National Institute for Health and Care Excellence. Multimorbidity Scope Consultation Table 06/08/14-10/09/14

Transcription

1 National Institut fo Halth and Ca Excllnc Multimobidity Scop Consultation Tabl 06/08/14-10/09/14 I Collg of Physicians (RCP) Alzhim s Socity Od Sctio No 3 Gna l 1 Gna l Commnts Plas inst ach nw commnt in a nw ow. In th sction on managmnt, in addition to th lngth of consultation th guidlin should xplo th us of mot consultation, th us of tlmdicin and tchnology fo mot monitoing of physiological paamts. Alzhim s Socity blivs that this guidanc is too simplistic and is not hlpful o usabl in its cunt fom givn th naow cicumstancs that it covs. vlop s Rspons Plas spond to ach commnt Thank you fo you commnt. W acknowldg this dvloping aa and th intst in potntial us of tlhalth in mdical ca. Howv w nd to pioitis what will b includd in th guidlin and do not consid us of tlhalth applicabl spcifically to popl with multimobidity. In paticula, w will not b looking at spcific conditions and th monitoing of physiological paamts. Thank you fo you fdback. W acknowldg that th guidlin will cov only som aspcts of ca of popl with multimobidity. NICE is dvloping guidanc in oth aas of th pogamm which will cov aas complimntay to this guidlin. W hav claifid ou woding about what is xcludd fom th guidlin and movd th two pviously xcludd goups which includd popl with dmntia. Th guidlin will not cov th managmnt of spcific 1 of 63

2 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. vlop s Rspons Plas spond to ach commnt conditions, but th pincipls fo assssing and pioitising ca will not b diffnt fo ths goups Phamacuti cal Socity Bitish Acupunctu Council 1 Gnal As pat of viwing quality, w would suppot considation of th local languag nds of local communitis which may diff fom community to community. This would off thos patints who may wish to conduct a convsation in Wlsh th ncssay suppot wh it is saf and bnficial to do so fo th patint. 2 gnal As with oth intvntions acupunctu has lagly bn valuatd fo singl conditions. Th is powful vidnc is in spct of chonic pain [Vicks 2012; Smith 2014], which tnds to fatu in most MM. Focusing on singl conditions is not, howv, chaactistic of nomal pactic, which favous a mo holistic appoach. Th usual patint pofil in acupunctu clinics is on with mo than on, oftn many, conditions, of long duation and a svity quivalnt to hospital outpatints [Shaw 2007]. Boad holistic bnfits, coving multipl physical and mntal symptoms and slf-mpowmnt outcoms a chaactistic of acupunctu [Rugg 2011]. In on andomisd contolld tial with a multi-condition appoach acupunctu was associatd with positiv outcoms fo mdically unxplaind disods in a population with a high lvl of social dpivation [Patson 2011]. Thank you fo you commnt. W ag that implmntation of guidanc and local svic dlivy nd to b sponsiv to local communitis. Any quality issus a considd at all stags of guidlin dvlopmnt. Thank you fo you commnt. W ag that this is an impotant aa, howv, this is outsid th mit of this guidlin, which is th assssmnt, pioitisation and managmnt of ca. W a not addssing spcific tatmnts fo popl with multimobidity. Tials wh comobid conditions a masud indicat that acupunctu dos bst in th sub-goups xhibiting th comobidity, fo xampl tatmnt fo dpssion in popl also suffing physical pain [Hopton 2014]. In this lag RCT patints with dpssion but no pain spondd similaly acoss th th tatmnt ams; whn th was comobid pain thn acupunctu tatmnt was substantially supio to both counslling and usual ca. Obsvational pilot studis in advancd canc populations hav dmonstatd chang ov a wid ang of symptoms, alongsid 2 of 63

3 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. impovd quality of lif and ability to continu living at hom (an- Clow 2010, Takahashi 2009). A small RCT of acupunctu compad to nus-ld ca in patints with incuabl canc potd global bnfits without significant sid-ffcts o oth tolanc issus (Lim 2011). Popl with canc who us CAM (20-40%) gt hug bnfits in th ability to slf-ca: not a cu but pat of a long-tm suvivoship pocss [Hous of Commons Halth Committ 2014]. That sot of positiv fdback fom CAM vs non-cam uss is sn mo gnally acoss chonic illnss. vlop s Rspons Plas spond to ach commnt Bitish Acupunctu Council 1 gnal Givn th poblms fo othodox mdicin and th NHS in poviding good ca fo popl with multimobiditis (MM) it was supising that th was nobody ls psnting complmntay and altnativ mdicin (CAM) at th scoping mting. Also it is disappointing to s no mntion of CAM in th daft scoping documnt. Th natu of CAM pactic (th consultation, th consultation nvionmnt and th mpowmnt pocsss) fits wll with th halthca dmands of popl with MM and th a high ats of CAM us by such popl. Tnds towads gat involvmnt of svic uss in dcisions about thi tatmnt will invitably incas th dmand fo commissioning CAM [Hous of Commons Halth Committ 2014]. Making a positiv spons to such popl is thaputically powful in its own ight. Thank you fo you commnt. W ag that this is an impotant aa, howv this is outsid th mit of this guidlin, which is th assssmnt, pioitisation and managmnt of ca. W a not addssing spcific tatmnts fo popl with multimobidity. Ca of popl with MM is paticulaly lvant to gnalist ca and most pofssional acupunctuists a gnalists. Thy can povid th continuity of ca and coodinatd ca that a so oftn lacking in NHS xpincs fo ths patints. Acupunctuists will f to oth pactitions, othodox and CAM, if thy think that this is appopiat, but thy a abl to off a ang of thaputic appoachs suitd to th halthca nds of popl with vaious and multipl conditions. Acupunctu can b povidd in th NHS by pofssionals who a wll placd to coodinat with oths in a NHS tam in od to off an intgatd packag. Thus th a diffnt possibilitis to suit diffnt situations. 3 of 63

