Collaborative Care and Support Planning Toolkit

The landscape of the NHS and primary care is changing; an ageing population, increasing multimorbidity and frailty, and an overburdened workforce means that primary care needs a more effective way of addressing the bio-psychosocial elements of health. It requires a shift towards prevention, self-care and integrated care.

Collaborative care and support planning (CCSP) offers a framework, which recommends a proactive holistic, flexible, and tailored approach to care, and recognises the individual as an expert in their own care. This toolkit provides a collection of relevant tools and information to assist members of the primary care team to implement the six-step model of collaborative care and support planning.

Step one: Context



When introducing CCSP it is essential that certain components are in place to ensure successful implementation. These are described by Think Local Act Personal and include:

1. Identifying the cohort of people to whom you are going to offer CCSP
2. Identifying individuals and generating a comprehensive database
3. Proactively inviting individuals
4. Developing robust call/recall system
5. Quality assurance of the process

The role of surgery MDT meetings is important to ensure the whole team contribute to deciding who might benefit from the process, along with clinical acumen. When beginning the process of CCSP it is important to start small and don’t be afraid to go around the loop more than once.

Identifying the cohort

RCGP’s Stepping Forward suggests five methods for identifying participants (p.24-27).

Resources for risk stratification of population

In addition, there is the added complexity of information governance requirements when applying risk stratification tools to populations. Providing a practice can demonstrate that this is for direct patient care, that sufficient fair processing has been undertaken (e.g. posters in the waiting area, leaflets and that patients have had the chance to opt out) these issues can be overcome. However, it is essential that practitioners and practices seek advice from local experts within their Clinical Commissioning Groups to ensure that they are working within their local information governance frameworks.

Segmenting into specific cohort

This involves identifying groups of people who share similar characteristics, e.g. frailty as measured by the Timed up and Go test (TUG test), the frailty index, or people with one or more LTCs. This approach allows for an incremental increase in the number of people benefiting and represents an easy place to start. However, it risks excluding people who are not in the cohort and also treats single conditions rather than offering a holistic approach.

Organic identification by practices

Clinical judgement plays a key role in identifying people who would benefit from being offered a proactive approach to their care and members of multidisciplinary teams and general practice staff are well placed to know their population better than anyone. However, this does not take a whole population view, so may exclude people who aren't known to the MDT, practice or practitioner and so introducing inequity of access to care.

Identifying and working with people with either higher or lower activation

Activation, an individual's level of knowledge, skills and confidence to self-manage, measured by completing the Patient Activation Measure (PAM) survey, can be used to tailor interventions, as well as a measure of success of an intervention. Those with higher levels of activation are more likely to access health and wellbeing inventions and undertake behavioural change activities, while those with lower levels of activation, are more likely to have higher utilisation of unscheduled care in both a primary and secondary care settings. By working with those with lower levels of activation, there are greater opportunities for improved outcomes for individuals and the system as a whole. However, by targeting those with low activation, this may exclude people with higher activation who have greater complexity and associated risk.

The PAM tool can be completed by sending the survey out to specific cohorts or by asking people to complete the survey when attending for the CCSP consultations. Codes for PAM level and score are now available within most GP electronic health records (EHR) so allowing for systematic coding of this data and subsequent data collection and database creation.

Identifying individuals and generating a comprehensive database

The database to be generated will depend on the context within which you want to start offering CCSP and what outcomes you plan to achieve. The database should be easily accessible, updated regularly and be accurate.

Proactively inviting people for review

Individuals may not previously have been invited for a CCSP consultation and so it is important to ensure the invitation provides clear, easy to read information about the care being offered. Letters of invitation will need to reflect the context within which the CCSP consultation is being offered.

A record should be kept when the initial invitation and any subsequent invites have been sent. IT systems that automatically link the invitation to the EHR will ensure that the health and care team are aware that an invitation has been sent and so can proactively encourage individuals to book their CCSP consultation (e.g. Patient Chase).

Using text messages to alert people that an invitation has been sent and encouraging them to respond to the invite can increase uptake and so improve outcomes.

Developing robust call/recall systems

Since the inception of QoF, general practice has introduced processes to ensure people with specific health conditions were systematically invited to attend for their annual health checks. Typically checks were disease specific and focused on the biomedical model. However, there is evidence that this approach has not impacted on prevention, health and wellbeing and has not promoted self-management.

