [a] person taking more and more pills and needing a blood test every third day and having no quality of life – that is not the point of all this. Finding a way to determine what looks good for a patient [with multiple conditions] is extraordinarily important.’

Professor Haslam stressed NICE guidance was not intended to ‘force’ clinical decisions about treatments on GPs and their patients. He said targets based on NICE guidance ‘were another matter’ altogether and that GPs’ responsibility was to their patients first and foremost. ‘[The] guidance is not mandatory. Healthcare professionals should take NICE guidance fully into account when exercising their clinical judgement but this does not over-ride their responsibility to make decisions appropriate to their circumstances and the wishes of the patient.’

From both a clinical as well as strategic perspective it probably therefore makes more sense that most of the older patients with multi comorbidity are seen under the umbrella care of a Specialist elderly care physician who manages the multi-morbidity whilst in secondary care but can refer for specialty opinion when necessary. How this can be done within the constraints of the growing ageing population and limited numbers of trained geriatricians is a challenge that has been recognized by many including the Future Hospitals Commission of the Royal College of London.

We welcome the statements by Prof Haslam and support that a new guidance on Multi-morbidity is required. It is now time for action. We are here – ready, willing and able to support NICE.

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