Better management of multimorbidity: a critical look at the ‘Ariadne principles’


The principles may cause conflicting responses in some readers. One likely response
is that they simply represent what would be expected of any ‘good GP’?, harking back
to well-known principles of ‘patient centred’ care which have been outlined before
9]-11]. Although there are important modifications to take account of multimorbidity, the
essence may well be familiar.

The opposite reaction may be that the principles are face valid, but that achieving
these principles with patients in the reality of busy clinics, with limited resources,
and with patients already struggling under multiple pressures, represents a standard
which is unlikely to be achieved routinely in practice.

The Quality and Outcomes Framework (QOF) is a popular whipping boy as a potential
cause of the single-condition, guideline-focussed care which is seen as so problematic
in the context of multimorbidity. Martin Roland is fond of challenging critics to
remember the major gaps in quality that existed before QOF and other initiatives that
improved the care of single long-term conditions. Other readers may be reminded of
an earlier study of patient-centred training, which saw more satisfied patients, but
also reductions in clinical quality measures 12]. Would the introduction of the Ariadne principles in the context of the QOF lead
to similar tensions?

If the Ariadne principles can be married to effective clinical care, it is worth highlighting
three additional challenges.

A core part of Ariadne is an improved assessment, leading to a fuller discussion about
patient goals, and a care plan to assist in achieving those goals. Although perfectly
reasonable in principle and in line with thinking in behaviour change, the authors
mention a wide range of factors that need to be included in this assessment, including
social circumstances, financial constraints, living conditions and social support,
health literacy, functional autonomy and coping strategies. All very sensible, but
how are these to be assessed in a way that is reliable and useful, and how can those
factors be used to deliver better care? The experience of depression assessments in
the UK found significant professional resistance to standardised measurement 13]. Of course, it is argued that GPs are in an excellent position to know their patients,
and that a return to professional judgement and clinical decision-making is needed:
Greenhalgh et al. talk of ‘rapid, intuitive reasoning informed by imagination, common sense, and judiciously
selected research evidence and other rules
’ 8]. However, GP assessments of important facets of their patients are not always accurate
14],15]. How can we ensure equity and consistency in how these complicated factors are assessed
and somehow ‘taken into account’ 16] in clinical decision-making?

In support of Ariadne, there is a fair amount of agreement on the broad nature of
clinical practice best suited to managing multimorbidity. The bigger challenge may
be around implementation. Many primary care interventions aimed at changing practitioner
behaviour have fallen foul of the adage that feasible changes are not effective, and
effective changes are not feasible. Financial incentives may be poorly suited to facilitating
these principles, as they are a blunt tool and unlikely to lead to high quality implementation
of complex behaviours – the experience of the depression incentives being a case in
point 17]. There is also an important issue around patient preparation. Thinking about priorities
among treatments and outcomes, setting SMART goals, becoming ‘activated’ – all these
may be as unfamiliar to some patients as they are to practitioners.

Finally, the evidence base concerning multimorbidity is relatively limited 18],19], and it may be premature to suggest fundamental changes to care on the basis of limited
data. There is a significant qualitative literature on the problems faced by patients
and practitioners in managing multimorbidity 3],20],21], but the quantitative literature is much thinner. Our own study comparing the experience
of chronic illness care in patients with single and multiple conditions found few
differences 22]. Although the experiences reported in qualitative research are undoubtedly salient
and valid, those experiences may not be universal. Intervening to reduce treatment
burden on patients will only lead to major improvements if burden is a key driver
of poor outcomes, and we are only beginning to understand the impacts and how they
might be reduced.

The potential of principles such as Ariadne is theoretically profound, but caution
is required before assuming that these benefits will be achieved. Large scale, pragmatic
evaluations of the delivery and impact of these new models of care are required and,
fortunately, such evaluations are now underway 23].