Yet these robust call/recall systems, established in response to QoF, provide an excellent foundation by which people identified, by either/or a combination of the above processes, can be invited proactively for their collaborative care and support planning consultation.

In order to identify people for direct patient care easily, IT systems that are interoperable with existing GP EHRs will need to be available via GP systems of choice (GPSoC) and seen as part of the core GP IT service offer.

Quality assurance of the process

1. System used to identify the chosen cohort is robust
2. Database is comprehensive
3. Invitation accessible and user friendly, agreed percentage invitations reach individuals, agreed percentage people respond to invitations after agreed number of attempts
4. Once attended for CCSP consultations each stage of the process has been delivered and audited

Step two: Preparation


Introducing collaborative care and support planning into your practice will involve some organisational and cultural changes, not only amongst your practice team and patients but across your wider federation and CCG. Changes can still start at an individual general practitioner level but sharing with and involving more clinicians and commissioners will make any wholesale changes more widespread and cost-effective. Preparations should therefore be considered for the professional, processes within the practice and the individual.

For the professional

  • With any new changes in general practice, the questions of time and financial resources always come to the fore. In areas of the country where care planning is already being successfully implemented the local CCG’s have played a pivotal role. The examples of Leeds CCG and Somerset CCG in The Health Foundation’s Building the house of care describes the differing approaches to commissioning this type of service from developing it as an enhanced service to supporting and encouraging a wider cultural change.
  • The RCGP’s Improving the lives of people with long-term conditions explores the options around commissioning care planning in General practice and associated costs.
  • The Year of Care’s Thanks for the petunias discusses commissioning services involving non-traditional service providers allowing care planning to be shared beyond the confines of just the practice team.
  • House of Care training provides a one-and-a-half-day course on carrying out care planning and more person-centred consultations. On completion of this training a toolkit and further resources such as templates for recall systems are available.

For the practice and its processes

Within the practice itself, introducing a care planning process will require the development of a practice pathway for care planning, identifying a team who will carry it out and then training for the team to support the new processes. The team will need to be multidisciplinary, including not only clinical, reception and admin staff from the GP practice but also incorporating support from local and community services. Identifying an experienced person from the administration team to lead will help with development and implementation.

  • Some of the new models of care across the UK are looking at the use of non-clinical roles such as health coaches (e.g. the Symphony Programme and Village Agent Project in Somerset) who can either be commissioned by the CCG to work across practices, employed by individual practices or from the voluntary sector. They can act as a support for the person explaining and guiding them through the care planning process.
  • Think Local Act Personal have developed a personalised care and support planning tool which lists the preparations needed within the process, team and individual
  • A designated team is needed to develop, administer and deliver a care planning service. It shouldn't remain the sole domain of the general practitioner; involvement of practice nurses with long-term condition expertise, healthcare assistants, allied health and social services professionals and the voluntary sector can become involved. There may need to be a shift in the way a care planning consultation is delivered, moving from the traditional 10 minutes consult to one of 20-30 mins. Appendix C of the RCGP’s Improving the lives of people with long-term conditions provides examples of how a care planning consultation could run as well as templates and questionnaires.
  • The aim is to make sure the time spent in a care planning consultation is focused on planning for the future, identifying personal goals and creating a self-management action plan. Training for the team and then the subsequent use of social prescribing can help make the care planning process more personalised to need and de-medicalised where appropriate.

The GP should not be doing it all but where possible they should work with care / community navigators to support the person to prepare and, if possible, accompany the person at the next stage.

For the patient

  • Patients and their carers also need to be informed and educated about care planning. National Voices have developed a resource for patients, which can be used online, is printable but also has short films which could be displayed in waiting rooms.
  • Information can be sent out to patients before the appointment to inform them but also encourage their involvement – using bubble diagrams to stimulate conversation, but also providing information back to the care planner – including PAMS, LTC6, PH9Q etc self-assessment tools.
  • Health navigators can help patients to identify their goals and signpost them to resources and help within local and community services. Patients should experience a shift from the more traditional GP involvement in their care (which has become more reactive) to that of a proactive integrated team, which includes their GP.
  • Any initial plans for introducing CCSP within the practice will need to be trialled on a small enough group of patients to be manageable but large enough to be able to see the impact of change. The processes may well need adapting and it is important to make sure any problems are captured and fed back into quality improvement.

