The financial downturn has led to a frenzy of activity to increase productivity at lower cost but improved quality.  This is indeed a challenge for the NHS. Given the management of long term conditions in the NHS utilises 70 per cent of the expenditure in the NHS, a focused look at this arena could bring about considerable benefits in the current climate.  

The Our health, our care, our say white paper stated: “By 2010, we would expect everyone with a long term condition to be offered a care plan.” Several documents, including the recent NHS 2110-2015: From Good to Great, have signalled the move towards self care, personalisation and care planning.

Care planning involves recording, in the patient’s own words, the issues important to that individual and how these impact on self caring for the conditions that they have so that self directed goals can be set by the patient to actively improve self care. 

It is important to capture this information in the patient’s own words so that the patient can relate back to these on a regular basis.

There is evidence of the benefits of implementing care planning for patients with long-term conditions (1-6) as well as a number of national and regional strategic drivers citing the approach as “best practice”.

Using standardised care planning templates/datasets within a shared clinical system acts as an enabler to providing integrated services and improving the patients experience. The 2008/09 GP patient survey around care planning and financial savings found that 61 per cent of people with a discussion or a care plan say they have better care as a result.

A typical practice (6,300 patients) in the upper quartile for care planning will typically have 35 fewer emergency admissions, 360 fewer outpatient attendances and 30 additional elective admissions/day cases compared to the poorest quartile. These figures would represent a saving to the practice (if they are a practice based commissioner) of around £43,000 a year.

Further evidence following a literature search conducted by Department of Health analysts some years ago on the benefits of care planning found evidence of benefits relating to: reduced emergency attendances and inpatient days, quality-of-life, greater knowledge and confidence in being able to cope with a condition, better use of medication, reduced costs and overall improved quality of care.

Local experiences with care planning in Yorkshire and Humber region

Care planning has been piloted for adult patients who have diabetes in the several health communities across the Yorkshire and Humber region.

Bradford and Airedale

Bradford and Airedale piloted the diabetes care planning templates as part of an overall pilot of the Year of Care approach. The pilot concluded in 2009. A significant outcome was that the PCT is now recruiting two dedicated posts to train and support 40+ practices working towards Level 2 accreditation in implementing care planning with their diabetes patients. This work is part of the primary care trusts diabetes service redesign. 

An evaluation was performed as the pilots were implemented and yielded some important learning points. The pilot was mainly conducted in primary care, centring on six general practices. The practices received training on the care planning approach and the use of templates developed in SystmOne before using them in patient consultations.

Secondary care activity was limited to providing consultants with a view of the patient record created and maintained in primary care. This generated training issues for secondary care users that were not resolved during the pilot timeframe. Extensive learning was captured from each of the six practices about the use of the templates by clinicians. This is being used by the PCT to shape future implementation of the care planning approach with 40+ practices working towards Level 2 accreditation.

A review of the pilot did find that practitioners and patients demonstrated “substantial enthusiasm for the care planning approach and the concept of shared electronic health records”. The feedback from the study is being used to modify deployment and training methods for any subsequent roll-outs

Lessons learned about the requirements for training and support of users included:

  • the need for standard documentation to support care planning 
  • a clear explanation and management of the impact on working processes
  • the need for integrated training that covers the care planning consultation and use of the template from a clinician’s point of view (rather than from a system trainer) including how a clinician would work through some of the situations and barriers a clinician might face in practice with patients. Ideally this should be delivered by someone with a clinical background and understanding
  • dedicated post classroom training support for users is also needed.

NHS Kirklees

NHS Kirklees originally embarked on their pilot in partnership with NHS Wakefield & District. Earlier this year both communities agreed to dissolve the partnership pilot project in favour of aligning the deployment of the templates and implement the care planning approach across their respective health communities. 

In line with the original scope for NHS Kirklees, the care planning templates have been used by six general practices/medical centres, diabetic specialist nurses and podiatrists and will be evaluated.

To date, 744 care planning consultations have been recorded in Bradford and Airedale and Kirklees health communities (340 in Bradford and Airedale 404 in Kirklees)

Extending care planning to other long term conditions

From our experience with care planning with diabetes we now advocate the use of a generic care planning template with other long term conditions as well, and illustrate an example of how this has been implemented in a general practice below.

The management of long term conditions in the NHS is usually not proactive, is semi planned in most cases and often only deals with one condition per consultation, for example asthma clinics. This means that patients with several long term conditions will need to go to several appointments through the year with the associated travel costs and attendant organisational difficulties.

We describe a more proactive and planned approach to the management of long term conditions in primary care. This has been piloted in a general practice in Bradford.

All patients with one or more long term conditions were identified in the practice and then segregated into groups of one, two, three or more conditions. This amounted to about 25 per cent of the overall practice population.

These patients were then given appointments to attend the surgery to have a consultation for all their long term conditions. This involved the process of care planning with the patient, collection of relevant data needed for the management of the condition/s and providing a clinical link in the practice as liaison for the patient.

