A nurse sits down with a patient who has three or more long-term conditions—diabetes, depression, arthritis—and asks not about their blood sugar, but about what matters most to them: walking to the shops, sleeping through the night, managing pain. This is the core of a new intervention being tested in 32 GP practices across the UK, involving 1,383 patients. The problem it tackles is the fragmented, target-driven care that people with multiple conditions typically receive—separate appointments for each illness, little coordination between GPs and hospitals, and a focus on disease markers rather than quality of life. The intervention, called “3D,” gives these patients longer appointments, a comprehensive assessment every six months covering health dimensions, depression, and drugs, and a designated hospital physician for complex cases. If it works, the NHS could shift from ticking boxes on blood pressure targets to genuinely improving how patients feel and function, while potentially reducing hospital admissions and overall costs. The results will be measured at 6 and 12 months, with a parallel economic evaluation.
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This is a pragmatic cluster RCT with nested process and economic evaluation of an intervention in general practice designed to improve the management of patients with multimorbidity. We hypothesise that this intervention will improve patients’ health related quality of life and experience of patient-centred care, and will be more cost-effective than conventional service models. After initial optimisation & piloting in 4 practices we will recruit 32 general practices and randomise them to the intervention or usual care. Participants will be adults aged 18+ with multimorbidity, defined as 3 or more long term conditions (LTCs). The intervention addresses the problems of illness burden (poor quality of life, depression) treatment burden (multiple unco-ordinated appointments, polypharmacy, poor primary/secondary care co-ordination) and lack of patient-centred care (low continuity, disregard of patients’ priorities) experienced by patients with multimorbidity. These patients will be prioritised to receive enhanced continuity of care and longer appointments. They will be invited to a comprehensive ‘3D’ assessment every 6 months. This focuses on (i) Dimensions of health (patient’s priorities for improving quality of life e.g. mobility, pain before addressing disease markers e.g. BP) (ii) Depression (identified and treated as a priority) (iii) Drugs (addressing polypharmacy & poor medication adherence). The nurse will complete a bespoke computerised template to address these 3D elements, collecting relevant data and arranging tests. The GP will review all the information, thoroughly review medication, and agree a written care plan for the patient to take away. To improve primary/secondary care integration, each practice will have a designated hospital ‘general physician’ to discuss patients with complex needs. To ensure the intervention is effectively implemented, it will be incentivised as if it were an Enhanced Service. Practices will train in local collaboratives to share ideas. We will allow local adaptation, appoint a practice champion, provide training and monthly feedback on perfomance. Control practices continue usual care. This usually involves patients being recalled to clinics to see different nurses to review each of their LTCs, with a focus on QOF targets rather than quality of life or patients’ priorities. Outcomes will be measured at baseline, 6 and 12 months and include measures of health related quality of life (EQ-5D-5L: primary outcome); depression; disease control; patient experience; use of primary and secondary care resources (including admission rates). A parallel mixed methods process evaluation combining quantitative and qualitative methods will provide understanding of trial delivery, intervention implementation and responses of targeted participants. An economic evaluation will be undertaken from the perspectives of (a) NHS and personal social services and (b) patients, providing a cost-consequences analysis and a cost-effectiveness analysis. Sample size: 1383 patients from 32 general practices. With 80% follow-up at 12 months, and ICC at practice level of 0.03, the study will have about 90% power to detect an effect size of 0.274 SDs in the EQ-5D. Benefits and potential impacts: This intervention could improve the quality of life of patients and their experience of care and reduce NHS and patient costs. Working with the RCGP, we will ensure that the intervention (if effective) can be implemented rapidly.
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