Collaborative Care and Support Planning: is it relevant to care for older people?

houseofcareDavid Paynton is RCGP National Clinical Commissioning Lead and can be contacted on

A revolution is starting to sweep through clinical practice. Clinicians, exhausted as they are in dealing with a seemingly endless tide of demand, are testing out new ways of working: trying to move upstream, developing proactive care plans with the person with long term conditions and their carer and changing the conversation from “how can I help” to “what is important to you”.

As we see an increase in multi-morbidity, exemplified by frailty as a constellation of symptoms building into a diagnosis in its own right, we have to move away from the NHS obsession with single disease specific solution. Collaborative Care and Support Planning (CC&SP) is the new paradigm, being at the centre of the metaphorical House of Care (pictured above).

So what is different? Let me take you back to the first days of medical school when the tradition medical consultation model was drilled into our DNA:

History → Examination → Investigation → Diagnosis → Treatment → Review

This approach is highly reactive to what is presenting on the day; there is now a new delivery model  of proactive care planning, expanded in the guidance document Stepping Forward.

Context → Preparation → Discussion → Record → Make it happen → Review

This new delivery model, endorsed by National Voices, is gradually being introduced by Clinical Commissioning Groups. At the same time the Royal College of General Practitioners, supported by NHS England, has established a clinical network of champions (one from the BGS) who are implementing this approach into everyday clinical practice.

At the same time we will see this slowly introduced into the curriculum for health professionals.

So do we ignore the medical model of care?

Absolutely not. There are times when our clinical skill are critical when we do have to focus on the urine infection, blood pressure, glucose levels or renal function.

Of course patient-centred care requires us to take these factors into account and sometimes, when necessary take on the “paternalistic” medical model of care. Collaborative Care & Support Planning is simply another set of tools in our toolbox.

Neither is right or wrong – it depends on the situation, the person and the condition/s but in facing unfathomable medical, social and psychological complexity collaborative care can be liberating for the clinician as well as the person.

Does this technique work in the context of frailty?

Currently most of our efforts on frailty are focused on those at highest risk. Intermediate care with services such as community matrons, Rapid Response and community geriatrics have proved their worth for those with greatest need, but if we are honest the care plans for these people are more orientated towards the medical crisis plan.

Perhaps we need to think about those people who are starting to creep up the frailty index before they get to that crisis stage.

Working with social services, primary care, the voluntary sector and community staff, systematically proactively working through the population finding out “what is important to you” is at the heart of this new way of working.

The model works in the context of every long term condition be it frailty, end of life care, diabetes, mental health, learning disability.

The only thing that is different is its application.

2 thoughts on “Collaborative Care and Support Planning: is it relevant to care for older people?

  1. I’m a GP and Year of Care trainer – we have been using this appoach for our LTC multi morbidity clinics over the last year and would never go back to the “old” way. We share certain results with patients prior to their annual review, along with some agenda setting prompts. Not all older people engage – but not all younger people engage either. I’m delighted how many older people bring their paperwork to their appointment covered with notes and questions and ideas. Patients who, for years have said “Whatever you think is best Dr Haines” are now bringing their own ideas and opinions to the conversation. They also often share result with their relatives before they come and it means the whole family can feel more involved. These consultations feel different. I listen more and I learn more, I talk a lot less! We set realistic goals including what support we can offer for self management or practical difficulties. It just feels right. Formal patient feedback data awaited, informal is either positive or neutral, we’ve not had any negative feedback.

  2. This is great stuff. To be fair we were taught this along with medical model at medical school in 1985. The idea is not new it is just that it is really difficult to get different groups together and then keep them together. Politics interferes.

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