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Care planning for long-term conditions: part one

Key learning points
- Personalised care planning is a modern way of engaging and collaborating with people with long-term conditions 
 - It is an effective approach that prioritises the patient's decisions and personal goals
 - The 'acute model' and 'person centred' model in self-managed conditions 
This is the first of a series of three articles looking at personalised care for people with long-term conditions, including practical and straightforward ways that this can be implemented in everyday practice.
Articles in the next two issues will cover 'the personalised consultation' and 'engaging and activating people in their health care'. To start the series, this article gives an overview, explanation and implementation guide to the personalised care planning approach, a systematic way of more effectively engaging and involving people in decisions about their care and taking action towards their goals.
As a health professional, you will be very familiar with the idea of a care plan and how to write and implement one. It's something most of us were taught in training and have carried through to the work we do today. Traditionally, a care plan is made for a person, based on the model of a patient unable to care for themselves in some way, for example around the time of an operation, period of severe illness or debilitation. It helps health professionals to be clear about their medical and personal needs and not to forget any aspect of care or treatment. Such a care plan may or may not involve the person in discussion or delivery, depending on their situation. In short, it is a 'medical model' of care, absolutely ideal for acute and/or short-term periods where people are, necessarily, passive recipients of care. 
Over recent decades, there has been a massive increase in the number of people living with long-term conditions. This is due in part to increased life expectancy, in some ways to a response to a modern-day environment, but also because of research and the development of effective treatments. These conditions, including diabetes, asthma, arthritis, stroke and heart disease, to name but a few, are largely self-managed. Nearly a quarter of the UK population live with a long-term condition, and these account for up to 50% of all general practice appointments.1 Today's care planning therefore has a whole new meaning, albeit with the same name.  
In self-managed conditions, it is only what people decide to do themselves every day in relation to their condition that will make a difference to their outcomes. So rather than us deciding and delivering care to people, in the 21st century, our most important role is in collaborating with people to decide about and deliver care to themselves. In order to do this effectively, people need to be engaged and participate in their care much more, and the personalised care planning (PCP) approach has been developed as a way of enabling this to happen.  
PCP provides us with both new ways of looking at our roles in providing care and also new systems in which to work which are more likely to encourage involvement and active decision making for self-care. The PCP approach has been shown to improve attendance, reduce and shorten consultations, reduce costs and enhance self-management, satisfaction and quality of life.2,3
Policy background
Since the late 1980s, successive governments have acknowledged the shift from acute to chronic conditions in the nation's health by gradually including promotion of self-care in health policy. It was most explicitly recognised from 2000 onwards with the creation of a more patient-centred health service and 10 year 'national service frameworks' for many long-term conditions.4 A great deal of research and many publications on implementing self-care followed, including the earliest iteration of personalised care planning, for diabetes care.5 There then followed a three-year investigation into the effectiveness of a new system of care, with diabetes as an example condition, known as the 'Year of Care' approach. The pilot project was completed in 2011 and found to be effective in reducing consultation times and costs and improving satisfaction and experience.2
The most recent NHS reforms in 2013 have echoed and continued the person-centred and personalised care theme, elegantly capturing its ethos with the phrase 'no decision about me, without me'.6 There seems no doubt that personalised care planning is here to stay and it is now mandated by the NHS England,7 articulated in policy documents8 and recommended by key organisations representing health professionals, independent policy analysts and people with long-term conditions, using the 'House of Care' model heralded in the Year of Care pilot project.9 A more personalised approach to long term conditions, promoting self care and proactive problem solving, also contributes to wider health policy ambitions, such as fewer and shorter consultation times and a reduction in unplanned admissions to hospital.1,2
Psychological background
PCP is based on the psychological person-centred approach, which recognises that people are autonomous beings who are more likely to act on the decisions they make themselves rather than following the instructions of others. This is true of people generally, rather than those with a long-term condition. Person-centred models prize autonomy and feature empathy, warmth and congruence (genuineness) as essential components of the helping relationship. These have been explored in many long-term conditions, and found to be influential in achieving and improving management of the condition.10,11 PCP is also based on evidence from those with long-term conditions that shows that the long-term maintenance of effective self-management includes active experimentation, the opportunity for reflection, positive and pro-active support from others, and goal-setting.11
People also respond more effectively to repeated success, with confidence, known as self-efficacy, being a key ingredient in the ability to take action. Confidence is also influenced by the experiences of others in a similar position, information and by stress reduction.12
What does personalised care planning look like?
PCP brings together the medical and psychological evidence discussed above, into a practical system, which includes the following elements:13
 - Awareness raising among people with long-term conditions about involving them more in their care.
 - Routine tests and investigations relating to the condition (blood tests, medication levels, physical examinations, etc) performed in advance of the care planning consultation.
