Personalised care and support planning addresses the holistic needs of an individual patient, including physical and mental health and care needs.
More than 15 million people in England are living with a long-term condition (LTC) and a rising number have multiple LTCs. Yet they only spend a few hours per year with health and care professionals; the rest of the time is spent self-managing their condition. People who are engaged in their health and care are more likely to receive care and treatment that is appropriate to their needs, to adopt healthier behaviours, and less likely to use emergency care.
On their inspections of GP practices, CQC inspectors want to see evidence that people who use services and those close to them are involved as partners in their care (key line of enquiry C2).
This GP mythbuster was a collaboration with NHS England, developed by clinical fellows Dr Devin Gray (CQC) and Dr Deborah Kirkham (NHS England).
What is personalised care and support planning?
Definition from the Coalition for Collaborative Care:
"Personalised care and support planning encourages care professionals and people with long-term conditions and their carers to work together to clarify and understand what is important to that individual. They agree goals, identify support needs, develop and implement action plans, and monitor progress. This is a planned and continuous process, not a one-off event.”
A service-user’s perspective, National Voices:
“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.”
Benefits of personalised care
Using a collaborative approach, patients, health and care professionals, families and carers discuss*:
- What is important to them, setting goals they want to work towards
- Things they can do to live well and stay well (and, for some, die well)
- What support they need for self-management; agreeing actions they can take for themselves
- What care and support they might need from others
- What good support looks like to them as an individual
- What action to take in an emergency or they feel like they are deteriorating
- Preparing for the future, including making choices and stating preferences for end of life care (if appropriate)
Examples of personal outcomes
To:
- better manage my pain relief so I don’t wake up at night
- stay in my house as long as possible
- meet new people in my local area
- receive end of life care at the hospice close to my sister
Personalised care and support planning is not:
- about single disease pathways
- intended purely to help practitioners make decisions about an individual’s care and treatment
- a one-off short conversation (so can’t be tackled in one standard-length GP consultation)
- a tick box exercise producing a standardised plan for individuals with similar circumstances or a particular condition.
Care Plans
These need to:
- be owned by the patient
- be recognised by all agencies across health and social care rather than by a single provider
- be written in conjunction with the patient
- aid transition through the system and reduce the patient needing to repeat their story
Difference between care plans and treatment or management plans
- A care plan is produced with the patient.
- A treatment or management plan is given to the patient by the health professional with no patient involvement.
Implications for inspections
On inspection we will check care plans:
- are a care plan and not a treatment or management plan
- have been shared with other agencies and are recognised across health and social care
- contain outcomes from personalised care discussions*.
Examples of outstanding care planning in primary care
Where our inspectors have seen this done exceptionally well, practices have demonstrated a commitment to delivering high-quality personalised care and support planning. For example:
- A Midlands town centre practice with around 12,250 patients redesigned their services to offer 30 minute care-planning appointments to patients aged over 75.
- A semi-rural practice with about 4,500 patients in an affluent area of the south east:
- Developed enhanced anticipatory care plans for patients at high risk of hospital admission or using out-of-hours services, including patients’ wishes about their ‘ceiling’ (upper limit) of treatment.
- Provided comprehensive care planning for patients with LTCs, in care homes and receiving palliative care. Care plans were given to patients so they were fully involved and to help share information with other services.
- Reviewed care plans at least every three months.
Find out more
GP mythbusters
SNIPPET GP mythbusters RH
Clearing up some common myths about our inspections of GP and out-of-hours services and sharing agreed guidance to best practice.