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I cannot believe that the focus is on a medically driven service yet again, we already know that doesn't work. The needs of the elderly and those with long term conditions are far broader with crises arising due to socially related factors.
It's about time care planning was realistic, and not thought up by what is still a largely middle class, middle aged male dominated group of doctors with little appreciation of the what the real world is like for most of the population.
Rather than GP led it should be Community Services led to encompass health and social care employing a range of professionals including GPs & specialists to deliver holistic support funded through personal health budgets.