Reviews for multimorbidity risk in people with inflammatory conditions: a qualitative study

Duplication and fragmentation of care

HCPs suggested that QOF meant that people with mLTCs may be invited to multiple reviews about individual conditions, with some patients even receiving duplicate reviews:

‘I think what the problem is with QOF is that it deals with individual conditions and risk factors for those and the next step in my view should be that we need to start to align some of that around multimorbidity.’ (FG03, P14)

People with IRCs reported the number of reviews added to their treatment burden and that reviews tended to have a single disease agenda with little room to discuss the wider context and/or address their own agenda:

‘You can feel like you’re just going from one review to the next and back round again.’ (P14)

‘You don't get treated as a patient as a whole patient, you get treated for one bit or you get treated for another bit or another bit.’ (P01)

HCPs described being under increasing pressure to meet the requirements of the QOF, and with time-limited appointments, there was little space for the patient agenda or exploration of patient concerns:

‘There’s a lot of pressure on completing those tick boxes. And if you forget one, you don't get the points and you don't get the payment.’ (FG03, P11)

Poor integration and challenges around communication between primary and secondary care providers lead to further challenges for practitioners and patients:

‘How can we join up the patient's care and ask all these different people to be involved in that patient’s care when actually we can't even see their record from one building to the next so not having the systems there to support the clinicians.’ (FG02 P07)

‘The NHS does not talk to each other … They are separate silos.’ (P01)

Consequently, this can lead to some patients going without a review, while others receive duplicate reviews:

‘And if they are attending those reviews [with secondary care] we don't tend put them in with the GP for another review.’ (FG03, P11)

This fragmentation of care may impact on person-centredness as patients reported feeling they are not being viewed as a ‘whole person’. People who had experienced LTC reviews suggested that reviews are just a ‘tick-box exercise’:

‘I feel like it’s just a box that they've got a tick. They do it [the review] and then I'm out of there without feeling like I've participated really.’ (P07)

HCPs described the challenges aligning patient and practitioner agendas in one appointment to create a more holistic approach, owing to time constraints:

‘The patient’s priorities are very different to the clinician's and what’s important to them can be worlds apart really.’ (FG01, P03)

‘We'd all love to fully understand all of our patients and you know, concerns and expectations but in the real world when you've got 10 minutes … it really doesn't always play out that way.’ (FG03, P14)

Inequity in access

HCPs reported a gap in providing care that helps detect and prevent health problems to those who need it most. HCPs suggested that people who would benefit most from a risk assessment review, those most likely to be at risk of mLTCs, may also find reviews more difficult to access. Both people with IRCs and practitioners suggested that patients with greater needs owing to limited health literacy, poor digital access, or poor mobility would find it more difficult to access reviews.

‘Accessibility of those services is disproportionately difficult for people who have the greatest health needs.’ (FG02, P10)

‘You can't always get on this particular booking platform that’s on there [online] which makes it a bit difficult.’ (P16)

HCPs highlighted the need for reviews to target underserved communities, as they are more likely to experience higher disease burden yet may access care less frequently:

‘I think one of the challenges that exists fundamentally is that most of the diseases that we'll be talking about will have a greater impact and there'll be a higher disease burden in the communities that have got higher levels of socioeconomic deprivation.’ (FG02, P10)

However, inequities in care commissioning can mean that those who are most in need receive less care:

‘You know it is a postcode lottery for some of these people.’ (FG02, P07)

Conceptualisation; content and outcomes

People with IRCs struggled to conceptualise what an IRC annual review would include. At the time of interview one person with an IRC had received invitation from their GP for their RA review but had no insight into what this would involve:

'I’ve had a text message — It says on the text your annual rheumatoid review. That’s a first. Never had one before so. What that entails I do not know until I’ve been.’ (P16)

The idea of having a ‘RA review’ yet talking about other conditions, such as CVD or osteoporosis, did not align for some people with IRCs as this was not something they expected. Given that people with IRCs conceptualise their review to be a holistic ‘whole-person’ approach, many people suggested that a physical examination would be an important part of such a review:

‘I think they [the review] should be in depth, including a physical examination.’ (P16)

Conversations surrounding mood and lifestyle were accepted and generally areas that patients wanted to be explored within such a review:

‘It'd be nice to chat about it, I think. If there’s anything any way that you could be doing things differently that might help.’ (P02)

