This chapter explores how the wider collaboration of health and social care professionals works together. The number and scope of these professionals are diverse and often complex. The larger team is required for patients and their carers with multiple problems: physical, psychological and social. The greater the number and types of professionals involved, the more diverse the range of values and thus the need for collaborative goal-setting is crucial for optimum care.

While the following refers to the USA, it resonates with recent reports from the UK: ‘The experiences of vulnerable older people are shaped by our basic values, including attitudes about frailty and dependence. In extolling the virtue of independence and self-reliance, the dominant culture in the United States devalues those in need of assistance, often stripping them of their power, authority and even dignity’ (Olson, 2003, page 10).

Fred and Rose’s story

Until recently Fred, an 87 year old, lived in a bungalow with his wife, Rose, who is also his carer. He has three sons and eight grandchildren, all of whom live some distance from the couple but whom he loves to see when they come for visits. Fred is a proud man, always smartly dressed, who has never drunk heavily and never smoked, but he does like to socialise with his friends in the local social club. Rose has always, until recently, had good health and is 7 years younger than Fred. he couple celebrated their diamond wedding anniversary last year and have photos of family and friends scattered around their home that depict the celebrations which took place at the time. Rose has however had ‘a bit of trouble’ with her let wrist in the last few months and has been referred to the hospital and put on the waiting list for a minor carpal tunnel operation.