4 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. Unlik othodox mdicin, clinical ca by pofssional acupunctuists is not lagly infomd by singl disas vidnc and guidlins. It is lagly infomd by thoy and accumulatd xpinc on a oot (undlying illnss pattns) and banch (psnting symptoms) basis acoss all th halth aspcts of th individual at onc. In oth wods, it is st up to tat th pson ath than (o as wll as) th disas. In combination with othodox mdicin acupunctu may hlp with pvntion/impovmnt as wll as illnss managmnt; fo xampl, hyptnsion [Li 2014], hypglycamia [Lin 2014]. vlop s Rspons Plas spond to ach commnt Monito 5 Gna l 7. 7 Just th Job 1 Gna l Collg of Gnal Pactitions Collg of Gnal 26 Gna l 25 Gna l In placs, th scop of th guidlin is uncla and inconsistnt and may (albit unintntionally) infoc th bais to mo clinical coodination ath than sk to addss thm (s points 6-13). It sms wong and lacking in quality that individuals with laning disabilitis an t bing considd in th sam way as oths. It would also b usful to undstand whth accumulation of sval multimobiditis alts motivation to ngag in slf-hlp and lifstyl chang. A ths patints mo o lss likly to b woth tagting fo lifstyl suppot? Should suppot svics - g halth tain svics, accss to ti 3 baiatic suppot, b mo gad to patints with multimobidity o should b phaps limit fing ( i. focus on patints with singl mobiditis) this goup if vidnc shows thy a lss likly to gain bnfit? (RP) It would b vy usful to undstand btt th impact of lifstyl chang that alts multimobidity - g what is th ffct of wight loss o stopping smoking o incasing xcis whn sval co- Thank you fo you commnt. W hav claifid aas in th scop that stakholds flt w uncla o inconsistnt. W hav a spcific topic on multi-pofssional ca and on bais to optimising ca fo popl with multimobidity. Thank you fo you commnt. W hav claifid th scop and popl with laning difficultis a no long xcludd. Thank you fo you commnt. W ag that th a a numb of impotant aas fo considation in ca of popl with multimobidity. In this guidlin w plan to addss th assssmnt, pioitisation and managmnt of ca but not consid how spcific intvntions may hav diffnt outcoms in popl with multimobidity.. Thank you fo you commnt. W ag that th a a numb of impotant aas fo considation in 4 of 63

5 Pactitions Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. mobiditis co-xist? A th bnfits multiplid? Would this scop xtnd to commnt on th ffct of baiatic sugy/significant wight loss on how multimobidity should b viwd? It would b impotant not to ovstimat th halth bnfits as undlying isks may not alt at th sam at - g solution of diabts following apid wight loss may not duc th undlying associatd cadiovascula isk at th sam at. (RP) vlop s Rspons Plas spond to ach commnt ca of popl with multimobidity. In this guidlin w plan to addss th assssmnt, pioitisation and managmnt of ca but will not consid how spcific intvntions may hav diffnt outcoms in popl with multimobidity Lundbck UK 1 Gnal Lundbck is an thical sach-basd phamacutical company spcialising in bain disods, such as dpssion and anxity, bipola disod, schizophnia, Alzhim s disas, Pakinson s disas and alcohol dpndnc. Thank you fo this infomation. Lundbck wlcoms this NICE consultation on clinical pactic guidlins on multimobidity fo us in th NHS and qusts that considation is givn to idntification and intvntion at an aly stag to diagnos and tat conditions in od to both allviat symptoms and to manag futh xacbation of oth conditions Lundbck UK 8 Gna l Rfncs 1. Public Halth England, Alcohol tatmnt in England , Octob Availabl onlin at: Thank you fo you commnt. W hav notd you fncs which w will f to, if appopiat, duing guidlin dvlopmnt. 2. Alcohol Concn, Guid to alcohol fo Councillos, Sptmb Availabl onlin at: ohol% %20approve.pdf 3. patmnt of Halth wittn vidnc submittd to Hous of Commons Halth Committ Thid Rpot of Sssion : 5 of 63

6 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. Govnmnt s Alcohol Statgy Ev73 London: Hous of Commons, 2012 vlop s Rspons Plas spond to ach commnt 4. Alcohol Concn, Making alcohol a halth pioity, 2011, p12, availabl h: 5. Rhmn J t al., Intvntions fo alcohol dpndnc in Euop: a missd oppotunity to impov public halth, 2012, p7, availabl h: may.u/ 6. Pay C, Pata J, Rhm J Alcohol consumption and noncommunicabl disass: pidmiology and policy implications Addiction 2011;106: Ronksly PE, Bin SE, Tun BJ t al Association of alcohol consumption with slctd cadiovascula disas outcoms: a systmatic viw and mta-analysis Bitish Mdical Jounal 2011;342:d AHA/ASA Guidlin, 9. Univsity of East London, Alcohol and iabts s.pdf 10. WHO, Us mpowmnt in mntal halth a statmnt by th WHO and Rgional Offic fo Euop, 2010; Bitish Liv Tust, Rducing alcohol ham: covy and infomd choic fo 6 of 63

7 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. thos with alcohol-latd poblms, 2011 vlop s Rspons Plas spond to ach commnt 11. Alcohol Rsach UK, Woking with Old inks 12 NICE, Alcohol-us isods, Th NICE guidlin on iagnosis, Assssmnt and Managmnt of Hamful inking and Alcohol pndnc, Alcohol us disods in ldly popl dfining an ag old poblm in old ag BMJ 2003; 327 doi: (Publishd 18 Sptmb 2003) 14 Lakhani N. Alcohol us amongst community-dwlling ldly: a viw of th litatu. J Adv Nus 1997; 25: Bitish Acupunctu Council 3 gnal Rfncs an-clow E t al. Acupunctu as palliativ thapy fo physical symptoms and quality of lif fo advancd canc patints. Intg Canc Th 2010; 9: Hopton A t al. Acupunctu, counslling o usual ca fo dpssion and comobid pain: sconday analysis of a andomisd contolld tial. BMJ Opn May 2;4(5): Thank you fo ths fncs. As outlind in ou spons to you pvious commnts w a not addssing spcific tatmnts fo popl with multimobidity in this guidlin. Hous of Commons Halth Committ. Managing th ca of popl with long-tm conditions. Scond Rpot of Sssion Volum Jun Li Z t al. Acupunctu fo ssntial hyptnsion: a mta-analysis of andomizd sham-contolld clinical tials. Evid Basd Complmnt Altnat Md. 2014;2014: of 63