People with LTCs described a range of attitudes regarding whether they would be motivated to attend a review focused on their risk of potential future conditions. Some perceived increasing awareness of their personal risk of other conditions as negative:

‘Having someone talking about the possibilities of related conditions would simply serve to make me feel more anxious.’ (P12)

Whereas others perceived it more positively:

‘Forewarned is forearmed, if you know what’s coming you can do something about it.’ (P10)

For a review to be perceived as valuable, people with IRCs considered it important to have clear understanding of the review purpose and outcomes:

‘If nothing is going to come of it (…) not going to follow-up on something that I’ve said then what is the point of ringing me because all you have done is taken 10 minutes out of my day.’ (P10)

Preparation and flexibility

People with IRCs and practitioners suggested that preparation resources (for example, written information sent out to a patient before the review) may be beneficial. This could provide an opportunity to align patient and HCP expectations and agendas, helping patients identify their priorities for discussion. To accommodate this person-centred approach, the review must remain flexible and responsive to the patient agenda. One HCP reflected that this approach had potential to increase patient engagement with healthcare reviews and improve health outcomes:

‘We just invite patients to a chronic disease review and they turn up thinking it’s something different. So I think outlining what our aims are for the purpose of the appointment helps align it with patient’s expectations of the review. I think that’s something I’ll feedback to our team (…) because that does sound like it might save us some of the difficulties, we have in getting patients to attend and engage.’ (FG03, P12)

Preparation materials were considered of high importance but would only be meaningful if they were accessible to all. One person with an IRC spoke about how family members would differ in their ability to access preparation materials owing to reading and writing comprehension:

‘It’s [RA] still seen as an elderly disease so whether they are able to do this [preparation]. My mum would, but my mother-in-law, probably not. So would that mean she got less care because they didn't do it? So, I don't know how you would encompass everybody.’ (P13)

The additional administrative requirements for this to work efficiently was also highlighted as a consideration:

‘It’s fine sending things out and getting things back, but somebody has to look at it and code it and put it on, so it’s lots of admin.’ (FG03, P11)

Delivery

Participants discussed the delivery of the review, and where it should take place. All people with lRCs suggested that they would prefer to have a face-to-face review rather than a remote consultation. However, patients acknowledged that the delivery of a review needs to consider patient preference and needs. This is particularly the case for patients who may have barriers to communication or impaired mobility:

‘Some people find it hard to get to whether they’re going to go, so they might prefer over the phone. But I don't. I prefer to go and sit and talk with somebody.’ (P16)

Patients suggested that the review could take place in primary or secondary care, as long as practicalities were considered such as travel and parking:

‘It’s just I suppose where it was and if I can get to there you know transport and how far away it was, how near.’ (P11)

Practitioners from both primary and secondary care suggested that the review should take place in primary care, offering more ‘holistic’ consultations, compared with specialist care that focused on the index IRC and its treatment:

‘Their attitude is that the rheumatologist is there to make the decision about treatment.’ (FG03, P12)

‘Lots of that [review content] is general health stuff. And I think the more that we [secondary care] take on of that, there is a risk that the GPs will view that as "oh, they're under rheumatology and therefore we better not do anything".’ (FG01, P04)

People with IRCs and HCPs reflected that GPs were ideal to undertake holistic reviews. However, when reflecting on existing pressures and rising demand on GPs, practitioners also discussed utilising broader primary care roles. These roles (lifestyle coach, wellbeing practitioner and so on.) were suggested to be helpful supporting people at risk of mLTCs, providing them with the time they need:

‘Our lifestyle coach was brilliant. He would see people with difficulties dealing with their comorbidities on a regular basis and he had the time to follow them up (...) He had really good results like that because they engaged with him.’ (FG03, P11)

However, people with IRCs and HCPs stressed that, regardless of the HCP role, appropriate skills and expertise are needed to be able to cover all areas sufficiently. Specifically, knowledge of the IRC was deemed important:

‘It’s got to be someone who’s got some inside knowledge of the condition and how it affects people in general. Obviously, they’ve got to have a good insight and good knowledge of how to advance care.’ (P06)

‘It’s about the expertise, isn't it? That you need to be able to review that patient correctly because you know you need certain competencies and expertise to be able to manage the condition.’ (FG02 P09)