Personalising care and managing multimorbidity throughout 2016

Professor Nigel Mathers, Honorary Secretary for the RCGP, Vice-Chair for the Coalition for Collaborative Care

We all understand the rhetoric behind why personalised care is so important; an ageing population that effectively collect conditions through the years has resulted in unprecedented numbers of patients with multimorbidities, the importance of self management for people with one or more long term condition, NHS England’s Five Year Forward View and GP Forward View, the Scottish Government’s ‘Realistic Medicine’, Prudent Healthcare in Wales, Northern Ireland initiatives like Project Echo NI, new models of care, NHS Vanguards all have a part to play.

This isn’t a new concept, and is something that the RCGP has been involved with since before our 2011 inquiry into care planning for people with long term conditions (link to However it could be argued that 2016 has been the most significant year yet for person-centred care within the RCGP, and for primary care more widely.

CC&SP: Ready to be a Reality,  a paper which went to RCGP Council in June 2016, set out the significance of this movement for primary care. It recommended that the RCGP endorse CC&SP as core business for general practice, recognise it as a key tool for managing multimorbidities, support its inclusion in the GP Curriculum, and acknowledge the part it has to play in making GPs’ jobs more satisfying – bringing the joy back into general practice. The paper was a resounding success, and heralds a change in attitudes within primary care. With all recommendations passed by Council, this official endorsement of CC&SP by the RCGP represents a momentous change for the College and puts it at the forefront of the movement towards person-centred care.

Feeling optimistic following this announcement, a further cause for celebration was the news that the RCGP curriculum team has decided to include a new module into the curriculum; Caring for Patients with Long Term Conditions and Cancer. Whilst this is still subject to GMC approval, the CC&SP programme team within CIRC are currently working with the curriculum editors to get this drafted. The significance of a module within the GP curriculum shouldn’t be underestimated – it means that every newly qualified GP will be finish their training with a good understanding of the skills and competencies needed for CC&SP, an understanding of the importance of better conversations between themselves and the people that they support, the ability to empower people to self manage, and it will help to ensure the sustainability of CC&SP for the workforce.

An endorsement by the RCGP and a new module in the GP curriculum are both triumphs, but neither would be as significant without the involvement of individuals who are committed to supporting this way of working. The RCGP’s CC&SP Network of Champions is now at 35 members, all of whom are passionate and dedicated. RCGP has also become involved with NHS England’s Integrated Personal Commissioning (IPC) programme, and has established a primary care network across the IPC sites. Together, the two networks have contributed to all of the achievements by the CC&SP programme team, and have been a real driving force behind the movement.

And so with the movement towards truly personalised care within primary care in full swing, how can we now ensure that GP trainees are being trained and assessed on the core skills, competencies and understanding needed for CC&SP? How can we support struggling practices and overworked GPs to introduce and embed this way of working? How can we ensure sustainability for the right reasons rather than as a tick box exercise as care planning has existed in a previous life? These are the areas for the CC&SP programme team to focus on going forwards, and with thriving networks and passionate clinicians involved … watch this space!


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