8 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. Lim JT t al. Is th a ol fo acupunctu in th symptom managmnt of patints civing palliativ ca fo canc? A pilot study of 20 patints compaing acupunctu with nus-ld suppotiv ca. Acupunct Md 2011; 29: vlop s Rspons Plas spond to ach commnt Lin RT t al. Acupoint-spcific, fquncy-dpndnt, and impovd insulin snsitivity hypoglycmic ffct of lctoacupunctu applid to dug-combind thapy studid by a andomizd contol clinical tial. Evid Basd Complmnt Altnat Md. 2014;2014: Patson C t al. Acupunctu fo 'fqunt attnds' with mdically unxplaind symptoms: a andomisd contolld tial (CACTUS study). B J Gn Pact Jun;61(587): Rugg S t al. Taditional acupunctu fo popl with mdically unxplaind symptoms: a longitudinal qualitativ study of patints xpincs. B J Gn Pact 2011;61: Shaw J t al. Exploing acupunctu outcoms in a collg clinic: Patint pofil and valuation of ovall tatmnt bnfit. Euopan J Ointal Md. 2007;5(4):55-63 Smith BH t al. SIGN Chonic Pain Guidlin vlopmnt Goup. Managing chonic pain in th non-spcialist stting: a nw SIGN guidlin. B J Gn Pact Jul;64(624):462-4 Takahashi H. Effcts of acupunctu on tminal canc patints in th hom ca stting. Md Acupunct 2009; 21: Vicks AJ t al. Acupunctu fo Chonic Pain: Individual Patint ata Mta-analysis. Ach Intn Md 2012;172(19): Rthink Mntal 1 Gnal Rthink Mntal Illnss wlcoms this nw guidlin on multimobiditis. Popl affctd by mntal illnss di, on avag, 20 yas young than th gnal population, oftn du to pvntabl physical halth Thank you fo you commnt. W hav claifid th scop to mak it 8 of 63

9 I Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. 0 Illnss conditions. Compad to th gnal population, this goup has twic th isk of dvloping diabts and th tims th isk of dying of hat disas. W know that dspit xtnsiv vidnc highlighting ths isks, popl affctd by mntal illnss a not civing th ight suppot fo thi physical halth. Th 2012 National Audit of Schizophnia showd that only 29% of popl using community mntal halth svics had civd all th NICE commndd physical halth chcks in th pvious ya. W a thfo ncouagd that this paticula issu is pickd out in th Epidmiology sction of th scop and think th guidanc could play a ky ol in stting out a famwok fo holistic ca. Rthink Mntal Illnss has long bn intstd in this topic and has cntly dvlopd a ang of soucs to suppot btt physical halth ca in mntal halth sttings in lin with th 2014/15 CQUIN (Commissioning fo Quality and Innovation) to impov th physical halth of popl affctd by mntal illnss. Ths soucs a availabl at Monito 4 Gna l 3.2 (a), 4.5.1, 4.5.2, Risk statification and population pofiling. Monito blivs that th way ca is dlivd must suit local cicumstancs and th nds of local populations and will diff dpnding on th nds of paticula patint cohots, such as thos with multi-mobiditis. W would thfo commnd that NICE conducts a thoough mpiical o pidmiological analysis of th multi-mobid population bfo th guidlin scop is finalisd. This could b don using linkd data sts that a oftn dvlopd by local aas, such as Somst and Knt, to statify and pioitis thi patint population, basd on dfind population isk cohots. Such appoachs hlp to mov away fom singl disas and pogamm commissioning appoachs. Th Nuffild tust may also b abl to sha thi linkd datasts. In this way, data is linkd acoss all lvant svics such as social, pimay, community and mntal halth ca to: impov undstanding of multipl mobiditis in th population; vlop s Rspons Plas spond to ach commnt cla that w a xcluding popl who only hav multipl mntal halth poblms and no physical halth poblms. W will f wh appopiat to oth NICE guidanc highlighting th issus you ais. Thank you fo you commnt. W a unabl to conduct mpiical o pidmiological analysis bfo th scop is finalisd. Howv, th guidlin will consid both individual indicatos and multi vaiabl pdiction tools fo idntifying popl who most nd a tailod appoach. W look fowad to th publication of you guidanc. 9 of 63

10 NHS England (Quality Famwok Tam) Od No Sctio Gna l Commnts Plas inst ach nw commnt in a nw ow. consid th impact on halth and ca svics ov tim fo diffnt population cohots; assss population souc consumption; and poactivly idntify thos with th gatst nds who might bst bnfit fom nw ca modls. Monito s wok to hlp local aas dvlop linkd patint-lvl data sts has hlpd thm btt undstand thi local populations souc consumption acoss povids and w will shotly b publishing som guidanc which you may wish to fnc in you final guidlin. Thank you fo th oppotunity to commnt on th abov Clinical Guidlin. I wish to confim that NHS England has no substantiv commnts to mak gading this consultation. vlop s Rspons Plas spond to ach commnt Thank you fo you commnt patmnt of Halth Gna l Thank you fo th oppotunity to commnt on th daft scop fo th abov clinical guidlin. I wish to confim that th patmnt of Halth has no substantiv commnts to mak, gading this consultation. Thank you fo you commnt Public Halth England - Impoving Halth and Livs Laning isabilitis Obsvatoy 4 Gna l Th Confidntial Inquiy found that popl with laning disabilitis a mo likly to hav multipl conditions than thos in th gnal population and spcifically commndd that NICE guidanc should tak multi-mobidity into account. W a concnd to s this goup xcludd fom this NICE guidanc in a vaity of ways. Thank you fo you commnt. Th scop has bn claifid and popl with laning difficultis a now includd. 10 of 63

11 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. vlop s Rspons Plas spond to ach commnt Just th Job 2 Gna l Th Collg of Psychiatists Th consultation should includ all aspcts of multimobidity fo popl with laning disabilitis, as it dos with oth patint goups. 3 gnal Th pofoma stats this just applis to th last fw days of lif but I assum that is an o sinc impoving managmnt of multimobidity should stat much ali and this is implid in th consultation. Thank you fo you commnt. Th scop has bn amndd and popl with laning difficultis a now includd. Thank you fo you commnt. This was an o Collg of Physicians (RCP) 1 Gna l Th RCP is gatful fo th oppotunity to spond to th daft scop. In doing so w would lik to ndos th submission of th Bitish Giatics Socity (BGS) and th Association of Bitish Clinical iabtologists (ABC). W would also lik to mak th following commnts. Thank you fo you commnt Univsity of Bistol 1 Gna l Th cnt Confidntial Inquiy into pmatu daths of popl with laning disabilitis (CIPOL) ( found that 98% of 247 popl whos daths w viwd had on o mo long tm condition in addition to having laning disabilitis and 17% had 4 o mo long tm conditions. Intnational studis suggst that popl with laning disabilitis hav 2.5 tims th numb of halth poblms as oths (Lantman- t al. 2000) and a gat vaity of halthca concns than thos of th sam ag and gnd in th gnal population (Havman t al. 2010). Thank you fo you commnt. W hav claifid th scop and popl with laning difficultis a now includd. Th managmnt of ths halthca conditions is gnally pooly managd and th nds of popl with laning disabilitis a fquntly not mt. This would suggst that paticula attntion must b paid to this population in any NICE Guidlins. Rcommndation 3 of th CIPOL pot was that NICE 11 of 63

