Collaborative Working to Enable Coordinated Care

Right Care

A key benefit of collaborative working across health and social care teams is that people are supported to exercise choice, control, and active partnership in their care. When professionals work together effectively, individuals receive the right care, assessed and delivered in a way that reflects their unique needs, preferences, and circumstances. Within this collaborative model, nurses and midwives play a central coordinating role. Their holistic perspective, continuous contact with individuals, and clinical expertise place them in an ideal position to:

• Ensure that care is individualised, evidence‑based, and grounded in a shared understanding of what matters most to the person;
• Assess, plan, and monitor health care interventions so they are delivered by the professional with the most appropriate skills and competence;
• Appraise the complexity of a person’s health needs, expected outcomes, and any identified risks—taking steps to mitigate these through proactive planning;
• Consider the skill mix, scope of practice, and capacity of the wider multidisciplinary team, ensuring seamless coordination and avoiding duplication;
• Facilitate truly person‑centred decision‑making, supporting individuals to understand their options and agree the care that best aligns with their goals and wishes.

Through this leadership in assessment, communication, and coordination, nurses and midwives help create an integrated approach where every member of the team contributes effectively to achieving optimal outcomes.

Expected Outcome

People receiving health care should expect treatment and support that are evidence‑based, personalised to their needs and choices, and delivered efficiently without unnecessary duplication between practitioners. This ensures a smoother, safer care experience and supports better overall outcomes.

Right Person

People living in the community are often supported by a wide range of health and social care staff such as nurses, midwives, physiotherapists, GPs, social workers, social care practitioners, classroom assistants, and personal assistants. Each brings a specific set of skills, competencies, and professional responsibilities to the person’s care. Unlike hospital or care home environments, individuals living at home do not have continuous access to a health or social care professional throughout the day. Nurses and midwives have a role to ensure health care need is assessed, planned and delivered by the staff member with the appropriate level of competence, working within their regulatory and professional scope of practice. Nurses and midwives can promote safe, effective, and person‑centred care by promoting the following:

• Each staff member contributing to the care plan must have the skills, knowledge, and training required to perform their duties confidently and safely;
• Agreed protocols, communication pathways, and shared understanding of roles help ensure that everyone involved, including classroom assistants and other support staff, know their boundaries, responsibilities and when to escalate concerns.

Expected Outcome

People receiving health care should expect that all assessment, care delivery, monitoring and escalation are carried out by the most suitably qualified, skilled and competent staff member, ensuring safe, effective and person‑centred care.

Right Time

Ensuring that people receive timely access to the most appropriate health care interventions is essential for preventing avoidable complications. Early access to tests, assessments, or specialist input can reduce the risks that arise from delayed treatment, and prevent unnecessary interventions that add cost or expose individuals to avoidable harm.

Care should be delivered at the time it can have the greatest impact, early enough to prevent deterioration and responsive enough to meet each person’s unique needs. When every member of the multidisciplinary team has a clear understanding of their own role and the complementary skills of others, the timeliness and effectiveness of health care interventions naturally improve. This clarity supports safer care delivery and enhances the overall experience for the person receiving care. Nurses and midwives play a pivotal role in ensuring timely care.  As professionals who often have the most continuous contact with individuals, they are uniquely positioned to:

• Coordinate and anticipate health care needs as they arise;
• Identify early signs of deterioration or changes in a person’s health status;
• Initiate or escalate concerns to the most suitably competent health care professional, at any time, including out‑of‑hours;
• Support the alignment of care plans so that interventions occur exactly when they are needed;
• Through proactive assessment, coordination, and communication, nurses and midwives help ensure that no opportunity for early, effective intervention is missed.

Expected Outcome

People receiving health care support should expect that their interventions are assessed, planned, and delivered at the point of greatest benefit, avoiding delays that might worsen their condition, cause unnecessary distress, or reduce the likelihood of a positive outcome.

Right Place

Nurses and midwives play a central role in coordinating the work of the multiprofessional team to ensure that people receive their care in the right place, in settings that maximise comfort, safety and personal preference. Through effective coordination, nurses/midwives help individuals maintain choice and control over where their health needs are met, whether at home, or environments such as classrooms, provided it is clinically appropriate and safe. As more people live at home with complex and changing needs, nurses are key to shaping a flexible and responsive workforce model. Their responsibilities include:

• Assessing which environment is most suitable for safe and effective care;
• Ensuring that care delivered outside clinical settings meets professional standards, safeguarding both the individual and the staff supporting them;
• Through leadership in assessment, communication, and coordination, nurses and midwives help ensure that people receive timely care in the most appropriate setting, reducing unnecessary admissions to hospital/care homes, preventing deterioration and enhancing the person’s overall experience.

Expected Outcome

People receiving health care should expect their interventions to be delivered in the safest, most appropriate and accessible setting, where possible reflecting their individualised preferences.