1. Why personalised care planning is important

• Around 6 in 10 adults in the population report some form of long-term health problem
• Care of long-term conditions accounts for 60% of bed days in hospitals, 69% of the total health and social care spend in England
• By 2030, incidence of long-term conditions in the over 65s is estimated to more than double
• In the South West almost a million people are registered by GPs as having a long term condition
• People with long term conditions account for more than half of all GP appointments, two-thirds of all hospital outpatient appointments and nearly three-quarters of all hospital inpatient care
• Numbers are predicted to increase due to factors such as an ageing population and certain lifestyle choices that people make
• Ill health among the working population places a significant burden on health and social care
• There are huge benefits to the population and financial savings to be made if health and social care communities invest in effective long term conditions management.

Because self care, self management and personalised care planning are inextricably linked, reference should be made to the self care resource pack which is available on the same website.

2. Policy context

• The NHS Plan (Department of Health 2000) Self care and self management is highlighted as one of the key building blocks for a person centred health service
• NHS Improvement Plan (Department of Health 2004) Self care and self management is one of the key elements of this improvement plan in order to improve well-being, maintain independence and improve quality of life. Self care and self management is a target area for long-term conditions, highlighting a new emphasis on changing patterns of care from a secondary to primary setting and increasing use of self-care, self management and preventative approaches
• The Operating Framework for the NHS in England 2009/10 Vital signs – the proportion of people with long term condition supported to be independent and in control of their condition (Department of Health 2008)
• National Service Frameworks
• Our health, our care, our say (Department of Health 2006) This has a very strong focus on the role of self care and self management support for people with long term conditions
• Commissioning framework for health and well-being (Department of Health 2007)
• World Class Commissioning The vision for World Class Commissioning places emphasis on personalised services
• High Quality Care for All: NHS Next Stage Review Final Report (Department of Health 2008) This endorses the vision expressed in Our health, our care, our say that an integrated personalised care plan should be offered, by 2010, to everyone who has a long term condition if they want one
• Putting People First: A shared vision and commitment to transformation of Adult Social Care (Department of Health 2007)

3. Definition of personalised care planning

Personalised care planning is a process whereby people are supported to develop confidence and competence in managing the challenges of living with their condition(s), so that they have an improved quality of life, improved clinical outcomes and make more appropriate use of health and social care resources.

The process is one of discussion, negotiation and decision making between a professional and individual, which should address a person’s full range of needs, taking into account not just their health, but also their personal, family, social, economic, educational and cultural circumstances. A care plan is drawn up as a result of that discussion.

It is neither a plan of care or treatments offered for a specific condition nor a list of treatments or support available for a particular condition.

4. Delivering personalised care planning

Care planning will generally be delivered in primary care in GP practices by staff such as practice nurses. It may also be delivered in hospitals by staff such as specialist nurses, and in people’s homes by staff such as community matrons, case managers and social care workers.

The Department of Health estimates that each personalised care plan will cost on average £18.61 based on the labour cost of nurses leading the process. There is no new money available for implementation which will eventually be paid for by efficiency savings within the system.

5. The long term aims of self care, self management and personalised care planning

• That people with long term conditions take greater control and responsibility for their health, including those being case managed in the community, so that quality of life, health and well-being are improved
• That people with long term conditions have improved independence and attainment of personal goals, improved experience of service provision and that services provided are those they want and need
• Stimulation of genuine choices for people, which feed into commissioning decisions
• That there is a planned, proactive approach to health and social care services and a fully integrated system of health, social care, community and voluntary organisations, which is flexible and responsive to individual needs
• That front line staff understand the principles of self care, self management and personalisation
• Improved staff job satisfaction and fewer complaints from patients and carers
• That self care, self management and personalised care planning, becomes an integral part of all policies, care pathways and service specifications
• A reduction in health inequalities
• Greater efficiency savings such as reduced hospital admissions, GP consultations and hospital outpatient appointments

Actions to take:

• Use national and local data to assess local numbers of people for whom a care plan should be offered
• Review current data collection and information sharing arrangements
• Identify people at risk and local health care inequalities
• Articulate an unambiguous high level description of the purpose of care planning (see definition)
• Use Joint Strategic Partnerships, Joint commissioning Boards and Local Area Agreements to support planning and commissioning with shared goals
• Recognise the enormity of the task and break down into manageable chunks by deciding the first section of population to target
• Develop a timetable for introducing the next target populations
• Work with providers to set up a system for measuring each of the domains within the description and the care planning process
• Work with providers to make clear the different roles, especially the role of GPs, community matrons, case managers and other front line staff
• Include self care and self management and care planning in job descriptions
• Review commissioning plans (including practice based commissioning), contracting and procurement arrangements, service agreements and specifications and consider how these fit with personal health budgets
• Identify what services and support for self care/ self management there is currently in place that people will be able to access as part of their care plan, including the use of assistive technology, telecare/telehealth/ telemedicine, signposting, information prescriptions and multidisciplinary teams with a mix of skills to meet the needs that are indentified
• Design, redesign or commission/decommission services, working with people with long term conditions, all agencies including GP practices, other partners and stakeholders to fill gaps in current provision
• Develop business cases for new or redesigned services
• Check links with other local policies, strategies and protocols