As a society we are becoming increasingly unwell. More and more individuals are experiencing multimorbidity. This is generally defined as having two or more chronic physical and/or mental health conditions. Complex multimorbidity refers to those with three or more such issues. Rates of multimorbidity are rising rapidly, with the prevalence of multimorbidity in the UK population now around 27%.
Whilst it can affect anyone, multimorbidity is a function of inequality. We know that those who live in poverty are disproportionately affected by multimorbidity. People who live in areas of increased socioeconomic deprivation are diagnosed 10 to 15 years earlier than those in more affluent areas. Multimorbidity also increases with age. The number of people in the UK over the age of 85 is set to double in the next 20 years and treble in the next 30. Multimorbidity is simply not going away.
Despite these increasing levels of multimorbidity, our healthcare system is not set up to manage these patients effectively. Secondary care is largely divided into specific subspecialties, with patients often seeing multiple different doctors to manage their separate but related health conditions. This system risks duplication and error, as well as representing an unsatisfying experience for many patients.
We know that managing multimorbidity badly results in worse outcomes for our patients, particularly the most vulnerable members of our society. This module will equip you with the skills to help you ‘join up’ care for patients living with multiple conditions.
This module will look at issues that commonly affect people that live with complex multimorbidity, including frailty and polypharmacy. It will address decision making and balancing risks Vs benefits in complex cases. You will be asked to think about deprescribing and how to reduce the harm that comes from over investigation. We will also touch upon communication, both with patients and the MDT. This module fits really well with person centred practice module, as individuals with complex health conditions have the most to gain from having a say in their treatment.
A great place to start with this module is by watching this TEDxNHS talk from Lucy Watts. She is a patient with complex health needs who discusses how someone taking the time to work out what she wanted totally changed her life:
Like modules one and two, this is designed to be completed in FY1. However, all the issues covered are relevant to healthcare professionals of all grades and we would encourage anyone with an interest to take part. This module can be completed in as little as six hours, but there is plenty of content you can explore over more time if you would like to.
Resources
This a is a list of resources, divided by the main outcomes of the module. We have tried to keep them as varied as possible, and you will find articles, eLearning, videos and podcasts that are relevant to the domain.
You can pick the resources that interest you most, and you are more than welcome to find your own too! If you find something that you think would be helpful to share, feel free to let us know here.
Module Basics
– The Enhance Guide for Foundation Doctors (15 minute read) gives an excellent overview of the Enhance programme with links to other useful resources
– The Enhance Handbook (15 minute read for section) is an in-depth document that gives an overview of the whole programme, along with describing the six enhance domains in detail. You can access individual sections or a PDF of the whole handbook via this page
– The module workbook (8 minute read)
– The pre- and post- module self assessment matrix (2 minute read)
– The evidencing engagement form (2 minute read)
– The REAL form is now on the Horus ePortfolio, accessed here
Frailty
– The MDtea podcast (various) is an engaging podcast series that covers lots of issues relevant to frailty. There are twelve series in total
– Frailty for the non specialist (25 minute listen) is a podcast from the RCP that outlines how to recognise frailty and the importance of adapting treatment for frailty patients. It is also available on Spotify and Apple
– British Geriatrics Society (BGS) introduction to frailty (various) is a website that collates lots of useful resources that introduce the concepts around frailty
– BGS what is frailty? poster (5 minute read) is designed for patients to explain frailty
– BGS keeping safe and well at home (various) is a website that collates patient information leaflets on how to stay safe and home when living with frailty
– BGS frailty eLearning (9 hour eLearning, multiple modules) is a free comprehensive resource from the BGS that covers understanding, identifying, communicating and managing frailty. This is much more in- depth than their introductory page, but is an excellent source of information if you want to learn more
– eLearning for healthcare: frailty (various) is a free package provides teaching on frailty. It is divided by audience, so we would recommend tier 2b for most people on the enhance programme
– eLearning for healthcare: long term problems (various) is a free online module that looks at how short and long term conditions can affect people’s day to day lives. This is a very large module, so select the sections that are relevant to you
– Harvard implicit bias check (10 minute test) assesses your implicit bias towards older people
Multimorbidity and long term conditions
– One sentence that changed my life (17 minute video) is a really engaging talk from Lucy Watts, who has been living with a rare long term condition since birth. She speaks about living with her condition, and about how doctors need to speak more about quality of life and goals, and less about her conditions
– The challenge of multimorbidity (45 minute video) is an absorbing talk by Professor Main, an expert on multimorbidity
– Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study (18 minute read) is the paper that led to the concept of multimorbidity being much more widely discussed in healthcare research. It shows how population health factors can affect rates of multimorbidity
– We need minimally disruptive medicine (9 minute read) is an article that discusses the patient factors at play in multimorbidity, and some principles that can help our practice in this area
– Thinking about the burden of treatment (3 minute read, OpenAthens login required) is a BMJ editorial on the burden of being treated by multiple healthcare professionals
Polypharmacy and safe prescribing
– Dr Mucci’s deprescribing masterclass (25 minute video, free sign up required) is a video masterclass on the concepts around polypharmacy and deprescribing. Dr Mucci also has an Instagram profile which frequently posts very useful free resources on a variety of topics relevant to the care of older people
– Deprescribing.org (various) is a Canadian website which has modules on deprescribing, along with useful resources for weaning medications
– Specialist Pharmacy Service tools for medication review (various) is a comprehensive website which gives links to various peer reviewed tools to aid deprescribing, including SIGN and NICE guidance
– eLearning for healthcare safe prescribing (various) is a free online module that looks at the principles of safe prescribing
– Safeprescriber.org (various) is a website with a variety of eLearning for NHS prescribers
– Polypharmacy in older people: a guide for healthcare professionals (30 minute read) is a guide from NHS Wales on deprescribing
– Anticholinergic burden scale (5 minute exercise) is a website, also available as an app, that helps you calculate this score for your older patients
– STOPPSTART toolkit (various) is a document that outlines the principles of the STOPPSTART criteria for deprescribing
– eLearning for healthcare long term problems (various) is a free online module that looks at how short and long term conditions can affect people’s day to day lives. This is a very large module, so select the relevant prescribing sections for you.