6. Key elements of the care planning process

• The process is viewed as a collaborative partnership between individual and professional
• Condition specific information and advice are given in language that is easily understood so that the resulting care plan empowers the individual to manage their condition. If appropriate, the process should also look at contingency arrangements for exacerbations or deterioration in the individual’s condition, so that the plan is explicit about what to do in those circumstances
• The resulting care plan is regularly reviewed. Reviews should include medication and medicines management as well as management of the condition and all services being accessed by the individual. Frequency of reviews should be determined by the needs of the individual and agreed by them
• Case management and community matron support is included where needed. Access to education, training, monitoring devices and assistive technology are considered if appropriate
• Information about support networks, including peer support, carers and family support groups is included
• Access to other services is provided in a coordinated and consistent way, including social care, benefits advice and support, advocacy, housing, transport, leisure, education, voluntary and community services
• A carer’s assessment and provision of appropriate services and support should be considered.

7. Key elements of a care plan

• A care plan is a written summary of a discussion that has taken place
• It identifies agreed needs, aspirations and goals
• It should be kept proportional to need, the level of detail depending on complexity of need
• It should include a named professional who has responsibility for overseeing the delivery of services agreed in the plan
• It should be owned and held by the individual who also decides who has access to it
• It should form part of the individual’s electronic record so that it can be shared and accessible as required by those providing services.

8. Key expectations of front line staff

• Understand the principles of self care, self management and care planning
• See the patient as the expert in his or her own condition
• Trained to communicate effectively
• Provide access to relevant, evidence based information
• Give advice on access to health and social care services, benefits, housing, transport, leisure, education voluntary and community organisations and support networks
• Aware of relevant resources and technologies
• Support people to gain relevant skills
• Help people set goals and manage identified risks
• Promote choice and independence based on people’s strengths and abilities

Pharmacies have a specific role in providing self care and self management support through the new community pharmacy contract. (See document no 5, Pharmacy in England: Building on strengths – delivering the future)

9. Benefits for people with long term conditions

• Empowerment, confidence and capability
• Improved quality of life
• Increased life expectancy
• Better control over symptoms
• Reduced pain, anxiety and depression
• Greater independence
• Reduction in days off work or possibly return to work

10. Benefits for the health service and the whole system

• Less duplication of effort
• A more cohesive system
• Better coordinated services
• Commissioners understand what people want and need
• Meets NI, PSA targets and strategic ambitions
• Improved quality of consultations
• Improved patient satisfaction
• Reduced visits to GPs by up to 69% and up to 40% for high risk groups
• Reduced hospital admissions by up to 50%
• Decreased number of days in hospital by up to 80%
• Reduced outpatient visits by up to 77%
• Reduced A&E visits by up to 54%
• Reduced medication expenditure
• Improved medicine utilisation by 30%

11. Monitoring progress

• NI124 People with a long term condition supported to be independent and in control of their condition
• PSA 19 has been reworded to be more outcomes focused – People feeling increased satisfaction with the support they are given to be independent and in control of their condition, will be measured as part of the Operating Framework 2009/10 (part of the Department of Health strategic objective Better care for all)
• NHS South West ambition: Ensure that all people with a long term condition have a personalised care plan that supports their self management by 31st March 2010.

Local decisions must be made on how to measure performance and outcomes.

Actions to take:

• Consider how to capture and aggregate the information in care plans (micro-commissioning) to develop the services (macro-commissioning) that people want and need, ensuring that unmet needs are also captured
• Find ways of incentivising primary care to implement care planning
• Decide on how to manage performance and evaluate outcomes, including patient experience and value for money
• Identify training needs and invest in training for frontline staff in order to meet the expectations
• Make the right thing to do the easy thing to do by ensuring an IT structure that supports the process and principles of care planning
• Use evidence on costs, benefits and efficiency gains to make the business case
• Link with colleagues commissioning services for people with learning disabilities. LD services employ Strategic Health Facilitators whose job it is to ensure that people with learning disabilities have a personal health care plan as part of their overall care plan.

12. Quick Checklist for commissioners

• Needs assessment based on the prevalence of various conditions in the local population
• Baseline mapping of current care planning processes
• Baseline mapping of existing services and providers from all sectors
• Numbers of people with a care plan (be aware there are different names for the same thing) and numbers of people who might want one
• PCT named commissioner with responsibility for self care, self management and care planning

13. Next steps

1. Agree vision and principles with partners
2. Agree a local action plan
3. Develop a detailed specification to implement care planning
4. Develop plans for local workforce training to ensure appropriate skills and behaviours to support this approach
5. Decide how to measure performance (process) and quality (outcomes)