12 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. Guidlins should tak into account multimobidity in lation to popl with laning disabilitis (Hslop t al. 2013). vlop s Rspons Plas spond to ach commnt W wlcom that NICE Guidlins on multimobidity will b poducd, but a xtmly concnd about a numb of aspcts of th scop of th daft guidlins and th appant xclusion of som popl with laning disabilitis fom thm. W suggst that such xclusion dos not accod with th quimnts of th Equalitis Act Collg of Gnal Pactitions Collg of Gnal Pactitions NHS Choics - igital 9 Gna l 32 Gna l Gna l Th scop looks boad and sms to cov vything. Th is littl mntion mad of th intaction btwn mdical and social ca but it dos fnc th social ca guidlins fo th ldly and phaps this is covd th. No mntion Is mad of psonal halth budgts and th vidnc to suppot thm in this goup howv this may hav bn omittd fo political asons? (GR) This is a vy difficult guidlin gading spcifics as vything to do with multimobiditis is uniqu to th individual affctd. Th gnal pincipls that a outlin a vy admiabl and I would ag with most of thm but I would suggst ths a commonsnsical and that th guidlin would b of littl us in spcific clinical situations with patints. Unfotunatly I do not think this guidlin will b of much pactical us to Gnal Pactitions howv is a good summay of pincipls involvd in multimobiditis. (M) W wlcom this publication and hav no commnts on its contnt as pat of th consultation Thank you fo you commnt. Cuntly a ight to hav a halth budgt is availabl only to popl who a ligibl fo NHS Continuing halthca which is a small subst of popl with multimobidity. Thank you fo you fdback. Paticipants at th stakhold wokshop suggstd that th inclusion of pincipls w impotant in a guidlin. Th scop includs a numb of aas such as considation of th absolut isks and bnfits of intvntions which will infom discussion btwn th clinician and pson with multimobidity gading whn to stat and to stop mdication. Thank you fo you commnt. You suppot is appciatd. 12 of 63

13 Assssmnt Svic Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. vlop s Rspons Plas spond to ach commnt Monito 10 Gna l 4 Monito 12 Gna l 4.3.1a) 4.4a) Monito 13 Gna l 4.3.1f) Suggstion to includ ca planning fo nd of lif in scop. In tms of ca planning fo popl with multi-mobiditis. You may wish to consid whth this guidlin is an appopiat vhicl fo addssing som of th difficult qustions aound whn ca pofssionals and patints thmslvs may wish to stat planning fo a managd dclin (i.. advanc ca planning fo nd of lif) ath than activly tating on o mo of thi conditions. Futh dtail on pimay and sconday ca quid. W a plasd with th fnc in th guidlin scop to th fact that multi-mobidity is oftn associatd with unncssay o unplannd hospital admissions and that a poposd outcom includs th numb of pimay ca appointmnts. Howv, no mntion is mad in th main body of th guidlin of th ols of pimay and community ca in avoiding hospitalisation, aanging dischags and pvnting admissions. Th xclusion of.g. pvntion, aly intvntion and halth maintnanc dos not fit with th Consultation s focus on tackling avoidabl admissions, fo xampl. Suggstion to mo xplicitly includ th patint pspctiv. W a plasd that th guidlin fncs th impotanc of a tailod appoach to patint ca fo thos with multi-mobiditis and that th is som, albit limitd, cognition of th ol of slf-ca and slf-managmnt. Howv, w consid that th patint pspctiv should b mo xplicitly covd in this guidlin. Ensuing that patints (and thi cas) a fully mpowd in, and includd in all aspcts of, thi own ca is an impotant lmnt of impoving ca coodination. Th National Thank you fo you commnt. Th guidlin addsss ca planning und th sction on continuity of ca and this would includ th aas covd in you fdback. Thank you fo you commnt. Th sction in th scop on managing ca will includ looking at intvntions aimd at avoiding hospitalisation and pvnting admissions. Thank you fo you commnt. W undstand th impotanc of th patint pspctiv and bliv th scop covs this. 13 of 63

14 Od No Sctio Monito 1 Gna l3.1 (a), (a) Monito 3 Gna l4.5.3 Commnts Plas inst ach nw commnt in a nw ow. Voics I statmnts puposfully st out th xpinc of intgatd ca fom th individual s own pspctiv. And thy usfully cov aas such as tansitions and th impotanc of undstanding thi ca plan and any mdicins thy tak with thm, what to xpct and how to kp in contact with pvious svics and pofssionals. Including patints and cas within scop, including th commndations, will hlp nsu that patint xpinc is flctd in th outcom masus and hlping to nsu that,.g. admissions o unncssay admissions and GP visits a ducd. finition. W a plasd to s th fncs mad to th impotanc of coodinatd svics fo patints with multimobiditis. W consid that this patint goup is likly to dictly bnfit fom oganisations and ca pofssionals dliving mo intgatd ca. As statd, this can hlp to addss issus such as unncssay o unplannd hospital admissions, polyphamacy, quiing social ca, duplicat tsting and mdical advic that is not joind up among pofssionals o ca sttings. Evidnc bas. Th Consultation asks fo vidnc on th clinical and cost-ffctivnss of diffnt statgis to impov th ca of popl with multi-mobidity, fo xampl aound psonal and managmnt continuity. Th vidnc fo intgatd ca mo gnally, in tms of impovd patint outcoms and financial savings, is limitd. Howv, it is cla that logically (and basd on som local vidnc and pomising intnational xampls), that patint xpinc should impov svic us outcoms and that ducing gaps and infficincis in ca can off oppotunitis fo savings. You may wish to viw Policy Summay 11, What is th vidnc on th conomic impacts of intgatd ca?, Elllt, Emma Pitchfoth (Wold Halth Oganization), vlop s Rspons Plas spond to ach commnt Thank you fo you commnt. Thank you fo you commnt. W will accss th policy summay you f to. 14 of 63

