Quality statement 1: Identification
Identifying all adults with multimorbidity is the first step towards finding those who may benefit from an approach to care that takes account of multimorbidity. Multimorbidity is often associated with reduced quality of life, higher mortality, polypharmacy and high treatment burden, higher rates of adverse drug events, and much greater health services use. Some people with multimorbidity have conditions that significantly affect their everyday functioning. Some people find that managing their care is burdensome and involves a number of services working in an uncoordinated way.
Evidence that GP practices identify all adults with multimorbidity.
Data source: Local data collection from service protocols.
Proportion of adults with multimorbidity identified by the GP practice.
Numerator – the number in the denominator identified as having multimorbidity by the GP practice.
Denominator – the number of adults registered with the GP practice.
Data source: GP practice health records.
Service providers (GP practices) ensure that systems are in place to identify all adults with multimorbidity. Identification may be opportunistic during routine care or involve a systematic search of electronic health records.
Healthcare practitioners (such as GPs, practice nurses and practice managers) identify adults with multimorbidity proactively using health records and opportunistically during routine care. They record this information in health records.
Commissioners (clinical commissioning groups and NHS England) ensure that GP practices identify all adults with multimorbidity and have monitoring arrangements that show this is being done.
Adults with more than 1 long-term health condition, including a physical condition, are identified by their GP practice. The practice may do this by looking at health records or having discussions about health problems during routine appointments.
Multimorbidity: clinical assessment and management (2016) NICE guideline NG56, recommendation 1.3.1
Adults with multimorbidity have 2 or more long-term health conditions where at least 1 of these conditions must be a physical health condition.
Long-term health conditions can include:
defined physical and mental health conditions such as diabetes or schizophrenia
ongoing conditions such as learning disability
symptom complexes such as frailty or chronic pain
sensory impairment such as sight or hearing loss
alcohol and substance misuse.
People who have multiple mental health problems and no physical health conditions are not included because their care will be largely delivered by psychiatric services.
[Adapted from NICE's guideline on multimorbidity, recommendation 1.1.1 and full guideline]
GP practices can identify adults with multimorbidity:
opportunistically during routine care
proactively using electronic health records.
[NICE's guideline on multimorbidity, recommendation 1.3.1]