Step three: Conversation


It's important to remember that care planning should be more than just completing a template; it's a conversation to be directed by the patient, exploring their health and well-being. It also doesn't have to be just with the GP. Building an integrated team around a patient made up of other practice staff, healthcare professionals, health navigators and the voluntary sector ensures a multidisciplinary approach.

  • There will often be more than one conversation and all of these build into a journey for both the individual and the team. By preparing correctly for the care planning consultation, issues of health ‘housekeeping’ and QOF, can be set to one side to focus on developing a personalised action plan with patient selected goals. Personalised care planning information sheet 1 and information sheet 2 are useful resources for healthcare professionals.
  • Training programs focus on helping health care professionals develop skills to allow these conversations to take place. They encourage a shift from a disease-centred paternalistic approach to a person-centred holistic approach and incorporate the techniques of shared decision making and health coaching.
  • Shared decision making is the conversation that happens between a person and their health professional to reach a healthcare choice together. This conversation needs the professional and the patient to understand what is important to the other person when choosing a treatment.
  • Health coaching has been defined as ‘helping patients gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified health goals.’ The use of health coaching techniques ensures that any goals set are done so by the individual and they are encouraged to develop plans around how they can be achieved.
  • Understandings a patient’s health literacy also can allow tailoring of discussions to ensure patient participation. Health literacy is defined as ‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health… Health literacy is needed for patients and the public to understand and act upon health information, to become active and equal partners in co-producing health, and to take control of their health to help to shape health environments and health services for themselves, their families and their communities.’
  • The Gold Standard Framework in primary care is an aid for more holistic consultations.
  • Some care plan templates also help to direct the conversation for both clinicians and patients, e.g. My Life Plan and appendix D in the RCGP’s Care Planning.

Finally, as the initial conversation approaches an end there needs to be plans put in place for review and follow-up with the patient.

Other resources

Step four: Record


Getting agreement - don’t forget this is their plan not our plan for them

This is the process that moves from the planning by the person – supported by an advocate and health professional – to a physical plan on paper or electronic format (or both). Gaining commitment is an essential part of the conversation during stage three.

Translating the planning into a physical reality is no easy task but has a number of purposes.
1. Enabling the person to have a better understanding and take more control of their lives and long term conditions.
2. Enabling the system, especially in urgent care to respond accordingly taking into account the person’s preferences.
3. Underpinning a commitment by the person and statutory services to work together.
4. Informing future commissioning intentions.

The emphasis will depend on the underlying context but we see the planning process as of equal importance to the plan itself. And so it is crucial that the agreement must in the person’s own words with both parties agreeing to use ‘best endeavours’ to making it happen.

While some highly activated people will be very happy to agree their plan by themselves, in many or most cases, other carers/health professionals/advocates working with the person will be involved as they will play an important part of supporting implementation.

It is so easy to forget or become diverted and some people really do struggle, especially if going through this process for the first time to know what they want to focus on and so plans must be sufficiently granular, realistic, relevant to be achieved. It is also crucial to ensure people commit to their goals before leaving in stage three.


All plans will have basic ‘passport’ details but depending on the context ideally they will also include a:

  • care plan articulating the person’s own goals
  • management plan including a combination of medical and social prescribing
  • escalation plan so the urgent care system can respond appropriately.

The format of any of the care plan must be heuristic as the process of formulating and creating a plan allows people to reflect on what really matters.

Information Governance

It is essential that processes in the surgery support this with clear documentation including recording consent to share within the plan. Concerns around information governance must be resolved within the context of a local system agreement. We recommend practices check with the local CCG or health board on the locally agreed framework for templates and  information governance.

While we fully expect that this process will become digital in future, these are not yet well developed systems and the most vulnerable may still prefer paper records. Taking a pragmatic approach is best, allowing surgeries and people to experiment with what works for them.

The care plan should be seen as attempt to support people in taking greater ownership in the condition. It is not legally binding although may include mandates such as ‘do not resuscitate’ or ‘power of attorney’ and as such, health professionals will need to understand issues around mental capacity.