15 Collg of Gnal Pactitions Univsity of Bistol Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. 3 Titl Unsu what common multimobiditis in titl of documnt mans? (EE) 12 Rfncs Euopan Consotium in Halthca Outcoms and Cost-Bnfit Rsach (2013) Euopan Guidlins fo Cost-Effctivnss Assssmnts of Halth Tchnologis. Laflt_Guidli ns final.pdf vlop s Rspons Plas spond to ach commnt Thank you fo you commnt. W undstand this to f to common pattns of multimobidity. Howv, it is intndd that th appoach of th guidlin would b appopiat fo popl with any pattn of multimobidity as ths will b quit individual. Thank you fo you commnt. W will f to you fncs, if appopiat, duing guidlin dvlopmnt. Havman, M., Hll, T., L, L., Maaskant, M., Shooshtai, S., & Stydom, A. (2010). Majo halth isks in aging psons with intllctual disabilitis: An ovviw of cnt studis. Jounal of Policy and Pactic in Intllctual isabilitis, 7, Hslop, P., Blai, P., Flming P., Hoghton, M., Maiott, A., Russ, L. (2013) Confidntial Inquiy into pmatu daths of popl with laning disabilitis. Univsity of Bistol, Bistol. McCaon, M., Swinbun, J., Buk, E., McGlinchy, E., Caoll, R., McCallion, P. (2013) Pattns of multimobidity in an old population of psons with an intllctual disability: Rsults fom th intllctual disability supplmnt to th Iish longitudinal study on aging (IS-TILA). Rsach in vlopmntal isabilitis 34, Nod, E., Pinto, JL., Richadson, J., Mnzl, Pl., Ubl, P. (1999). "Incopoating socital concns fo fainss in numical 15 of 63

16 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. valuations of halth pogamms". Halth Economics 8,1, doi: /(sici) (199902)8:1<25::ai- HEC398>3.0.CO;2-H. PMI vlop s Rspons Plas spond to ach commnt Offic fo National Statistics (2012) finition of avoidabl motality. Offic fo National Statistics, London. van Schojnstin Lantman-, H. M. J., Mtsmaks, J. F. M., Havman, M. J., & Cbold, H. F. J. M. (2000). Halth poblms in popl with intllctual disability in gnal pactic: A compaativ study. Family Pactic, 17, Collg of Gnal Pactitions NHS England, Thams Vally Aa Tam (a) (a) Again pag 2 th final sntnc nds to b vy cla about tating symptoms ath than tating isk factos. (KG) Consid th following amndmnt: ca of popl with multimobidity is paticulaly lvant to gnalist and multiagncy ca. Thank you fo you commnt. Thank you fo you commnt. Th paagaph has bn ditd Monito (a) Monito (a), 3.2 finition. Howv, w would qustion whth th appoach, which would lagly b th sam fo any complx, high-isk patints, such as old popl, would matially diff in pactic whn caing fo patints with multi-mobiditis o co-mobiditis. Futh dtail on polyphamacy quid. W a plasd to s fncs to polyphamacy (o th concunt us of multipl mdications by on individual), which is incasingly common and divn by simila factos to th nd fo mo intgatd ca, that Thank you fo you commnt. W ag that th appoach would b simila and th diffnt dfinitions a not ncssaily hlpful. W hav thfo movd this distinction. Thank you fo you commnt. Th guidlin dvlopmnt goup will consid you commnts duing guidlin dvlopmnt. This guidlin will also coss f to th 16 of 63

17 Collg of Gnal Pactitions Collg of Gnal Pactitions Od No (a) (a) Sctio (a) Monito (a), 4.1.2a), 5.2 Commnts Plas inst ach nw commnt in a nw ow. is, th aging population and gowing pvalnc of multimobidity. Howv, w consid that th guidlin would bnfit fom futh dtail on th common difficult issus associatd with this. Evidnc (such as by th King s Fund) suggsts that mdicins managmnt plays a lag ol in both nsuing: timly dischag of patints (tak-hom psciptions a oftn lat); and saf and ffctiv dischag (as many admissions a du to patints xpincing advs dug intactions o not taking th mdicin as pscibd du to a lack of undstanding o agmnt). In addition, th ol of phamacists is not always includd in th contxt of intgation and coodination of ca, yt it may b usful to includ hospital and community phamacy in th scop of this guidlin. I don t ally gt th diffnc btwn co- and multi-mobidity. It sms to m that in pimay ca thy will always b multi, bcaus th whol lot has to b dalt with, but in sconday ca.g. a cadiologist will only b daling with th hat on of thm and ignoing th st. Th tm dpnds on th pspctiv of th physician, not th patint! (JS) I think that it must b vy cla th diffnc btwn co mobidity and multimobidity fo xampl diabts, cadiovascula disas and CK wh at th tim of an acut vnt on may b dominant but thy a all so closly linkd that it is difficult to assss which is dominant. (KG) Inconsistncy in scop xclusion of childn young popl. W consid that childn and young popl und 18 yas should b within th scop of th guidlin, paticulaly as th is fnc in th guidlin to th fact that multi-mobidity is found in young popl. A al poblm in this aa is th tansition to adult svics fo childn with complx poblms with multipl conditions who vlop s Rspons Plas spond to ach commnt NICE guidlin on Mdicins optimisation which is cuntly in dvlopmnt. Thank you fo you commnt. Following stakhold consultation w hav movd this distinction as th diffnt dfinitions a not ncssaily hlpful. Thank you fo you commnt. W ag that th appoach would b simila and th diffnt dfinitions a not ncssaily hlpful. W hav thfo movd this distinction. Thank you fo you commnt. W considd w could not adquatly addss th nds of young popl with multimobidity within this guidlin. Th incidnc of multimobidity in childn and young popl is much low than in 17 of 63

