Care and support planning must play a key role in redesigning services for people with long term conditions and making integrated care a reality, says Laura Robinson

NHS England’s new guidance on the participation of patients highlights the need for every person with a long term condition or disability to have a personalised care plan supporting them to develop the knowledge, skills and confidence to manage their own health.

With coordinated care and long term conditions at the forefront of current health and care policy discussions, the vital role of care and support planning in enabling system redesign has never been so clear. It provides a way of identifying a person’s goals and the best care, support and self-management actions to achieve them.

A new narrative

Earlier this year, the National Collaboration for Integrated Care and Support agreed a common system narrative, developed with National Voices and Think Local Act Personal, which sets out what good person centred, coordinated care feels like.

Care planning plays a central role in this perspective. Statements such as “I can decide the kind of support I need and how to receive it” and “I have as much control of planning my care and support as I want” emphasise the importance of a truly person centred approach.

‘The concept of care planning in itself is not new: numerous policy documents have pledged support to make it happen’

Indeed, the agreed definition of coordinated care − “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” − makes planned care the goal of “integration”. 

It is also increasingly becoming a central strand of current debates about the future of primary care and enabling better support within local communities.

Overseeing care

Jeremy Hunt’s vulnerable older people’s plan stresses the importance of a proactive approach to managing long term conditions and people having clarity about who is responsible for overseeing their care. The proposed changes to the GP contract build on this policy intention through the identification of a named GP responsible for coordinating out of hospital care. This is complemented by discussions on a separate “care coordinator” role; someone who will work to ensure that a person’s plan is delivered.

‘There is a groundswell for change. The “house of care” model has gained significant support’

The concept of care planning in itself is not new: numerous policy documents have pledged support to make it happen. The government’s response to the No decision about me, without me consultation recognised that care planning is “a vital part of empowering patients to manage their conditions” and the content of the NHS constitution was subsequently amended to reflect this.

The NHS mandate, similarly, included access to personalised care plans as one of its objectives. Despite this, surveys reveal that only 36 per cent of people with diabetes, 18 per cent with osteoarthritis and 14 per cent with epilepsy report having developed a care plan.

House of care

So what is different now? Why is now the right time to make good on the countless commitments?

There is a groundswell for change. The “house of care” model, based on the best international evidence and trialled in real life care situations, has gained significant support. Placing care planning at its heart, it helps professionals work through the key issues that need to be addressed and the main support needed to tailor the model to new communities.

‘We set out an approach that starts from the person’s perspective, enabling better tailored care and support, with a focus on prevention and self-management’

A new group, the Action on Long Term Conditions Coalition, bringing together primary care, Year of Care experts, think tanks, voluntary organisations and national NHS bodies, is planning a resource centre to provide professionals with practical support to implement the house of care approach to system change.

Working with this coalition, National Voices’ charity members and a range of partners have developed the principles of care and support planning.

Common understanding

These principles, which are referenced in NHS England’s participation guidance, aim to create a common understanding of what care and support planning is, both among professionals in different roles and the people who could benefit. They build on the best practice and policy from both health and social care. And they set out an approach that starts from the person’s perspective, enabling better tailored care and support, with a focus on prevention and self-management. This supports a more proactive and holistic focus on wellbeing, as advocated in the participation guidance and the Care Bill

The principles are designed to be accessible and we have developed some draft materials to help put them into practice. A broad range of organisations and individuals have contributed to and supported this work so far, including the Royal College of GPs, National Association of Primary Care, Royal College of Nursing and Allied Health Professionals Federation, commissioners, frontline professionals, our charity members and people who use services.

Now we will develop these materials into a full toolkit. Throughout October, we will be hosting an online conversation on the project and we need views from health and care staff so that we can make sure it works for you. To find out more, express your views and get involved please visit our website.

Laura Robinson is policy and communications adviser at National Voices