There is an important role for GP surgeries to ensure the right administration processes are in place to support this process.

The local system

While commissioning systems vary across the four nations, there will need to be a broader system responsibility at either CCG or health and social care board level recognising we are all ‘learning by doing’.

  • Working with local surgeries and MDTs to develop care, management and escalation plans.
  • Taking into account care and support plans when considering commissioning intentions
  • Facilitating CCSP by ensuring there is a quality improvement plan for its implementation at all levels from general practices to teams working in MDTs across localities etc, including the recording into primary care systems by a) developing action learning systematically, b) enabling quality time is set aside to test options with a few surgeries, capture reflections before applying in the local system.
  • Enabling plans to be shared easily across the local urgent care system subject to the right information governance framework.
  • Providing practical support, including training for surgeries trying to implement the record into primary care system.
  • Facilitating conversations with local groups such as Health Watch, local government, community services, ambulance and hospitals about the importance of paying due recognition to care and support plans in day to day clinical practice.
  • Ensuring strategies to develop Digital Technology take into account Care Plans.
  • Making sure contracts for other services support CCSP reflecting that for the majority of people there will be ‘One Plan’ for each individual embedded within the primary care system.
  • Improving Digital Literacy of the local population with partners.

We recommend as with general practices that local planning systems start small, working with willing practices to develop CCSP as they build up organisation learning. This may pass onto new models of care in future work on the rule of thirds.

Step five: Making it happen

 Making it happen

The surgery

Social prescribing for non-statutory services creates huge opportunities to help convert plans into reality. For most people starting to develop a health and social plan based on ‘what is important to me’ is a daunting task even if they are supported. But it is likely that most will rapidly loose interest if it is felt that the plan is meaningless.

Equally while the plan should be aspirational, it also has be grounded in reality with detail on how to make it happen and who will support the person. It is therefore essential that once there is an agreement, there is a genuine attempt by both statutory and non-statutory services to enable the person to put the plan into action.

In some cases people will not need help and will be able take control of their own plan. In other cases people will need support from a range of statutory and non-statutory services funded to provide support. These will range from community nursing to community navigators often from the voluntary sector.

The essence of making it happen is to put the person in control but that does not mean everything done for them by hard pressed NHS staff. A key element of making it happen is to reduce – not increase – the dependency cycle, recognising the benefits of an asset based approach to care.

Surgeries, working with other surgeries within the neighbourhood, to contribute to the identification of a range of alternative services that would need to be available locally and funded by local CCG,LAs or local health and social care boards will help support this approach.

Without this local intelligence, supported by surgeries who are best placed to know what their local registered population needs and can act as advocates, encouraging local funders to commission these services locally people won’t be supported to achieve their own goals.

The local system

In the devolved nations, we already see Health and Social Care Boards while in England, CCG are committed to an element of pooled budgets with local authorities called the Better Care Fund.

Whichever part of the UK GP surgeries are based, we feel it is important for surgeries to engage with the local system on behalf of their registered list. Increasingly across the UK practices are grouping into neighbourhoods with population 30-60,000 in which community, social and voluntary services are working together.

Equally the local system has to have a responsibility to listen to what GP surgeries are saying and also to ensure arrangements are in place with non-statutory services to enable CCSP.

We envisage that over time local systems will develop a directory of services that will be available to the local population with access to these being encouraged as part of social prescribing as an alternative to pharmaceutical prescribing or referral to an NHS service.
We do not believe that primary care should be the only route to these services but they will facilitate access using social prescribing in support of CCSP.

Personal Health Budgets (PHB) are being promoted in some areas as part of the process and it is inevitable that there will be some demand for a PHB. This should be seen where possible as a means to enable CCSP and not an end in itself.

There remains the vexed question of how do we respond if a person includes a service in there plan which does not have an evidence base. There is no right or wrong answer here except to say that the evidence base for many of the services provided by the NHS is weak in the context of multimorbidity and local discussions are required.

Step six: Review


When reviewing the process of CCSP a number of perspectives need to be taken into account; that of the patient, the clinicians & practice team and commissioners.

An important part of the development of the care planning pathway will be deciding on the tools or methods used to assess the success and challenges involved in it.

The review process would comprise broadly of two main parts. First part is to focus on reviews of Individual care plan and the Second part is to review the whole process at local CCG Level for quality assurance to ensure resources are being used judiciously.

