Why choose collaborative care and support planning?

Nigel Mathers

You might be wondering why, at a time when there are so many priorities that you are being asked to give attention to, we think implementing collaborative care and support planning will help you. How can it be anything other than yet more hard work? How can it possibly make your life and the lives of your patients easier?

Rather than give you the facts and figures, or the reasoned academic arguments, we would like to instead share with you the experience of Professor Nigel Mathers. This was not written in his capacity as Honorary Secretary of the RCGP, but rather from his perspective as a GP facing the same challenges as you: time poor and stretched, trying to balance his work as a GP with his life outside of practice.

Then suddenly...

It was a late Monday afternoon in November and I was coming to the end of my third surgery of the day. To say that I was tired would be an understatement. I had a quick look at the number of patients who were still waiting to see me - five more! And it was already ten to six. Monday night was my Chinese class night and I knew if there was any chance of me arriving on time this week I would have to leave surgery by 18:45. So, five patients at 12 minutes a time took me up to 18:45 and if I managed to keep my energy levels up and strictly limit the length of each consultation, I should just make it...

I went to fetch Mrs Smith (not her real name) from the waiting room and, greeting her like an old friend, I walked back with her along the corridor into my consulting room. "Please sit down", I said, "How are you today?"

"Oh I'm fine", she replied - I did wonder why she had to see me if she was fine - I'm under a lot of pressure to leave in what is now 57 minutes time. I gave a non-committal smile, took a deep breath and asked her pleasantly, "So what can I do for you tonight?"

"Well, it's about my diabetes", she began, "the nurse said I had to come and see you because 'it wasn't good'."

"I'm not sure what you mean by 'wasn't good'" I said. "Well, I'm not sure either", said Mrs Smith, "I mean you're the doctor and you're supposed to know about these things.".

Then suddenly, I heard the clock ticking very loudly inside my head. They say you need broad shoulders and an everlasting supply of the milk of kindness in general practice. Well, at five to six on this Monday evening, I thought my milk of kindness had just curdled.

I smiled (professionally), "Do you mean that your diabetes is not under control?" I asked her. "I see from my computer that you are taking tablets for your diabetes. Have you been taking these regularly?"

"Oh no," she said, "I only take them when I feel I need one."

"Oh." said I. "So when did you last take them?"

"Oh doctor, you are a one," she said, "putting me on the spot like that". She smiled broadly, "I'm really sorry doctor, but I can't remember."

It was now 18:01 and half of her allotted consultation time had passed. I took another deep breath, smiled professionally (again!) and counted to ten. There had to be a better way than this of supporting people with diabetes. She was expecting far too much time and was showing a very passive way of dealing with the doctors and nurses as well as with her illness. Fragments of a long-forgotten lecture came to mind: "Patients have illness and doctors have diagnoses = again, the trick is integrating your patient's illness with your diagnosis."

Mrs Smith had learnt from us to be a passive recipient of healthcare and there has to be a better way. It was not her fault but she needed some time here tonight to start the long process of teaching her about illness and how to manage it, supporting her in her own efforts to deal with it and finding the best way for us both to manage her diabetes.

I could, of course, just tell her what she needed to do if her diabetes was to be brought under control, but that would just perpetuate the problem and reinforce her behaviour of learned helplessness. I rolled my metaphorical sleeves up, gave up all hope of getting to my Chinese class on time, took a deep breath and asked, "Tell me, how is the diabetes affecting your life and how do you think I can best help you tonight? We might not be able to do everything tonight together but we can make a start on sorting out your diabetes. What do you think?"

Can we work smarter

The vision...

It was late on a Monday afternoon and I was on my third surgery that day, running late with five more patients to see and a Chinese class booked for 19:00. If I was going to get to my class then I needed to work quickly. My next patient was Mrs Smith, whom I've known for a long time and with whom I've been working to try and help her manage her own diabetes. You see, diabetes is one of those many long-term conditions that we all get as we get older and one which, above all, we have to manage ourselves. If we're lucky, we might see our doctor or nurse for a maximum of two hours per year and that leaves 8,760 hours to look after our own diabetes. Mrs Smith and I had been working together on this for the past year.

I started sending Mrs Smith the results of her blood tests and invited her to come and see the practice nurse to discuss these results and whether she needed to do anything about them.

She had done this prior to her consultation with me this evening.

"Hello Mrs Smith, how're you doing?" I said as I collected her from the waiting room and walked back down the corridor to my consulting room.

"I'm doing fine, Doctor", she said, and out of her handbag pulled out a little notebook which she calls her 'diabetes book'. "When I saw the nurse last week she said that my control wasn't very good and that my blood test show this. I explained to her that I was having a hard time at the moment because my daughter's marriage had just broken up and it was very difficult to remember to take my tablets as well as being careful about what I ate. She said that my diabetes control had been very good up till then so it was probably just a temporary thing. I thought I'd come and talk to you about it Doctor, although I know we weren't due to meet again for another couple of months."

"Well, let's have a look at your results," I said and turned the computer screen to where she could see it. "Look" I said, "the nurse is right, your sugar has been a bit off recently. How many tablets have you missed?"

"Oh, not many" said Mrs Smith, "I think it was one on Saturday and a couple last week. Saturday was bad because of the children, you see. My daughter's got two small children and they were very upset about their daddy, but now after this, I can never forgive him for what he's done to my daughter and my grandchildren."

She looked tearful and looked away. We had a brief moment of silence and then she said, "It's okay doctor, I know I've got to take my tablets and watch what I eat so I'll try really hard this week to make sure that I do everything we agreed in my care plan. I think what I would like to do when I see you again in a couple of months time is have a think about whether I need some new objectives for my diabetes care plan and whether I do need to change my treatment if all this family stress keeps getting in the way. I think things will settle down for my daughter and for me and the children, although it will take a while. So, if it's okay with you, Doctor, I'd like to keep my treatment just the same and see how it goes. Thank you for listening."

She stood up, "Maybe I could see you in a couple of weeks time rather than a couple of months", she said.

"That would be fine." I replied and walked with her to the door of the consultation room. "Take care" I said, "I'll see you again soon."

I checked my watch, yes! Nine minutes, I was going to get to my Chinese class after all.

Listen Understand Develop

Find out more about care planning here.

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