NHS must redesign care around multimorbidity, NICE experts warn

GPs should not fall into the trap of treating diseases rather than patients as the NHS faces a growing population with multiple long-term conditions, senior NICE doctors have warned.

Professor Bruce Guthrie (Photo: Pete Hill)

The essence of NICE’s recently published multimorbidity guideline is about optimising, not withdrawing or increasing drugs and treatments, NICE leaders told the RCGP annual conference in Harrogate on Friday.

Professor Bruce Guthrie, who chaired development of the NICE guideline, cautioned GPs not to ‘fall into the risk of treating the disease and not the patient’.

GPs should actively check whether drugs - for example to treat symptoms of long-term conditions - are still working, or if patients are taking them needlessly.

‘If you want to know whether a symptomatic drug works, you have to stop it to see,’ he said. ‘GPs should actively check whether these are working when reviewing treatments.’

End of life care

Patients may informally introduce the topic of their death or wanting to stop drugs if they feel they are approaching the end of their life and find it hard to address directly.

They may, for example, use jokes to communicate this, such as ‘if I were a dog you’d shoot me’ or ‘I’m rattling with all these pills’, he said.

GPs should be aware of this and possibly interpret it as a serious cue that the patient may be open to discussions about the end of their life, and their treatment priorities  and goals during this time.

NICE chairman Professor David Haslam said the disease burden had changed dramatically in recent years, and healthcare systems and professionals need to adapt.

‘Just one professional career ago, people who would have died can now survive due to advances in science,’ he said.

Long-term conditions

‘Every time someone doesn't die, they have the opportunity to develop something else. It’s an unintended consequences of our really quite astonishing success.’

Life expectancy is expected to rise by five years to 84 for men and 87 for women for children born in 2037. But as life expectancy increases, ‘the number of long-term conditions they collect rises’.

Professor Haslam said the health landscape had undergone ‘remarkable’ changes. For years, infectious disease was the main challenge, followed by an ‘era of acute medicine’.

‘The assumption was people were well until they got one condition. That was the paradigm that most hospitals were developed for.

‘But actually now many patients have multiple problems. People don’t die but live with multiple diseases. Now we need to build care around these people - and the vital increasing role of the generalist comes along with this.’

‘I believe the future of medicine has to be specialism. The essence of healthcare is care, and the essence of care is humanity - and splitting care into body parts is a problem.’

He said NICE was ‘trying to address’ its contribution to this problem - as most NICE guidelines deal with just one disease area, and feed on evidence that actively excludes patients with multiple conditions.

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