Within primary care, recent policies in many countries have encouraged the development of new types of providers of primary care with the aim of promoting patient choice, encouraging competition between providers and improving access to health care. For example, the NHS in the UK has introduced walk-in centres, which offer nurse-led advice and treatment without an appointment. However, this type of care can be inefficient because of duplication of effort, leading to poor coordination of care, undermining the development of trusting relationships with health professionals and risking confusion for patients (Figure 11.2).

We should recognize that these multiple providers have often arisen because of deficiencies in the service provided by general practices, particularly in terms of access to care. However, it is likely to be more effective and efficient to improve access to general practice than to develop multiple alternative providers.

There may be benefits from having multiple providers of primary care in terms of improving access to care, but these benefits need to be balanced against a reduction in continuity and coordination of care. The balance between these advantages and disadvantages may be different for different groups of the population. For example, young people with few previous health problems, who rarely consult doctors and have busy working lives, may appreciate the convenience of walk-in centres. But the people with the biggest health needs are those with multimorbidity, and they are disadvantaged by a policy of investment in multiple new sources of care rather than in improved provision from a single, local, healthcare provider who is able to provide first contact generalist care for all their problems in one place and at one time.

Shared records

To some extent, the problem of patients with multimorbidity attending different specialists for each of their problems can be reduced if all the different healthcare providers have a shared system of electronic medical records. Achieving this should be a high priority for any health system that seeks to provide integrated care for people with multimorbidity, so that each care provider can take account of investigations and treatments provided elsewhere. However, the difficulties of creating a system of shared records should not be under-estimated, given the very different record-keeping needs of the different types of healthcare professionals and provider organizations within a large and complex healthcare service. Furthermore, although shared records are likely to be very important in order to promote coordination of care, it should not be assumed that a so-called ‘information continuity’ is a substitute for personal, relational, continuity with a known and trusted clinician.

Promoting generalist skills

If patients are able to attend one healthcare facility as the first point of contact for almost all of their health problems and if it is important to encourage continuity of care from a small number of professionals, it follows that these professionals must have an understanding of a wide range of diseases, a broad range of skills and an ability to make complex judgements when faced with multiple considerations (e.g., a patient with diabetes and asthma who does not adhere to medication because they are depressed and sees no point in living to an old age and whose breathing is made worse by poor housing). These healthcare professionals need to have a sophisticated understanding about the relationship between these physical, psychological and social factors as they make decisions about diagnosis and treatment and have an attitude that focuses on the overall needs of the patient rather than on abstract notions of ideal disease control.

Training doctors and nurses

In training doctors and nurses, more recognition needs to be given to the fact that most patients they see will have multimorbidity rather than a single disease. Students need to learn more about the key factors highlighted by the chronic care model, such as promoting patient self-management (rather than assuming that doctors make decisions and patients do as they are told), the need for individual accountability in coordinating the care of complex patients and the importance of organizational factors such as recall and reminder systems. Most importantly, students need to be encouraged to develop a patient-centred attitude rather than a disease-centred attitude and an approach to consulting which is based on understanding the patient’s context, sharing decisions with them and reaching an agreement about an individual management plan that reflects their priorities.

Valuing generalism

At a national level, healthcare systems need to value and promote careers that are based on generalism rather than specialism. This may be reflected in the involvement of generalist doctors in national decision-making bodies, the length of training that is deemed necessary for the role and the salaries of generalists versus specialists. In many countries, generalists earn less than specialists, and it is not surprising that in these countries it is difficult to attract the best doctors and nurses to work in generalist roles.

Planning and commissioning healthcare

Commissioners of health care seek to redesign care pathways in order to obtain the best outcomes at the lowest cost. As previously discussed, these care pathways are frequently designed on a disease-specific basis. Services are often commissioned from specific providers for an individual disease, and the performance of these providers is often monitored in terms of disease-specific targets. This can again lead to fragmentation of care. Therefore, when planning and commissioning services for individual diseases, it is important to ensure that providers can as far as possible manage common comorbidities without cross-referral and that they can communicate information effectively with the primary care professional who is coordinating the patients’ overall care.

Clinical guidelines

In most developed countries, guidelines have been developed for the management of chronic diseases. The authors of guidelines need to be explicit about the extent to which these are valid for patients with comorbidities. In some cases, there may be little or no evidence about the management of patients with comorbidities on which to base guidance. It cannot be assumed that interventions are equally beneficial in patients with comorbidities as in those without. For example, a patient with cancer or heart failure has a reduced life expectancy and may have less to gain from interventions that are designed to increase their life span but at the expense of drug side-effects in the short term.

On the other hand, in the absence of evidence from patients with multimorbidity, guidelines based on patients with a single condition may be all we have to go on. It is arguable that the benefits of treatment may be even greater in patients with multimorbidity because they are at a greater absolute risk of adverse consequences of disease and therefore have most to gain from interventions.

The solution to this dilemma is not necessarily a nihilistic rejection of guidelines. Instead, it may mean that we need more sophisticated guidelines and targets that carefully define the target population and take account of comorbidities. For example, blood pressure targets may need to be more relaxed for patients who have a reduced life expectancy due to a non-cardiovascular condition but conversely more strict for patients with other conditions such as renal or eye disease, which are more progressive in patients with uncontrolled hypertension. These patient-specific guidelines should be combined with decision aids to inform management decisions that reflect the evidence and also the individual patient’s preferences and needs (Figure 11.3). It is important to allow professionals to exclude individual patients from targets when there are particular reasons why achieving the target may be inappropriate or impossible; for example, because the patient makes an informed choice not to follow the guidance.