Policy Bite from the UK: the needs of patients with multimorbidity

February, 2017


This month’s Policy Bite is another ‘external invite’, this time by the Royal College of General Practitioners (RCGP) in the United Kingdom. The document deals with multimorbidity and our role as family doctors in caring for patients with multimorbidity. It is a 20 page monograph written by Maureen Baker and Holly Jeffers and is endorsed by the RCGP Council. 

Baker M, Jeffers H. Responding to the needs of patients with multimorbidity: a vision for general practice. Royal College of General Practitioners, London. 2016.

The Policy Document

Responding to the needs of patients with multimorbidity: a vision for general practice from the Royal College of General Practitioners was published in November 2016

Download the document

The Message

The provision of effective, person-centred care to the rising number of patients with multimorbidity in the UK is a key challenge for the NHS in the 21st century, and one in which general practice is very much at the forefront.

Living with multiple long-term conditions is already a significant burden. Patients often have to adapt their lifestyle to live with their conditions, attend numerous appointments, and follow complex treatment and medication regimens.

In addition, patients with multimorbidity often have a worse experience of the health and social care system. This can include a lack of access to services, consultations that are too short to discuss their multiple conditions, and fragmented care as a result of the disjointed, disease-specific approach of many specialisms and services.

General practice plays a vital role in caring for patients with multiple long-term conditions. However, GPs face many barriers in providing holistic care, including a lack of research into multimorbidity, complexities of polypharmacy, and incentives which are single disease focused.

To address these barriers, it is essential that action is taken at GP practice, local health system and national level.

Priorities should include:

• giving patients the opportunity to form ongoing relationships with the general practice team to ensure continuity of care;

• prioritising longer consultations for those who need them;

• care planning to support coordinated, holistic care;

• developing multidisciplinary teams so GPs have rapid access to other professionals;

• improving communication across the primary and secondary care interface, supported by better interoperability of IT systems;

• medicine reviews that incorporate the skills of GPs and practice based pharmacists;

• more experience of caring for patients with multimorbidity for those in foundation training;

• developing improved tools and guidance for GPs and patients;

• developing alternatives to performance related payments focused on disease specific targets that encourage person-centred care; and

• funding for research into multimorbidity, including common clusters of conditions and drug effectiveness.

This will support the cultural, clinical, contractual and organisational changes needed to improve outcomes for patients with multimorbidity.

The Authors

The RCGP is the professional membership body and guardian of standards for family doctors in the UK, working to promote excellence in primary healthcare. The RCGP is a member organization of WONCA.

The RCGP’S other policy work in integration of care.


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