Increasing Complexity

Evidence based guidelines (mostly developed for people with single diseases) are inappropriate for those people with multiple conditions, resulting in potential overtreatment and over-complex regimes of assessment and surveillance. Problems of harm due to over-treatment and from polypharmacy are likely to increase, exacerbated by the lack of oversight of individual patients in community settings. Clinical judgment becomes more important, not less, as evidence based guidelines become less applicable because of the increasing complexity of patients' illnesses. There is an increased need to listen and determine patients' priorities at the same time as new forms of organisation potentially make this more difficult.

The Challenges and Risks of Care Coordination

The coordination of the care of individual patients, at least those who are more seriously ill, is currently managed through a loose network of hospital doctors, general practitioners and nurses with precise arrangements varying across countries. Care will need to be coordinated and managed much more actively when more is delivered in the community. This will require different models of oversight and a very different organisation of care.

The provision of care to populations of people demands an integration of hospital care, primary care and home care in organisational structures which are already emerging in various forms in England (Dalton 2014). In the United Kingdom general practitioners will struggle to coordinate the increasingly complex care provided. It will be necessary to coordinate high technology resources and services in community clinics to fully supervise patients' health trajectories. Expanded teams and community based care will mean that non-physician providers take on larger responsibilities for patient care.

Patients' pathways are becoming more complex every day. A patient with a chronic condition often has a succession of carers, each for a short period of time, and with a dedicated role. Outside the hospital, and sometimes inside, there may be no overall coordination of care, except through the efforts of the patient and family themselves. Errors resulting from poor coordination between carers and patients are already common (Masotti et al. 2009) and could well increase dramatically. Information technology, team interventions and patient focused solutions can all play a part in the resolution of this issue but the challenge is immense and the solutions difficult to implement.

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