Through our research we have developed tools and guidance to help general practices introduce personalised annual reviews for patients with multiple long-term conditions.

Background

Many people have multiple long-term conditions needing regular review. At present most general practices review each of these conditions in isolation. This is inconvenient for patients and inefficient for practices. These disease-specific reviews fail to treat the patient as a whole person and can neglect to address the health problems that bother the patient most. 

We advocate doing a ‘whole-person’ annual review, instead of multiple disease-focused reviews. Our research indicates that this provides a better patient experience and it is also more fulfilling for clinicians. Many people think it is a good idea, but introducing this change is difficult and raises a number of issues. 

Tools and guidance

Please watch the Powerpoint presentation or read our guidance, which includes links to a range of tools:

• An outline structure for the review
• How to plan for the change, including guidance about process mapping
• Details of a computerised template for Emis practices to support the review
• Guidance about staff training, including a curriculum to help staff self-assess their training needs
• An audit search so that Emis practices that use the template can monitor their progress
• A list of issues that practice face when changing to personalised annual reviews, and suggestions for how to address them

Further information

See also:

• Project web page on the NIHR Applied Research Collaboration West (NIHR ARC West) website: Improving review appointments for people with long-term conditions - the PP4M study
• Multimorbidity and long-term conditions research from the Centre for Academic Primary Care.
• Watch the PP4M study video: