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Clinical management

Identifying people with complex lives who could benefit from holistic support

  • People with ‘complex lives’, who frequently attend, have numerous health and social issues and are prescribed multiple analgesic and psychotropic drugs can be ‘hidden in plain sight’. This group are intuitively known by clinicians but may not be easily identifiable from patient records.

  • A novel approach was developed using attendance and prescribing data to identify this group in practices. Review of their notes identified consistent themes of chronic pain, mental health problems and social adversity. The cohort was found to use more urgent appointments and often consult multiple GPs.

  • Identifying this cohort of patients could enable a multi-disciplinary approach to improve their wellbeing, including social and prescribing interventions and mental health support. This could also provide an opportunity to fulfil unmet patient needs and potentially reduce long-term appointment use.

o WiseGP actions:

  • Read the blog and linked QI proposal written by the team of GPs who led this project, to understand how they identified this cohort, so you can try and replicate it within your own practice or PCN.

Read more here:


Do your chronic disease reviews consider the patients’ own goals?

  • There is a growing international consensus that we need to change healthcare systems designed around the management of single diseases to focus on the whole-person and their individual goals. A trial of a whole-person centred model of care (the 3D trial) didn’t impact on quality of life or treatment burden, but there were significant improvements in how patients experienced chronic disease management.

WiseGP actions:

  1. Do your practice’s chronic disease reviews include discussion of the patients’ goals for care. Many Quality Outcomes Framework indicators are important, but they aren’t the only things that matter. Reviewing multiple conditions at once in detail can be overwhelming, so consider allowing opportunities for patients to share and discuss the problems that matter most to them.

Read more about the research informing these recommendations here:

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