Quality statement 2: Assessing values, priorities and goals
Adults with an individualised management plan for multimorbidity are given opportunities to discuss their values, priorities and goals.
A person's values, priorities and goals can affect how they experience long-term health problems and how these affect their life. They can also affect their need for care and support. Discussing and exploring what is important to a person with multimorbidity, recording this in their individualised management plan, and sharing the information can ensure that the planning and delivery of care reflects personal preferences. A person's circumstances may change, so values, priorities and goals should be reviewed and updated.
Evidence of local arrangements to ensure that adults with an individualised management plan for multimorbidity are given opportunities to discuss their values, priorities and goals.
Data source: Local data collection from service protocols.
Proportion of adults with an individualised management plan for multimorbidity whose plan has a record of values, priorities and goals.
Numerator – the number in the denominator whose individualised management plan has a record of values, priorities and goals.
Denominator – the number of adults with an individualised management plan for multimorbidity.
Data source: Audit of patient's individualised management plans.
Service providers (such as GP practices, district nursing services, community pharmacies, hospitals) ensure that staff providing care to adults with an individualised management plan for multimorbidity give them opportunities to discuss values, priorities and goals, and record these in the management plan.
Healthcare professionals (such as GPs, practice nurses, district nurses, community pharmacists) give adults with an individualised management plan for multimorbidity opportunities to discuss values, priorities and goals. They ask if the person would like a relative, friend or independent advocate to join the discussion; they explore if the person has any advance care plans or other preferences for care; they check throughout care if the person has any new or changed preferences. They record the discussions in the person's individualised management plan.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that use individualised management plans to deliver and coordinate care for adults with multimorbidity, and that these include up-to-date details of personal values, priorities and goals.
Adults with a management plan for multimorbidity are given chances to discuss what is important to them with a member of their care team. This includes their quality of life, their values, priorities and future life goals. Discussions are recorded in the plan so that all those providing care can take them into account.
Multimorbidity: clinical assessment and management (2016) NICE guideline NG56, recommendation 1.6.7
A plan for a person's care that takes account of multimorbidity based on personalised assessment. The aim is to improve quality of life by reducing treatment burden, adverse events, and unplanned or uncoordinated care. The plan includes a person's individual needs, preferences for treatments, health priorities and lifestyle. It aims to improve coordination of care across services, particularly if this has become fragmented.
[Adapted from NICE's guideline on multimorbidity]
These may include:
undertaking paid or voluntary work, taking part in social activities and playing an active part in family life
preventing specific adverse outcomes (for example, stroke)
reducing harms from medicines
reducing treatment burden
[NICE's guideline on multimorbidity, recommendation 1.6.7]
Healthcare professionals should take into account the needs of adults who are less able to understand and express their values, priorities and goals (for example, those with learning disabilities, cognitive impairment or language barriers). They should also assess a person's knowledge, skills and confidence in managing their own health and care. Reasonable adjustments should be made such as providing information in a format that suits their needs and preferences, asking if a friend or relative should be involved, and providing access to an interpreter or advocate if needed. For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's accessible information standard.