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Patients with multiple health problems make up most GP consultations

RCGP renews call for longer consultations, following study

Jo Carlowe

Tuesday, 13 March 2018

Over 14 million people in England have multiple long-term health problems.

This is the finding reported today in the British Journal of General Practice, based on a study* including over 400,000 adults, registered with a GP in England.

In total, 27.2% of the patients involved in the study had multimorbidity. The most prevalent conditions were hypertension (18.2%), depression or anxiety (10.3%), and chronic pain (10.1%).

The prevalence was higher in females than males (30.0% versus 24.4% respectively) and among those with lower socioeconomic status (30.0% in the quintile with the greatest levels of deprivation versus 25.8% in that with the lowest).

Physical–mental comorbidity constituted a much greater proportion of overall morbidity in both younger patients (18–44 years) and those patients with a lower socioeconomic status.

Multimorbidity was strongly associated with health service utilisation. Patients with multimorbidity accounted for 52.9% of GP consultations, 78.7% of prescriptions, and 56.1% of hospital admissions.

The authors, from the Universities of Cambridge, Bristol, and Utah, described multimorbidity as ‘common, socially patterned, and associated with increased health service utilisation.’ They said their findings ‘supported the need to improve the quality and efficiency of health services providing care to patients with multimorbidity at both practice and national level.’

Multimorbidity was defined in the study as patients having two or more currently active, long-term conditions. These include those heavily influenced by lifestyle factors such as coronary heart disease, diabetes or cancer.

“How health services are designed to care for patients with multimorbidity should take into consideration demographic factors, such as age and socioeconomic deprivation,” said the authors.

They continued: “This study found that in the younger age groups most of those with multimorbidity had both a physical and mental comorbidity. Similarly, those patients with the greatest levels of socioeconomic deprivation also had higher rates of physical–mental comorbidities. These data suggest that when GPs are caring for younger and poorer patients with multimorbidity, they should think about the intersection between physical and mental health morbidities. By comparison, when caring for older patients with multimorbidity, the sheer number of morbidities is more likely to define those patients’ healthcare needs.”

The Five Year Forward View called for a reorganisation of the NHS to support people with multiple health conditions, not just single diseases. The authors say their study provides more evidence of ‘the pressing need to fulfil this ambition at a time when general practice workload, prescribing, and hospital admissions continue to climb at alarmingly rapid rates.’

“As the majority of healthcare encounters are now with patients with multimorbidity, all health professionals must be trained to manage the cumulative effects of more than one chronic condition. Many ‘single-disease’ services in primary and secondary care will need to be redesigned to treat patients with multiple morbidities,” they concluded.

Commenting on the findings, Professor Helen Stokes-Lampard, chair of the Royal College of GPs, said: “It is becoming less common as a GP to see patients presenting with a single, long-term health issue. Indeed, as this research shows, more than half of GP consultations are for patients living with two or more long-term conditions.”

She added: “This large-scale, comprehensive research is further evidence of the increasing complexity of cases that GPs are dealing with, and the inadequacy of the standard 10-minute consultation.

"GPs need much more time with our patients with complex needs, so that we can properly consider their unique circumstances – including the different conditions they are living with – and develop the most appropriate treatment plan for them. This simply isn't possible in 10 minutes, but offering longer appointments means offering fewer appointments and our patients are already waiting too long to secure time with their GP.

"Today's research also highlights the rising number of cases of physical and mental comorbidity, particularly in young people, and the urgent need for enhanced mental health services, including more mental health therapists and more options for treatment, in the community - and for GPs and our teams to have better access to them.

"Whilst GP workload has increased by at least 16% over the last decade, our work has also increased in complexity - but the share of the overall NHS budget general practice receives is less than it was a decade ago, and our workforce has not risen at pace with demand.”

Professor Stokes-Lampard, also stressed the need for the prompt delivery of NHS England’s GP Forward View, which promises £2.4bn extra a year for general practice, 5,000 more GPs, and for every practice to have access to one of 3,000 new mental health therapists.

“These findings also suggest that for general practice to cope with the changing needs of our population, we need to consider alternative ways of delivering care to ensure all patients receive the most appropriate care for them. This should involve implementing systems to free up GPs' time so that they can spend longer with patients living with multiple, complex conditions, who really need their medical skills and expertise."

*Cassell A, Edwards D, Harshfield A, et al. The epidemiology of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract 12 March 2018; bjgp18X695465. DOI: 10.3399/bjgp18X695465

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