Helping you to help people with long term conditions: a call to fellow GPs

I have just read Martin McShane’s blog, with his call to enhance the quality of life for people with long term conditions.

It offers vital tips about how to do this in the form of three guides: person centred care and support planning, case finding and risk stratification and multi-disciplinary team development.

These materials show that we have learnt a lot – but also pose some major questions especially whether we can really shift the balance of the use of urgent and emergency care towards proactive and preventive service models.

Our WEL integrated care Pioneer programme (Waltham Forest, Newham and Tower Hamlets) held a session reflecting on what we meant by care and support planning across our three CCGs.

We agreed a need to distinguish between “crisis plans”- information shared largely between providers to coordinate transitions more effectively (eg potential hospital admissions) and the kind of care and support planning discussed in these documents – prioritising quality of life, support for self-management and carers, and a holistic service offer.

There are also real challenges about case finding within particular risk stratifications and which interventions seem to be effective. The WEL programme is mainly based on services targeted on risk of admission and much of the work so far had been about building effectively integrated intermediate tier services.

But the central importance of general practice as a partner is now very clear – both in helping with case finding, in supporting effective data flows and care navigation across the whole system and in offering appropriate step down continuity of care.

This is all based on a culture shift towards person rather than disease based care, with new ways of partnership working – with the person, their family and carers and across the multidisciplinary team as described in the RCGP Care and Support planning animation.

Back in the practice, while delivering care planning to people at high risk of admission, I first saw a lady left disabled after a subarachnoid haemorrhage 27 years ago. There was no scope for self-care, she lacked mental capacity for decisions about resuscitation and she already had a full package of care.

The focus with her was on the crisis plan, to document her current status and to outline a best interest decision, strongly supported by her husband, that she was not for resuscitation and would prefer if possible to stay at home.

Next was a follow up care and support planning encounter with a lady with five LTCs. Her previous goals were about retaining mobility, overcoming social isolation and getting back into paid employment. But she had not managed any of the agreed actions and on further enquiry we identified lack of motivation and poor concentration, probably as a result of a secondary depressive illness, and have now adjusted the agreed actions accordingly.

If you are a GP or commissioner interested in more proactive case for people with LTCs, aiming to improve the quality of their life but also to explore more appropriate care, these materials are for you!

I recommend that you start with the executive summary.


Isabel Hodkinson is a GP principal in Tower Hamlets, where much of the care for people with LTCs is delivered through enhanced service funding for packages of care via GP networks.

She is on the Tower Hamlets CCG board as lead for informatics and is the RCGP Clinical Champion for Care and Support planning.

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