Better training is needed to deal with increasing multimorbidity

Patients with multiple health problems are the norm not the exception, and the NHS is not set up to treat them properly, concludes a study carried out in Scotland. Most healthcare, research and education focuses on single diseases while many patients have several, and a new strategy is needed. Financed by the Scottish government’s Chief Scientist Office and published in the Lancet, the study was led by Bruce Guthrie of Dundee University and Stewart Mercer and Graham Watt of Glasgow University. They used a dataset covering 314 medical practices in Scotland, representing 1.75 million patients, and extracted data on 40 morbidities, working out how many patients were diagnosed as having one, two, or more.

Although multiple morbidities are recognised as being more common among older people, the team found that there were more in absolute terms in those under 65—210 500 versus 194 966 in people over 65. By the age of 50, half the population had at least one morbidity, and by 65 most had more than two. People living in deprived areas were more likely to experience multimorbidity, even though the population of such areas was on average younger. Young and middle aged people in the most deprived areas had rates of multimorbidity equivalent to those of people 10 to 15 years older in the most affluent areas.

More than a third of those with multimorbidity had a mental health problem, with women more likely than men to combine a mental and a physical health disorder, and older people more likely to do so than younger ones. The link with deprivation was much stronger for such comorbidities, and the chance that a person with five or more disorders would also have a mental disorder was nearly seven times greater (95% confidence interval 6.59 to 6.90) than one with no physical disorder.

The authors say that their data “challenge the single disease framework by which most healthcare, medical research, and medical education is configured. Existing approaches need to be complemented by support for the work of generalists, mainly but not exclusively in primary care, providing continuity, coordination, and above all a personal approach for people with multimorbidity. This approach is most needed in socioeconomically deprived areas, where multimorbidity happens earlier, is more common, and frequently includes physical and mental health comorbidity.”

Watt said: “Are the results typical? They’re certainly typical of Scotland, but not particularly Scottish. Any advanced country with an ageing population is either here or heading in this direction.” If anything, he said, the results underestimated the problem because they counted only diagnoses and could not include information on severity.

“The NHS has too many people addressing part of the problem” he said, “which is a recipe for fragmentation, poor coordination and inefficiency.” What patients needed was a long term relationship with somebody they knew and trusted—“it could be a specialist, it could be a nurse, but most often it will be a GP.”

To fill the role properly, however, GPs need better training. Even in countries where primary care is strong, the team says, the system faces substantial challenges from ageing populations and increasing multimorbidity. Training for primary care is typically shorter than that for specialists and there is little structured training on the organisation and delivery of chronic disease management and care coordination. Medical training at all levels needs reshaping to develop knowledge and skills in the management and coordination of longitudinal care.

In a commentary in the Lancet, Chris Salisbury of the University of Bristol writes that the problem has become more visible since the so called “industrialisation of medicine.” Chronic diseases were often managed by nurses working to checklists within disease-specific clinics. These guidelines were written by specialists, drawing on research on selected patients without comorbidities. “Treating diseases in isolation when most people have several disorders can lead to burdensome and potentially inappropriate treatment,” he concludes.

1. Burnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research and medical education: a cross-sectional study. Lancet 2012, doi:10.1016/S0140-6736(12)60240-2.

2. Salisbury C. Multimorbodity: redesigning health care for people who use it. Lancet 2012, doi:10.1016/S0140-6736(12)60482-6.