Each of the long term conditions can be considered as the patient wishes to enable a “true picture” to be built of the patient’s concerns and issues. During this process all parameters relating to quality outcomes framework for that condition/s can be recorded on the template with ease. 

This process can be followed for each of the long term conditions that the patient may have and enables all the information to be collected in one appointment rather than several appointments through the year.

The patient sets goals to address some of the issues highlighted eg weight loss or stopping smoking. These can be recorded on the care planning template, together with the chosen method to be used to work towards this goal. The template enable a facility to record whether this is a wellbeing goal, or to reduce complications and has several categories to capture this information. The chosen method can also be added so that the goal is driven entirely by the patient methods. 

Whether the required service is available at present in the locality or if there is an unmet need can also be recorded so that commissioning at a micro and macro level for that long term conditions can be properly informed.

Analysis of some recent data using this approach with diabetes has shown that the majority of the goals relate to immediate concerns, ie improving wellbeing. “Traditional” diabetes care focuses more on avoidance of long term complications, perhaps suggesting a mismatch with patient priorities. This data can be used to refine training for staff providing diabetes care and by commissioners for macro commissioning purposes.

The data collected for the long term conditions can help to improve the QOF figures in primary care as much of the data also populates the QOF templates. This process can also help to address shortcomings in underperforming practices in primary care. Doing this at one time rather than in a haphazard way in different consultations enables primary care to be more efficient in data collection and saves the patient form having to attend an appointment for each of their long term conditions.

Once the care planning process is complete, the information can be printed off and given to the patient as a record. This acts an aid memoir of the consultation, the goals agreed and potential discussion points for the next care planning session.  A named individual from the practice (eg nurse) can be assigned to the patient so they can contact this individual to clarify or speak about concerns or problems relating to care. 

Evidence indicates that this opportunity for the patient to contact a named person can lead to greater personal satisfaction with care and helps to lower out of hours A&E attendances and reduced admissions.

Once the above process is in place the patient access to the practice changes and appointments are freed up, thereby improving access for other patients needing to be seen acutely. Also follow-up appointments for these patients can be made to review progress against patient’s goals on an as required basis.

Learning points and future challenges

Care planning approach has identified that many patients are reluctant to accept responsibility for their care, as their care has been “medicalised” over the years. Patients on the whole like care planning and setting their own goals. This process has helped to identify gaps in patient education and misunderstandings which once filled enable better engagement and active self care.

The time spent care planning with the patient has led to many instances where the patient has had a moment of epiphany that has transformed their whole approach to self care. The process has helped with communication and allows the practitioner to “meet the patient where they are at” to influence self care. An identification of the methods used to achieve patient goals has provided valuable feedback to the commissioning process.

To illustrate the impact, one patient stated: “I have never been so involved in my care before.”


Where the integrated care planning approach is implemented using shared clinical templates/datasets to record the care planning consultation this further enables the patient record to be shared with secondary care so that e-consultations can be carried out instead of outpatient appointments.

This means that where a secondary care consultant opinion is needed then a task can be sent (providing that secondary care is using the same or a compatible system) with the attached full patient record for that opinion. This process is quicker; provides a timely response to the patient and is safer when compared with letter referral. 

An economic analysis recently conducted in NHS Yorkshire and Humber on the implementation of e-consultation for diabetes showed the potential for considerable financial savings for all trusts across the region.

Challenges to implementing care planning

Care planning requires time to do properly and well but gets easier as more consultations are done. It involves a change in the way general practice is conducted currently – makes patient management more patient centred and proactive than ever before.

One could argue that we do have call and recall systems for diabetes and other long term conditions and so do plan care for these patients but the care planning approach is more proactive, patient centred and motivates patients to actively self care. 

Some doctors however, may not like the shift in control to the patient nor the reorganisation in their current way to conducting general practice, although we have noticed this to be of significant concern in this region.

Practices will need to reorganise the workload for this to happen. This means careful planning of time and flexibility should this be needed until a steady state is developed in the practice population of people with long term conditions.

To do this properly requires a cultural change in general practice and leadership. Identification of patients with long term conditions is simple task but the reorganising of clinics is more of a challenge. Training is needed on the templates and the care planning process. In the Yorkshire and Humber region, the pilot practices have received training and, where required, one to one support with a clinician has been provided.

We propose that roll out of care planning for long term conditions could be carried out on a larger scale in the regions by training local champions, providing training on the templates and support for strategic health authorities and the DH. 

The current strategy we have adopted is to raise awareness of this approach for long term condition management in the region through an event; dissemination through the clinical leader’s network, practice based commissioning groups, national association of primary care regional events, and Healthy Ambition work streams. Given the national drive for the implementation of care planning this regional work provides evidence of the benefits and positive outcomes which can be achieved using this approach. 

We believe that this approach is not only innovative, but can be used to address the QIPP agenda for the coming years and provide savings and improved quality of care at a time when the NHS is severely challenged.