title: Multimorbidity, service organization and clinical decision making in primary care: a qualitative study.
abstract: BACKGROUND
  Primary care professionals often manage patients with multiple long-term health conditions, but managing multimorbidity is challenging given time and resource constraints and interactions between conditions.
  
  
  OBJECTIVE
  To explore GP and nurse perceptions of multimorbidity and the influence on service organization and clinical decision making.
  
  
  METHODS
  A qualitative interview study with primary care professionals in practices in Greater Manchester, U.K. Interviews were conducted with 15 GPs and 10 practice nurses.
  
  
  RESULTS
  Primary care professionals identified tensions between delivering care to meet quality targets and fulfilling the patient's agenda, tensions which are exacerbated in multimorbidity. They were aware of the inconvenience suffered by patients through attendance at multiple clinic appointments when care was structured around individual conditions. They reported difficulties managing patients with multimorbidity in limited consultation time, which led to adoption of an 'additive-sequential' decision-making model which dealt with problems in priority order until consultation resources were exhausted, when further management was deferred. Other challenges included the need for patients to co-ordinate their care, the difficulties of self-management support in multimorbidity and problems of making sense of the relationships between physical and mental health. Doctor and nurse accounts included limited consideration of multimorbidity in terms of the interactions between conditions or synergies between management of different conditions.
  
  
  CONCLUSIONS
  Primary care professionals identify a number of challenges in care for multimorbidity and adopt a particular model of decision making to deliver care for multiple individual conditions. However, they did not describe specific decision making around managing multimorbidity per se.
authors: National Institute for Health Research School for Primary Care Research, Manchester Academic Health Science Centre, Health Sciences Research Group, University of Manchester, Oxford Road, Manchester M13 9PL, UK. peter.bower@manchester.ac.uk
authors: Peter
authors: P
authors: Bower
authors: Wendy
authors: W
authors: Macdonald
authors: Elaine
authors: E
authors: Harkness
authors: Linda
authors: L
authors: Gask
authors: Tony
authors: T
authors: Kendrick
authors: Jose M
authors: JM
authors: Valderas
authors: Chris
authors: C
authors: Dickens
authors: Tom
authors: T
authors: Blakeman
authors: Bonnie
authors: B
authors: Sibbald