The key element is to focus on reviews of the individual plans to ensure they are updated on a regular basis and any new information added in the care plan document is shared among all parties involved in providing care.

We recognise that local teams would design their own care planning documents. With time – and improved integration between various parties involved –  a shared paper or electronic document would be a possibility.

It is vital to ensure that this document gets updated on a regular basis. The ownership of the document should be given to the individual who is being cared for. It will empower patients and encourage active involvement. In circumstances, where the individual cannot take ownership of their care plan, a nominated person can be involved to take ownership (eg carer, care navigators, GP, lead practice administrator).

With regard to reviewing the process for quality assurance, this can be broadly divided two different categories:

  • Reviewing to ensure clinical standards are met
  • Reviewing to ensure commissioning standards are met.

First element of a good review process is to Audit/ Review to ensure care plans are of good quality and are being reviewed regularly and Second element is to look at Review arrangements from Commissioning point of view. These two elements have to be approached jointly as they will complement each other and could not be addressed in isolation.

The local teams can consider having some form of recording system in place to ensure all care plans are reviewed on a regular basis. Regular reviews would ensure patient safety and improve quality of care for example: recording of drug allergies, change in contact details of family members etc.

Individual care planning reviews should be done at least on an annual basis. However, patients with complex health care needs might need more regular reviews. Recording systems to check care planning review is vital for quality assurance process. It can be a separate commissioned service or part of existing care schemes. 

A new process could be allowed to run and then assessed after a fixed period of time or there could be more of a PDSA cycle approach with regular feedback opportunities, leading to a more continual quality improvement approach (RCGP Care Planning, chapter 4).

Patients' feedback about the new approach can be acquired either by using feedback surveys which look at their experience of the service (RCGP Care Planning, appendix A2.3 and A2.4) or surveys that look more at the impact on their well-being such as the LTC or LWYLTC (RCGP Care Planning, appendix A2.1 and A2.2).

Similar methods can be used to gain feedback from clinician's and other practice staff exploring areas such as impact on their workloads and job satisfaction. This could be supported by analysing data looking for any reductions in the number of patient appointments in the groups receiving care planning.

More specific clinical outcomes can be gathered, depending on the groups of patients a practice may have chosen to target first and offer care planning. For example, when looking at patients on the unplanned admissions list the number of hospital admissions or out of hours attendances can be reviewed.  If care planning was more directed to a specific chronic illness such as Diabetes, HBA1c trends could be analysed or the usage of diabetic medications.

If a practice has adopted a health coaching approach to care planning, patient activation measures can be used to measure outcomes, with a PAM (patient activation measure) score measured initially and then 12 months later.

However, as with any change it maybe that the uptake by patients takes a while to gain momentum and the numbers involved will take time to show any significant impact on resources. As change is often only accepted as people begin to see the impact it is having on others around them, so sharing patient stories can also be very powerful initially.

From the commissioners point of view outcome measures will need to be measured on a bigger scale and reflect impact on the wider health economy. Often the CSU (commissioning service unit) can capture information across the services to develop dashboards to identify changes in usage.

In any new process unforeseen problems are likely to arise and they need to be captured so they can be addressed.

Developing local forums for clinician's to meet, share and discuss these issues with each other and commissioners will be an important part of developing a more collaborative approach for systems/processes. Individual care plan reviews could be a good learning tool for GPs and GP Trainees.

Background information and acknowledgements

CCSP flow diagram 

This section contains further useful background information on CCSP. This includes links to documents that provide an overview of the CCSP process and national drivers for adopting the model.

Coalition for Collaborative Care

This toolkit was produced in collaboration with the Coalition for Collaborative Care (C4CC). The Coalition for Collaborative Care is a partnership of 50 national organisations and 2000+ members and followers aiming to achieve a better deal for people with long-term conditions.  The Coalition’s purpose is to bring people and organisations together and grow a movement for change around the three ‘C’s – better conversations between health professionals and the people they support, co-production with people, families and carers and building strong, health-creating communities.  With a broad and extensive constituency of support, the Coalition is founded on the principle that more can be achieved by people and organisations working together for a common aim than can be achieved by acting alone. 

For more information, visit the C4CC’s website.


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