18 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. might significantly bnfit fom this guidlin on multi-mobidity, such as thos accssing CAMHS (paticulaly th highly spcialisd Ti 4 svics) o with laning disabilitis. You might thfo consid coss-fncing th NICE guidanc to hlp tackl tansition fom childn s to adult svics which w undstand is cuntly und dvlopmnt. vlop s Rspons Plas spond to ach commnt adults. Making commndations fo popl und 18 yas quis a diffnt GG constitution and viws of diffnt vidnc. NICE is dvloping guidanc on tansitions btwn child and adult ca fo childn using halth o social ca svics Monito (a), 3.1c), 4.1.2b) Collg of Gnal Pactitions Inconsistncy in scop paity of stm fo mntal halth. Monito ags that an impotant goup of popl with multimobiditis is thos with both physical and mntal halth nds. Of paticula impotanc a thos with long-tm physical poblms that may not hav thi mntal halth nds idntifid and ffctivly managd and vic vsa. W thfo commnd that you consid th intndd xclusion fom th scop of this guidlin thos popl with mo than on mntal halth poblm but no physical poblms, not last bcaus it will automatically xclud thos whos physical nds a as yt unidntifid and unmt. Such an omission is unlikly to b in th spiit of th cunt policy div to nsu th paity of stm btwn mntal and physical halth. You may wish to consid NHS England s cntly intoducd policy fo mntal halth staff to povid physical MOTs to mntal halth patints to hlp duc avoidabl daths. In addition, Lthal iscimination, Rthink, Sptmb 2013, is a usful fnc Th dfinition of mutitmobidity and comobidity is confusing. Nd to nsu you a faming th dfinitions of comobidity and multipl mobidity appopiatly. Goldbg (2011) thinks that co-mobidity is a tm which might b btt mployd to f to patints whos physical illnss is accompanid by a Thank you fo you commnt. Th scning of popl fo physical conditions is not within th mit of this guidlin, which is th assssmnt, pioitisation and managmnt of ca. Popl who only hav multipl mntal halth poblms and no physical halth poblms a xcludd bcaus thi ca will b lagly dlivd by psychiatic svics ath than by multipl svics. Thank you fo you commnt. This paagaph has bn ditd and fncs to co-mobidity movd. Following stakhold commnt it sms that using stict 18 of 63

19 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. mntal disod. In th daft documnt, multipl mobidity is statd as physical and mntal halth poblms co-xisting. But multimobidity in th daft scop stats it is also found in young popl, spcially in socially dpivd aas wh th co-xistnc of physical and mntal halth poblms is paticulaly common. Might hlp to giv an xampl of comobidity and multi mobidity? Impotant as unsu as to whth w a thinking of managmnt of complx multipl diffnt conditions with coxisting mntal halth poblms.g. aisd incidnc and pvalnc of dpssion and anxity in popl with diabts; co mobidity in tms of diabts and conditions latd to diabts such as amputations, blindnss, nal disas o multipl conditions coxisting togth- diabts, pilpsy, asthma. Impotant as managmnt may b diffnt and adhnc to guidlins diffnt fo diffnt scnaios. Also may qui diffnt outcom masus. So th vidnc fo a cas manag bing hlpful may b diffnt fo xampl whn somon has multipl diffnt unlatd conditions quiing th input of a numb of spcialists but not so hlpful whn somon has diabts and latd diabtic complications o diabts and anxity fo xampl. Comobidity among this population has contibutd to an incasd isk of mobidity and motality, which placs a significant conomic budn and an incasd dmand fo mdical souc in halth ca systm. Also, managing multipl comobid conditions is a challnging task fo halthca povids and patints, which in tun can intnsify th isk of bing poo clinical outcoms and conomic budn to halthca systm. Fo clinicians, patints having multipl mdical conditions could cat considabl managmnt complxity, focing clinicians to consid and pioitiz a lag aay of commndd ca, possibly placing valuabl tim in th offic visit that could b vlop s Rspons Plas spond to ach commnt dfinitions may not b hlpful as th budn of th disas and its tatmnt, and th possibl appoachs may b th sam. Th guidlin includs a qustion about how to idntify popl who would most bnfit fom a tailod appoach. 19 of 63

20 Collg of Gnal Pactitions Collg of Nusing Collg of Gnal Pactitions Collg of Gnal Pactitions Od No (a) (c) (a) (a) Sctio Commnts Plas inst ach nw commnt in a nw ow. spnt addssing issus which hav a gat impact on patint halth outcoms, thfo, physicians may hav a difficulty to adh to ctain disas spcific tatmnt guidlins, such as diabts ca, whn facing patints with multimobidity. Th us of th tm gnalist w fl this would b btt statd as ld and co-odinatd by pimay ca with spcialist suppot wh ndd R th point about co-mobidity ys it is impotant to dfin comobidity and multi-mobidity and acknowldg thy a spaat but th managmnt pincipls will b th sam. (LR & JR) W fl considation nds to b givn to housbound patint and ca hom patints who a unabl to lav thi sidncs (du to physically failty o cognitiv distss) and thfo unabl to accss ctain typs of halthca. I think that th issus a aound systm spcific spcialists ath than pofssionals taind in holistic ca and acting as gnalists. (KG) Th is actually littl vidnc fom clinical tials fo th tatmnt of popl with multimobidity. Most cadiovascula tials will hav xcludd popl with diabts, CK o ov 75 fo xampl and w may b using vidnc fom th tatmnt of young adults with nomal kidny function. (KG) vlop s Rspons Plas spond to ach commnt Thank you fo you commnt. A gnalist appoach may b takn by oth halthca pofssionals such as spcialists in ca of th Eldly. This paagaph has bn ditd. W hav movd fnc to comobidity as th diffnt dfinitions a not ncssaily hlpful and as you indicat th pincipls may b th sam. Thank you fo you commnt. Th guidlin dos includ th idntification of popl who would bnfit fom a tailod appoach and ths typs of indicatos will b considd. Thank you fo you commnt. W hav ditd this paagaph. Thank you fo you commnt. Th limitations of vidnc will b considd by th Guidlin vlopmnt Goup NHS England, (a) To claify, consid th following amndmnt: lack of infomation to guid dcisions about multipl mdicin us, Thank you fo you commnt. W hav ditd this sntnc. 20 of 63

