NICE guidance ‘Multimorbidity: clinical assessment and management’ (NG56) was published in September 2016. Quality standard (QS153) was then published in June 2017. The central theme of this guidance and associated quality standard is that people with multimorbidity require a holistic and person centred approach to care, which focuses upon a person’s individual goals and preferences and involves their family and/or carers accordingly to individual wishes.
The guidance defines multimorbidity as the presence of 2 or more Long Term Conditions (LTCs) in a person, which can include:
- Defined physical & mental conditions such as diabetes, heart failure, osteoarthritis and schizophrenia
- Ongoing conditions such as learning disability
- Symptom complexes such as frailty or chronic pain
- Any sensory impairment (eg hearing or sight loss)
- Alcohol and substance misuse.
Crucially, the guidance (NG56) also recognises the key relationship between frailty and multimorbidity. Furthermore, it acknowledges frailty as a long-term condition and makes clear recommendations regarding the identification, assessment and management of frailty in the context of multimorbidity.
The guidance recommends that frailty assessment should be considered for anybody with multimorbdity. It also makes the following recommendations regarding approaches to the identification and assessment of frailty:
- Assess frailty proactively and systematically using electronic health records, for example, using the Electronic Frailty Index (eFI).
- Assess for frailty opportunistically in both primary and secondary care using validated tools that are appropriate for the setting in question (e.g., the Gait Speed Test or the PRISMA-7 questionnaire in primary care, the Timed Up & Go test or PRISMA-7 in outpatient clinics in secondary care).
- Be cautious about assessing frailty in any person who is acutely unwell.
- Assessment of older people with complex needs in the hospital setting should start at the point of admission, be comprehensive in nature (e.g., Comprehensive Geriatric Assessment) and carried out preferably in a specialist unit for older people.
NG56 goes on to make the following key points about managing multimorbidity, including in the context of frailty, with particular reference to polypharmacy and care planning:
- NICE guidance for single health conditions may not be entirely appropriate for people with multimorbidity or frailty.
- Consider approaches to care that take multimorbidity into account for anyone on polypharmacy (generally considered to be any person taking 4 or more different medications on a regular basis).
- There is an increased risk of adverse drug effects for people on polypharmacy, especially in the presence of frailty.
- Individualised management plans should be drawn up and agreed with the person, and should include:
- Goals & plans for future care (including advance care plans where appropriate);
- A named care co-ordinator;
- Details of how the plan will be communicated to all the professionals and services involved;
- Details of follow-up and how to access urgent care.
Limitations and future research
It is important to note that NICE guidance is drawn up on the basis of available evidence and therefore in areas where there is a lack of published evidence NICE may not be able to offer guidance. When reading and interpreting NICE guidance it must be appreciated that guidance will necessarily be focused in areas in which published evidence is available. Furthermore, there may be important gaps in the guidance due to lack of published evidence in certain areas. NICE addresses this challenge by making recommendations for areas in which they feel further research is required.
This applies to all NICE guidance but is particularly relevant in the case of NG56, given that there is a paucity of published research in a number of areas relating to frailty and mulitmorbidity. This is because previous studies into long term conditions have often contained exclusion criteria relating to older age and mulitmorbidity.
In the case of NG56, the research recommendations reflect the dynamics and complexity of frailty and the critical role of understanding approaches to the organisation and delivery of care, as well as individual clinical interventions. Specifically, NG56 states the need for high quality research into:
- The clinical and cost effectiveness of stopping preventative medicines in people with multimorbidity who may not benefit from continuing them.
- The clinical and cost effectiveness of both holistic assessment in the community and different models for the organisation of primary care.
- Developing tools that can use primary care data to predict reduced life expectancy, in order to help inform the management of multimorbidity.
Interestingly, research is already take place in this last area using the electronic Frailty Index, with an eFI score threshold within the severe frailty category range having been identified as indicative of a person being in their last year of life.
Further information about the guidance
An NHS England blog about the guidance can be found here.
The full guidance and associated documens can be accessed by following the link with the main guideline and information for the public shown below.
Main guidelineFullscreen Mode
Information for the publicFullscreen Mode
Quality Standard – QS153
This quality standard covers clinical assessment, prioritising and managing healthcare for adults aged 18 years and over with 2 or more long-term health conditions (multimorbidity). At least 1 of these conditions must be a physical health condition. It describes high-quality care in priority areas for improvement. It does not cover care for people who have multiple mental health problems and no physical health conditions because their care is largely delivered by psychiatric services.
The Quality Standard is made up of four quality statements:
- Statement 1 Adults with multimorbidity are identified by their GP practice.
- Statement 2 Adults with an individualised management plan for multimorbidity are given opportunities to discuss their values, priorities and goals.
- Statement 3 Adults with an individualised management plan for multimorbidity know who is responsible for coordinating their care.
- Statement 4 Adults having a review of their medicines and other treatments for multimorbidity discuss whether any can be stopped or changed.
Further information is available on NICE website https://www.nice.org.uk/guidance/qs153