Category Archives: David Paynton, National Clinical Lead for the RCGP Centre for Commisioning

Collaborative Care and Support Planning – The clinical perspective

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”.

Equally as we see an increase in multi-morbidity including the social and mental health problems, we are slowly moving away from the NHS obsession with single disease specific pathways.

Collaborative Care and Support Planning (CC&SP) is the new paradigm being at the centre of the metaphoric House of Care (figure one)

Figure 1Figure one

So what is different?

In the first days of medical school the tradition, paternalistic medical consultation model (figure two) was drilled into our DNA. Some still even remember being examined on it.

Figure 2Figure two

This reactive medical model still works in responding to acute illness. The NHS is still very good at responding to “car crashes” but we need a very different way of responding supporting people living their lives with long term conditions as outlined in figure three as the delivery model for Care and Support Planning

Figure 3Figure three  

This new proactive social delivery model developed by TLAP and endorsed by National Voices is gradually being introduced by Clinical Commissioning Groups while at the same time the Royal College of General Practitioners, is working to mainstream this model into every day clinical practice.

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, asthma, blood pressure, glucose levels or renal function.

CC&SP is another set of tools in our toolbox. Deciding which end of the spectrum, or a synthesis between the two, requires a professional judgement working with the person and depending on the circumstances.

Figure 4

Neither is right or wrong – but in facing unfathomable medical, social and psychological complexity CC&SP can be liberating for the clinician as well as the person.

How does this work in practice

Currently most of our efforts 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 at lower risk 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, stroke care diabetes, mental health, learning disability etc. although application may be different.

Up and down the country clinicians are starting to work differently, sometimes trying on their own, but more often within a supportive clinical commissioning group so find out what is happening in your area.

RCGP National Clinical Commissioning Lead and can be contacted on david.paynton@nhs.net

For information about the Clinical Champions network please contact Alison Marsh on Alison.Marsh@rcgp.org.uk

Personalised Care and Support Planning in Practice

Dr David Paynton is the National Clinical Lead for the RCGP Centre for Commissioning. David is a practising GP from Southampton.

Within my practice we have been working to implement personalised care and support planning using the ‘House of Care‘. Over the past year we have been attempting to identify the top 10% of people who may benefit from this approach.

One of the mechanisms for doing this, has been to look at those people who attend GP appointments more than ten times each year. We find that these patients may or may not consume secondary care, but they do attend the surgery frequently. Each of those ten minute slots accumulates to quite a considerable amount of time in total but it is not used very productively in many of these cases.

The short consultation works when you are reacting to what a patient is presenting and dealing with it via prescription or referral, but it is not so suitable for more complex cases. When people are attending frequently with a long term condition, we often find that there is a hidden underlying element.

Identifying that hidden element is almost impossible during such a brief, reactive conversation.
But identifying people who you think would benefit from a more holistic approach, and providing them with information prior to a couple of lengthier consultations at the beginning, paves the way for a very different conversation and, ultimately, quite a different relationship. Enabling access to information is empowering for the individual and it allows for a more informed conversation. That information also helps to level out what can sometimes be perceived as a power imbalance between the patient and the healthcare professional. Health literacy is such a vital part of this approach.

In these cases, non-statutory agencies have a lot to offer. We really need to think more broadly about our approach and utilise what is available in our communities to full effect. We have trialled having volunteers working alongside us as ‘care navigators’ which can be very beneficial.

This model is fundamentally about a shift from reactive to proactive care planning, where we can support people to become more fully in command of their condition. The Personalised Care and Support Planning Handbook helps outline practical guidance for doing this, but we also need to be thinking about training all parts of the system to understand this approach more fully. We should be encouraging this through our commissioning and changing our systems in order to support the requirements of this approach. It is whole system change which will take time but the impact of doing so could be hugely valuable.