21 8 Thams Vally Aa Tam Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. including infomation on th ffct of stopping som tatmnts, infomation compaing th bnfits of diffnt mdicin combinations and gimns, and infomation to suppot slf managmnt. vlop s Rspons Plas spond to ach commnt Collg of Gnal Pactitions Collg of Gnal Valuabl oppotunity to addss ol of mntal halth and complx multimobidity o comobidity. In ith cas coxisting common mntal halth poblms such as dpssion and anxity can impact on th choic of mdication, mdication taping, pdiction and avoidanc of unwantd sid-ffcts, follow-up tatmnt and achiving full covy (Jakovljvić 2009, Jakovljvic t al. 2010). In patints with somatic disods, comobid mntal disods may 1. Modify subjctiv actions to somatic symptoms (amplification, diminution and nglct), 2. duc motivation to ca fo somatic illnss (dmoalization), 3. lad to dict maladaptiv physiological ffcts on bodily symptoms, and 4. duc th ability to cop with somatic illnss though limitation of ngy, cognitiv capacity, affct gulation, pcption of sham o social stigma. Impotantly in sv and nduing mntal illnsss such as schizophnia and bipola disod, th is an agumnt that thy should b considd as chonic disass in thi own ight as thy a indpndnt isk factos in thi own ight fo cadiovascula and mtabolic disas making a focus on th managmnt of physical halthca and halth pomotion and ill halth pvntion wok vn mo impotant. Maj 2009, idntifid that in popl with SMI, th w mo and sv advs vnts duing psychophamacothapy, 3. Mo tatmnt noncomplianc and nonadhnc, 4. Low quality of lif and low subjctiv and objctiv wllbing in gnal. (EE) (b) Is it asonabl to xclud popl with mo than 1 mntal halth poblm? This could b impotant if a patint has say dpssion and a dug and alcohol poblm. Th mdications fo both could Thank you fo you commnt. Popl who only hav multipl mntal halth poblms and no physical halth poblms a xcludd bcaus thi ca will lagly b dlivd by psychiatic svics ath than by multipl spaat svics. W cognis that popl who hav sv and nduing mntal illnss should b scnd and assssd (fo xampl, fo cadiovascula disas) but th planning and oganisation of this is outsid th mit of this guidlin. Thank you fo you commnt. W cognis that popl who hav multipl mntal halth poblms 21 of 63

22 Pactitions Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. intf with on anoth, just as in a physical halth poblm. Excluding mo than on mntal halth poblm if th a no physical poblms is iational bcaus ths patints also hav poo outcoms in just th sam way as th outcom fom physical poblms. I gt th fling th guidlin is mo biasd towads physical than mntal halth poblms, whn it should mbac both. (JS) vlop s Rspons Plas spond to ach commnt may hav poo outcoms. Howv, popl who only hav multipl mntal halth poblms and no physical halth poblms a xcludd bcaus thi ca will lagly b dlivd by psychiatic svics ath than by multipl agncis Collg of Gnal Pactitions Th Collg of Psychiatists Rthink Mntal Illnss Is th plan to includ popl with laning disabilitis o dmntia? Bcaus in sction a and b thy a xcludd. (KG) (b) (b) Should includ two mntal halth diagnoss gadlss of a physical diagnosis if on of th diagnoss was ith somatofom disod o factitious disod - sinc ths two mntal disods usually psnt to physical halth svics in th mann of a comobidity with any oth mntal halth poblms such as dpssion o psonality disod W a intstd in th ational fo why popl with mo than on mntal halth poblm, but no physical halth poblms, a xcludd fom th scop. Evn within mntal halth svics, co-occuing mntal halth poblms a oftn not wll managd. Local fal citia and commissioning aangmnts man that popl may not b abl to accss multipl mntal halth svics at th sam tim fo diffnt mntal halth conditions. Fom a paity of stm pspctiv, w fl that this should b includd if co-occuing physical halth conditions a covd by th scop. Thank you fo you commnt. Th scop has bn amndd and popl with laning difficultis and popl with dmntia a now includd. Thank you fo you commnt. W cognis that popl with th mntal halth poblm you dscib can psnt to physical halth svics. Th cognition of ths psntations is impotant but would qui a diffnt GG and a diffnt st of vidnc viws than could b containd in this guidlin. Thank you fo you commnt. W hav claifid th scop and a including popl with mo than on mntal halth poblm if thy hav co-occuing physical poblms. 22 of 63

23 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. vlop s Rspons Plas spond to ach commnt Rthink W would ask fo claification aound whth co-occuing mntal Thank you fo you commnt. Mntal halth conditions and substanc misus issus, o dual diagnosis will NICE will b dvloping spaat Illnss b covd by this guidlin. Again, this is an aa wh popl oftn guidanc on halth and social ca fall btwn th gaps in svics, as mntal halth svics will not wok nds of popl with sv mntal with popl until substanc us has bn addssd and dug and halth poblms who misus alcohol svics will not wok with somon until thi mntal halth is bing tatd. This guidlin could b a al oppotunity to bidg this substancs. This guidlin dos gap and nsuing popl can accss th ight suppot. not intnd to includ popl with dual diagnosis and no physical disas Should you also includ an aspct of non-complianc, such as Thank you fo you commnt Collg of (a) difficult to ngag, psistnt failu to attnd, difficult bhaviou (a) fs to xampls of popl Gnal as this is vy impotant in multi-mobidity managmnt? (JS) who may qui a tailod Pactitions appoach. Th guidlin dvlopmnt goup will dfin this qustion in mo dtail duing dvlopmnt. Alzhim s Alzhim s Socity has concns that th scop is limitd to all Thank you fo you commnt. Th Socity NHS sttings. Halth and social ca svics a inxticabl. guidlin will not b coving Many popl, including popl with dmntia, us both halth aspcts of ca fo popl with and social ca svics and this is ncssay fo managing thi individual conditions and in condition. Fo xampl, a pson with dmntia living alon in paticula aspcts of ca such as thi own hom may nd suppot fom a paid ca to mind mdicins adhnc and mdicin thm to tak mdication. Alzhim s Socity commnds that optimisation which a covd by social ca sttings a includd in th guidanc. oth NICE guidanc. Social ca nds qui assssmnt by social svics and w will includ fal to ths wh appopiat. Th intgation of halth and social ca nds fo popl with dmntia is alady in includd in NICE guidlin 42. Monito Futh claity on sttings quid. W ag that all sttings Thank you fo you commnt. Th guidlin dos includ all aas 23 of 63

