Personalised Primary care for Patients with Multimorbidity (PP4M)

Personalised Primary care for Patients with Multimorbidity (PP4M) – a primary care service improvement initiative

Lead: NIHR ARC West

Why the research is needed?

General practices regularly review patients with long-term health conditions included in the Quality & Outcomes Framework (QOF) using computerised templates (checklists).  This approach leads to fragmented care for people with multiple health problems (multimorbidity) and can ignore conditions that are not included in QOF. These are sometimes the problems that bother patients most. In the NHS Plan it is a priority to make care more personalised, as described in the NHS Comprehensive Model for Personalised Care.

What we will do?

Some practices have replaced separate disease-focused reviews with a combined annual review consultation for people with multimorbidity. A promising way to improve personalised care is to use a ‘smart’ template focused on what matters most to patients, which supports self-management and shared decision-making. It includes links to social prescribing and pharmacist review of complicated medication, and involves agreeing a care and support plan, while also meeting QOF requirements. This concept of a whole person review has been shown to improve personalised care in several research trials.

In this project we will adapt a template already developed for multimorbidity and make it more personalised. We will make it widely available to general practices, supported with training and other tools e.g. to identify and risk-stratify patients with multimorbidity, and to incorporate patient reported outcome measures. With CCGs, AHSNs and primary care networks in three areas we will support implementation of this approach (whole-person review, template, training, tools). To reduce health inequalities, we will start with practices in deprived areas and patients with multimorbidity including cardiovascular diseases.

What will be achieved?

Implementation will be evaluated using mixed-methods including routinely collected activity and clinical data, patient reported outcomes, and qualitative research. Normalisation Process Theory will be used to interpret findings. This project will provide evidence to support and inform wide-spread implementation of a ‘whole-person’ review for patients with multimorbidity in line with the NHS Comprehensive Model for Personalised Care.

When the findings will be available? 

October 2023

Collaborating ARCs:

  • NIHR ARC West Midlands
  • NIHR ARC Wessex
  • NIHR ARC South West Peninsula

Other Collaborating Institutions for Implementation:

  • NHS Bristol, North Somerset and South Gloucestershire CCG
  • NHS Hampshire and Isle of Wight STP

Contribution to National Priority Aims:

Cross-regional implementation of an intervention with evidenced potential to reduce the burden of multiple long-term conditions (multimorbidity).

Contact: PP4M Project Mailbox