Understanding usual care for patients with long-term conditions in 3 areas of the UK – an aspect of the process evaluation of the 3D study
A cluster randomised controlled trial to improve the management of multimorbidity in general practice – the 3D study, recruited 33 GP practices in 3 areas: Bristol, Manchester and Glasgow. Implementation of the intervention may differ between practices due to differences in resources, skills and diverse personnel. One factor may be the extent to which the intervention differs from usual care in each practice, as this may influence ease of implementation. Unintended consequences of the intervention or changes due to external influences may occur over the course of the trial and also affect outcomes. Understanding context, how it changed over time, and how it might have influenced implementation of the intervention are important aspects of the process evaluation of the trial.
A practice survey was developed to capture how individual practices currently manage individuals living with long term conditions, focusing on key components of the 3D intervention. These components include combining long-term condition reviews, seeing a named GP, depression screening, annually reviewing and optimising medication, providing a care plan to the patient and use of a specially-designed electronic template. The survey also included practice size, clinical skills, practice recall systems, how the reviews are managed and by which clinical professional. Each practice was first contacted by phone to identify their preferred respondent and give them the option of providing the information by telephone interview or by self-completed survey. The survey template was modified in light of emerging information which meant returning to some practices for additional information at the end.
Many practices are moving towards a combined review of patient’s multiple long-term conditions in one appointment and commissioners are pushing for better co-ordination and patient-centredness but this is difficult to achieve when systems (e.g. templates) are disease-focused. Various models of care were identified across the 33 practices from individuals being invited for a combined review of all their conditions in their birthday month to invitations for separate review of each individual condition. In some practices GPs undertake most reviews, leaving just respiratory and diabetes reviews to practice nurses. In other practices, nurses do the majority. Occasionally Health Care Assistants have been trained to complete various reviews from learning disability to diabetic foot checks. Fourteen of the 33 practices fully combine their reviews but none of the practices currently have fully combined review templates. Thirteen practices do no formal depression screening for individuals with multimorbidity. The remaining practices have a variety of depression screening policies.
Models of care depend on skills and resources available. There is still much scope for improving systems to support patient-centred, integrated care for people with multimorbidity.