Magdalena Skrybant and Celia Taylor stepped into the breach on the second day of our Scientific Advisory Group after one of our presenters was taken ill.

1. Mobilising tacit knowledge to
improve care for older patients
with multi-morbidity
Richard Lilford and Gill Combes
Theme 4
12/06/2015

2. Background
65% of 65-84 year olds and 81.5% of 85+ year olds have multiple long-
term conditions.(1)
Multi-morbid patients have higher mortality than expected from
summing the effects of individual diseases. (2)
Good quality care for multi-morbid patients requires coordinated
patient-centred care.

3. Background
Care is often sub-optimal:
- Patients report: repeated assessments and clinical tests; fragmented
care; conflicting advice; polypharmacy; and difficulties navigating
pathways.
- Many patients require multiple individuals to contribute to their care:
hospital specialists, GPs, nurse practitioners, pharmacists, social
workers and voluntary service workers.
- Professionals often work in silos or experience organisational barriers to
multidisciplinary team working.

4. Background
Limited evidence base for treating multi-morbid patients (3)
Optimal treatment for patients with multiple conditions resists
codification in guidelines.
Requires professionals to identify, elicit, integrate and communicate
many types of knowledge – concept of the ‘bricoleur’. (4)
These types of knowledge can be defined as tacit knowledge (5) or
sticky (6) knowledge.
Tacit knowledge can be surfaced and improved by structured group
education which mirrors the delivery of care.

5. Possible curriculum
CoolaCollaboration
across service
and professional
boundaries
Leadership and
followership
skills
Communication
with patients
and carers
Knowing what each
service does and the
constraints they face
Knowing when and
how to bring in
services
Communicating with
a range of other
professionals
Negotiating on
behalf of patients
Recognising the
role of specialists
in general care
Being able to
challenge and alter
specialist
prescriptions
Specialists being
willing to accept
decisions made by
generalists in
patients’ interests
Eliciting patient
preferences
Having an
adaptable
communication
style
Communicating in
ways which
enhance patient
empowerment
Prioritising when
treatments are
conflicting or over-
burdensome
Recognising crucial
treatments for
different
combinations of
conditions
Integrating patient
preferences with
clinical judgement
Clinical skills

7. Developing an intervention
Intervention could be a combination of:
1) Education
- team-based learning (hospital specialists, GPs, nurse specialists,
pharmacists, social workers)
- interactive, using scenarios/role play/simulation based on real patient
case studies
- 3-4 half-day sessions.
2) Team and organisational development
- on-going support for implementing changes to care
- facilitated team meetings every 4-6 weeks for 6 months
- could include peer observation and feedback.

8. Evaluation
Programme Development Grant
1. Intervention development
- curriculum development
- case studies and scenarios
- team and organisational element.
2. Pre-implementation evaluation
- feasibility of implementation.

9. Evaluation
Programme Grant
1. Development of outcome measures
- patient experience of care
- simulated quality of care
2. Pre-implementation piloting
3. Evaluation with teams from 6-8 GP practices
- 1 year intervention
- 12/18 months evaluation

10. Discussion questions
1. What theories are relevant to the acquisition of tacit knowledge?
2. Is the intervention powerful enough to impact on practice?
3. Is the intervention likely to be able to be implemented, given the
constraints on the NHS?
4. Are there alternatives to the team and organisational development
part of the intervention?
5. What observations might we use to test out if we are on the right
track (in the Programme Development Grant phase)?
6. What might be suitable designs for the final study?
7. What sources of evidence should we seek to collect for which end-
points?

11. References
(1) Barnett K., Mercer S., Norbury M. et al. Epidemiology of multimorbidity and implications for health care, research,
and medical education: a cross-sectional study. The Lancet. 2012; 380 (9836), 7–13 July: 37–43.
(2) Shiner A, Steel N, Howe A. Multimorbidity: what’s the problem? Quality in Primary Care. 2014; 22 (3):115-9.
(3) Rushton CA, Green J, Jaarsma T, Walsh P, Strömberg A, Kadam UT. The challenge of multimorbidity in nurse
education: An international perspective. Nurse education today. 2015;35(1):288-92.
(4) Lévi-Strauss C. The Savage Mind. Chicago, IL: University of Chicago Press; 1966.
(5) Polyani M. The tacit dimension garden city. NY: Doubleday and co., 1966.
(6) Boisot