24 I Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. 6 (a) in which NHS ca is dlivd should b within th scop of this guidlin. Howv, w think it would b hlpful to claify whth this dfinition covs th boad dfinition of NHS- fundd ca, which might potntially ntail ca dlivd in sttings oth than pimay, community, sconday, spcialist and ambulanc, such as in a patint s hom, in social ca sttings o by indpndnt o voluntay povids. Ensuing that a full ang of povids and sttings is includd is ssntial to nsu that ca fo multimobid patints is coodinatd acoss thi whol ca pathway. Collg of Gnal Pactitions W would add th tm holistic to tailod R th citia listd in bullt points w would add Living alon Popl with L and with dmntia R masus, w would add quality of lif in addition to lif xpctancy as this can b masud fomally too Continuity of ca should social ca b addd to th tm halth ca Co odination of ca should Multi-disciplinay mtings b includd? (LR & JR) vlop s Rspons Plas spond to ach commnt wh NHS ca is dlivd. Thank you fo you commnt. Th tm tailod was usd to dscib popl who may qui additional suppot without dfining what this may b (as this is th pupos of th guidlin). W hav addd budn of disas to this point ath than quality of lif as w considd it unlikly that w would wish to commnd that pactitions mak a dcision about tatmnt using quality of lif tools Ths a xampls of popl who may bnfit fom a tailod appoach a psntd and th guidlin dvlopmnt goup will dfin this topic in dtail duing guidlin dvlopmnt. Th idntification of social ca nds will b includd in this guidlin but how this ca is povidd is outsid of th mit. 24 of 63

25 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. vlop s Rspons Plas spond to ach commnt W hav addd modls of multipofssional ca NHS England, Thams Vally Aa Tam (f) lngth and fquncy of consultations. How will lngth of consultations b masud? Thank you fo you commnt. W hav ditd this to f to th fomat of consultations East & South East England NHS Spcialist Phamacy Svics East & South East England NHS Spcialist Phamacy Svics Collg of Gnal Pactitions Alzhim s Socity ( f) (a) a nd Bullt point- w suggst a namd community basd-halth ca pofssional appopiat to th patints nd ath than a namd GP. A combination of indicatos would pobably bst flct th nd fo a tailod appoach ath than a singl indicato in isolation All popl ov 90 hav a limitd lif xpctancy and so would thy all nd a tailod appoach? How do you dfin limitd lif xpctancy? W all hav a limitd lif xpctancy. (KG) Alzhim s Socity wlcoms that continuity of ca is a ky issu with gads to managing ca. Howv, w bliv that Thank you fo you commnt. W hav ditd this and now f to a halthca pofssional. Thank you fo you commnt. W hav ditd this sction and now f to individual indicatos and multi-vaiabl pdiction tools Thank you fo you commnt. W hav dltd this. Exampls of who may bnfit fom a tailod appoach a psntd and th guidlin dvlopmnt goup will dfin this topic in dtail duing guidlin dvlopmnt. Thank you fo you commnt. Th guidlin is a clinical guidlin 25 of 63

26 Od No Sctio Monito (f) Commnts Plas inst ach nw commnt in a nw ow. th guidanc must b xtndd to includ social ca sttings to nsu continuity of ca btwn halth and social ca sttings. Many popl with dmntia pot that thy do not civ any appopiat suppot following a diagnosis. It is fo this ason that th Socity calls fo an intgatd systm of halth and social ca and commnds that NICE includs social ca in this guidanc. Continuity of ca and multi-disciplinay tam woking. W ag with th inclusion of appoachs such as psonal continuity (such as lad coodinato o ca navigato), managmnt continuity though ca planning and multidisciplinay tam woking. Ths a oftn ky (and connctd) lmnts of an intgatd ca appoach fo old popl o thos with multipl o complx conditions. Ca coodination is a tagtd, community-basd and poactiv appoach to ca that involvs cas-finding, assssmnt and ca planning. It can b ld by clinical staff such as nuss o GPs, o non-clinicians in a namd ca navigato o coodinato ol. Such individuals a oftn suppotd by multi-pofssional tams (including gnalists woking alongsid spcialists fom halth and social ca), that a oftn basd in pimay o community ca sttings. Ths tams will b involvd in ca planning and co-odinating ca fo individuals that hav bn poactivly slctd and co-poducing psonalisd ca plans that match nds with svic povision. As such, th will b: joint discussion of cass; joint dcision making and multi-disciplinay assssmnts; a singl point of accss fo assssmnt and th joint ca plan; and assignd accountability of an individual o vlop s Rspons Plas spond to ach commnt which will includ th idntification of social ca nds and appopiat fal fo ths. Th guidlin will not b making comphnsiv commndations fo th ca of popl with dmntia as NICE alady hav a guidlin fo popl with dmntia which includs commndations on intgatd halth and social ca fo popl with dmntia. Thank you fo you commnt and infomation. 26 of 63

27 Od No Sctio Commnts Plas inst ach nw commnt in a nw ow. tam to th patints bing cas-managd. Exampls includ th Vitual Wad modl of cas managmnt dvlopd in th UK (.g. Coydon) wh th concpt of th hospital wad, with its multi-disciplinay tam, wad clk and gula wad ounds, is plicatd in th community. Patints at highst isk a idntifid, assssd and, wh appopiat, admittd to th wad and much of th ca and ca planning taks plac in th patint s hom. In PACE (USA), cas managmnt of old popl is oganisd fom dayca cnts though multi-disciplinay tams of nuss, physicians, thapists, social woks and nutitionists and has bn shown to duc bd days, admissions and lngths of stays. vlop s Rspons Plas spond to ach commnt Collg of Gnal Pactitions (c) Pfiz Ltd (a) Monito (f) I find this quit xciting!!! (KG) Idntifying popl taking a spcifid numb of dugs as a mans to infom a tailod appoach is not ncssaily staight fowad. Th will b patints who hav a lativly low numb of mdicins, phaps 3 o 4, but who still hav multipl-mobidity and do nd a tailod appoach. Impotantly this nds to b cognisd in th guidlin, as not all ths patints will b on high numbs of mdicins, but will still nd suppot. Impotanc of infomation-shaing. Monito ags that th continuity of infomation,.g. acoss sttings and within.g. multidisciplinay tams, is ssntial. Ensuing that th ight infomation is collctd and ffctivly dissminatd to th ight Thank you fo you commnt. Thank you fo you commnt. W hav changd this. Exampls of who may bnfit fom a tailod appoach a psntd and th guidlin dvlopmnt goup will dfin this topic in dtail duing guidlin dvlopmnt. Ou psumption is that ach individual indicato will hav som advantags and disadvantags and ths will b xplod. Thank you fo you commnt. W hav notd you fncs fo us duing guidlin dvlopmnt. 27 of 63