Top ten tips

Dr George Gavriel
RCGP Clinical Support Fellow, Collaborative Care and Support Planning

George is a First5 GP working in Buckinghamshire as a GP, trainer and GP Training Programme Director. His practice was the first in its area to introduce care and support planning, as part of a project he led to improve care for patients with diabetes in the practice. He is also the Honorary Treasurer for his local RCGP Faculty and enjoys spending his weekends at home with his young family.

In the busy and pressured environment of general practice we sometimes find ourselves frustrated because we are unable to prioritise the patient. Do you believe that general practice needs to work with patients to remain sustainable? Do you want to develop more human interaction with your patients that empowers them towards leading their own health and wellbeing? Are you committed to finding a way to deliver high quality health services in an efficient and satisfying way?

If so, this article could be the first step to helping you develop an approach to the treatment of long term conditions that shifts the focus from the disease to the person and takes a truly holistic approach to working with patients.

BUT HOW do you transform theory into practice and do things differently on the ground? With limited time to think, plan and resource change, how do you reconfigure your practice systems and processes and reshape the journey of your most vulnerable patients? How do you work within the constraints of QOF and disease specific guidelines?

Here are the ten key things we know so far about how to make the initial shift from disease focussed to patient focussed models of care:

1. Be realistic – Are you willing to think big whilst setting realistic goals?

A long term aspiration to implement care and support planning for all patients with LTCs is a tremendous long term vision, but it can only be realistically achieved through small steps. So begin by prioritising specific disease groups or patient types. This can be supported by CCGs as it is in Aylesbury Vale who are supporting practices to deliver advance care planning for patients at risk of dying in the next year. Alternatively you could consider care planning for patients with diabetes or similar LTCs as has been undertaken in Tower Hamlets since 2009. 

2. Be patient led - Have you ever walked in the shoes of one of your patients?

In order to truly understand the patient experience, it is essential at the conception phase to walk in the shoes of a patient with LTCs. Arrange a time to meet with some of your LTC patients, talk about how they would feel if they were empowered to take control of their own health and wellbeing rather than being a condition to be ‘managed’. If you had a LTC, how would you expect to be treated? And how would you want to be treated? We guarantee it will open your mind to the multitude of physical, mental, emotional and social determinants that influences a person’s health and wellbeing.

3. Be confident in your instincts and be a leader - You are a dedicated practitioner who can galvanise the support of your colleagues.

Care and Support Planning is about improving health outcomes for patients in a way that enhances general practice sustainability. Believe in yourself and your colleagues, you can gather the support of your peers to work together towards this goal. From administrators to nurses, healthcare assistants to fellow GPs, you can lead your team to consider the realistic changes that can be made to improve patient care and job satisfaction for the whole team.

4. Get counting – How much does your practice spend managing patients with LTCs?

Do you know how much it is costing to manage your patients with LTCs? Before you begin to consider how you might implement Care and Support Planning, it is worthwhile considering how much your practice already spends supporting patients with LTCs. Consider the clinical and administrative costs: even the DNAs and stationary costs will all be adding to your current expenditure on LTCs.

5. Be inquisitive – What administrative resources do you already have to support the management of patients with LTCs?

Taking a detailed look at the practice administration systems, such as the call and recall system, will give you an indication of the current resource that is needed to manage patients with LTCs within a disease specific environment. The Unplanned Admissions DES has led to many practices appointing a Care Coordinator, would this individual have the skills to administrate the delivery of a new and improved Care and Support Planning service for your patients?

6. Encourage your colleagues to be inquisitive about their roles – Are the right tasks assigned to the right team members?

In a busy practice it is very easy to slip into the culture whereby people are doing things that are outside the remit of the role. Take time to find out whether practice nurses are undertaking administrative tasks, GPs are undertaking jobs better fulfilled by nurses or whether health care assistants could take on some of the nurse responsibilities. Ensuring the right individuals are fulfilling the appropriate roles within the team will ensure the service is more efficient and effective.

7. Don’t stop asking questions! – Can IT systems in your practice be reconfigured and automated?

Effective practice IT systems underpin the practical application of Care and Support Planning. IT is supposed to work for us, not the other way around, and text messaging and email can save a significant amount of time compared with the standard practice of writing to patients. Templates can be set up for staff to ensure essential data is collected and with patients soon to have access to some parts of their medical records, IT systems can help encourage patients to engage with their own healthcare.

8. Be creative- Are you and your colleagues prepared to consider creative ways of working with existing resources?

Think about reorganising your existing resources as opposed to seeking additional ones which may not be available and may create additional work. For example, Care and Support Planning encounters provide an opportunity for patients to discuss issues or ask questions about their health in a meaningful environment whilst fulfilling QOF requirements for annual face-to-face LTC checks.

9. Realising assets – Do you know what local statutory, community and voluntary provision there is to support your patients?

Take the time to research where you can signpost your patients for support; this will be a huge benefit when you begin the care and support planning process. You will be able to confidently signpost your patients and ultimately demonstrate to them that you understand their personal needs and goals and are committed to helping them achieve them. These services are likely to be available for all practices in your locality, so start a dialogue and share information with each other for the benefit of all of your patients.

10. And one final piece of advice…know the pitfalls.

From thinking about implementing care and support planning to actually implementing it can take several months or even years. Don’t go for quick fixes. Have a clear implementation plan. Be patient, be prepared to learn and adapt and stay focussed on the end goal of ensuring your most vulnerable patients receive the support they need to develop the knowledge, skills and confidence to manage their own health and wellbeing.

If you would like to find out more about introducing care planning in your practice please contact


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