Collaborative care and support planning


The RCGP has been funded by the Health Foundation and NHS England to help primary care embed CC&SP for people living with LTCs and multimorbidity.

Many GPs report feeling overwhelmed and overburdened by their current way of working, whereby they regularly see a person about their LTCs but generally work according to a reactive medical model; seeking medical solutions or cures to problems and hence taking on the responsibility to 'fix' people's problems.

Implementing the CC&SP model is a way of easing the burden on primary care when managing conditions, symptoms and/or functional problems that affect people with LTCs. Using this model helps the person to develop the knowledge, skills and confidence to increase self-management of their condition(s), building on their personal strengths and harnessing the assets available to them in their social network (such as carers) as well as the wider community.

The RCGP programme builds on the 2011 RCGP publication Care Planning Improving the Lives of People with Long Term Conditions and the involvement of Professor Nigel Mathers, Honorary Secretary of the RCGP, as the Co-Chair of the Coalition for Collaborative Care. The RCGP programme will complement the Health Foundation's work on CC&SP and make use of the plethora of resources within the Health Foundation Resource Centre.

For further information contact

RCGP endorsement of collaborative care and support planning

In June 2016 the CC&SP programme team wrote a paper for the RCGP Council, as a result of which there is now a clear RCGP standpoint on care planning. ‘CC&SP: Ready to be a Reality’ [PDF]  sets out the necessity for care planning to be core business for general practice, and amongst other recommendations suggests that care planning is an effective way to manage multiple morbidities and should be incorporated in the RCGP curriculum. Approval of these recommendations is a great step towards ensuring the aims of the programme as described above.

CC&SP Network of Champions

We are partnering with NHS England to build a Network of Champions to promote person-centred care and CC&SP and support organisations to implement it. If you would like to request support from a Champion, ask them a question or just hear more about CC&SP / person-centred care please get in touch at and we will put you in touch with the champion in your region.

Integrated Personal Commissioning (IPC) Network

We are partnering with the IPC team at NHS England to build a network across the IPC sites to build an awareness and understanding of IPC in primary care and to support individuals to implement this new way of working. If you are based at an IPC site and would like more information, or if you would like some more general information, contact

Stepping Forward: Commissioning principles for collaborative care and support planning

We know we need a better way of working with people with long term conditions. Collaborative Care and Support Planning (CC&SP) is the tool that can deliver this.
The CC&SP programme aims to encourage a shift in general practice to bring the person with long term conditions (LTCs) to the centre of the decisions which are made about their care, working in partnership with the practitioner.

The Clinical Innovation and Research Centre have produced a guide to support commissioners and practice staff to implementing this new approach. Recognising that there is no ‘one size fits all’ approach, we provide core principles and building blocks for delivery which are backed-up by real life examples. Read the guidance here:

RCGP and NHSCC webinar - Stepping Forward: the challenges and rewards of commissioning collaborative care and support planning

The RCGP and NHS Clinical Commissioners held a webinar to accompany the launch of the 'Stepping Forward' guide. The webinar explored the experiences of two organisations that have implemented care and support planning. You can hear a recording of the webinar here.

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