Redesigning the general practice consultation to improve care for patients with multimorbidity

Patients with multimorbidity often need more frequent general practice consultations, and more complex and structured care, than those with a single condition. Their care is often shared and needs to be coordinated with specialist community and hospital teams. A recent article in this series drew attention to the importance of having one main coordinator of care for patients with multimorbidity,1 and Starfield and colleagues highlighted, almost a decade ago,2 the challenge that primary care practitioners face in managing patients with multimorbidity more effectively. The standard primary care consultation for patients with multiple conditions needs to change, but how?

Multimorbidity influences the general practice consultation in three main ways. Firstly, the amount of clinical information that must be collected for an individual patient with many different conditions can be extensive, especially when conditions and their stability change over time.3 Secondly, as conditions progress over time, management priorities and consequently information gathering, plans, and coordination of care must change.4 Thirdly, communication with other services involved in the patient’s care may be necessary to clarify clinical care plans, to ensure continuity of care, and to minimise conflicts in treatment decisions. How could the primary care consultation be redesigned to provide more effective care for patients with multimorbidity and meet their specific care needs?5

The usual length of a consultation in general practice is around 10 minutes. Both clinicians and patients think this is too short even for usual care.6 7 As the prevalence of multimorbidity rises it has been proposed that consultation lengths for patients with multiple chronic conditions, who have more complex needs and require more care, should be extended.6 Most of the current evidence that supports lengthening consultations has focused on patient satisfaction rather than impact on longer term clinical outcomes. A systematic review found that longer consultations in primary care might improve some aspects of the process of care.8 Longer consultations were associated with more preventive advice being given, lower prescribing, and higher patient satisfaction, but their effect on accuracy of diagnosis and referrals was inconsistent. Even though evidence of long term benefit is limited, from a practical point of view standard consultations for patients with multiple conditions should be longer to allow for their extended role and purpose.

The development of new methods for integrating and prioritising different clinical pathways that patients with multimorbidity might be engaged with is a key priority. Information technologies that draw on the electronic health record and are accessible during consultation need to be developed to support effective coordination of care.9 A study conducted in the United States investigated the usefulness of a case management tracking database alongside patient data and electronic health records, which could be shared with healthcare teams, and concluded that such specialised information technology tools could be useful in managing patients with multimorbidity.10 Such innovations could be adapted to healthcare systems in which primary care and general practitioners in particular coordinate care.

Lengthening the standard consultation might also improve continuity of care. A systematic review of studies of interventions to improve continuity of care found that longer consultations are associated with higher patient satisfaction and reduced healthcare usage.11 However, the optimal framework for delivering continuity for the patient with multimorbidity is not yet clear.

Evidence on the most appropriate models of care for patients with multimorbidity is still limited,12 and studies looking at changing the length and structure of the primary care consultation to improve integration of care have yet to be conducted. The so called guided care model—which is based on a nurse led coordination of interaction between the patient, primary care doctors, and healthcare teams—is an example of a strategy for integrating the care of chronic diseases.13 A trial of this approach found that it had limited effectiveness in reducing healthcare use. Existing models of integrated care for chronic disease comprise complex healthcare packages or pathways, and there have been few attempts at systematic evaluation. There is widespread interest in telehealth and its potential for use in patient care, but again evidence about its clinical impact is limited, especially among patients with multimorbidity.14

Future efforts to redesign the general practice consultation should focus not only on the structure (length and type) of the consultation, but also on developing practical tools that allow GPs and nurses to coordinate, integrate, and provide continuous care in a way that improves patient care. How newly developed approaches to consultations for patients with multimorbidity will align with individual disease quality frameworks, and whether new “business model” approaches will further fragment or enhance the delivery of holistic care, remain to be seen.15 However the general practice consultation is redesigned to take account of patients with complex needs, it should be borne in mind that this consultation is arguably central to the quality of the patient’s clinical care.