 - Sharing of results with the person, including an explanation of recommended ranges, and an invitation to reflect on these and plan ahead what they wish to achieve from the consultation.
 - A collaborative care-planning consultation, where the views and agendas of both health professional and person with long-term condition are equally valued and discussed, starting with those of the person. The consultation also includes goal-setting and it results in an action plan with items for both parties including for future reviews and consultations. We will be covering the care planning consultation, including key skills to use, in detail in the next issue.
You can see that this approach is in some ways a departure from the traditional model of consulting, where the health professional is much more in control and when results of tests and investigations are typically offered to a person during the consultation at which they are also discussed. This gives limited opportunity for people to process the information they are given, and also often focuses on the health professionals' view of what the results mean and which are most important to act upon. Where people are prepared for it, results sharing and consultation planning in advance has been shown to have a number of advantages, shown in Box 1.
Organisation of personalised care planning: how to get started
You can see that change is needed to the usual way of organising clinical appointments for long-term conditions. This requires some planning ahead, particularly to ensure that people know what to expect from their 'new style' appointment and to arrange results sharing. It is also important to plan changes as a practice or nursing team and to include administration staff.
It isn't necessary, or recommended, to make changes to your whole service for people with long-term conditions at once, unless these fit in with existing plans. PCP can be phased in gradually, starting with the aspect of the approach you feel would most benefit from more personalisation. For example, surveying people to find out if they would like to see their results in advance, or creating a consultation preparation guide for them to use in advance to decide what aspects they would most like to talk, or ask questions about. 
As with most changes, 'starting small', for example involving a few people with long-term conditions, gaining their feedback and reflecting on this, can be valuable in increasing your own confidence towards more collaborative care.
Results sharing can be achieved in a number of ways. After creating a results information sheet and invitation to reflect (Figures 1 and 2 show examples), people can be invited to collect their results a few days before their appointment, or it can be posted to them, emailed or faxed. It's likely that people will have different preferences, so a number of methods can be used. 
Common concerns
The most common concerns expressed by health professionals during training for implementation of PCP, are that people in their clinics will not be able or willing to attend two separate appointments and that they will not be able to understand, or will become unduly worried, about their test/investigation results.14 There is evidence to suggest these concerns are rarely borne out in practice, as acceptability and desire for PCP among people with long term conditions has been demonstrated, including the fact that some people are more likely to attend two appointments than one because of their increased personal relevance.3,15 Also, people may be more often caused worry by not knowing their results or not understanding their explanation by health professionals than by receiving them in advance.14
A further common concern about PCP is how it fits with the demands of the quality and outcomes framework (QOF). In fact, PCP makes a person more likely to achieve results within the recommended ranges for QOF points, because they are more likely to undertake a personalised action plan based on their own priorities, that they have collaborated in creating, than one that is simply given to them and are expected to follow. For example, seeing results for themselves and deciding which they wish to improve is extremely motivating and empowering.16
This article has described the background and context for personalised care planning and shown its benefits and some practical suggestions for how to implement it in practice. PCP is recommended in current healthcare policy to become the norm for people with long-term conditions, so that they are fully prepared and supported to successfully manage their own condition and remain healthy and independent. Subsequent articles will explore the personalised consultation and how to engage and activate people to participate more fully in their healthcare.
1. Royal College of General Practitioners. Care Planning. Improving the lives of people with long term conditions. London: Clinical Innovation and Research centre; 2011.
2. Year of Care. Report of findings from the pilot programme. NHS Diabetes. 2011.
3. Walker R, Davison C, Maher A-M, Law J, Reilly P, Fordjour G, Introducing personalised care planning into Newham: outcomes of a pilot project. Diabetic Medicine 2011,29,1074-8.
4. Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: Stationary Office; 2000.
5. Department of Health. Care Planning in Diabetes. Report from the joint Department of Health and Diabetes UK care planning working group. London: Department of Health; 2006.
6. Department of Health. Equity and excellence. Liberating the NHS. London: The Stationary Office; 2010.
7. Department of Health. A mandate from the Government to the NHS commissioning board April 2013-March 2015. London: Department of Health; 2012.
8. NHS England. Transforming participation in health and care. London: NHS Diabetes; 2013.
9. Coalition for Collaborative Care. Available at:
10. Ryan R. Facilitating health behaviour change and its maintenance: interventions based on self-determination theory. European
Health Psychologist 2008;10:2-5.
11. De Silva D. Helping people help themselves. Health Foundation. London. 2011.
12. Bandura A. Self Efficacy theory: towards a unifying theory of behaviour change. Psychological Review 1977;84:191-215.
13. Walker R, Rodgers J. Implementing Personalised Care Planning for Long Term conditions. SD Publications: 2011.
14. Walker R, Rodgers J. Personalised care planning for long term conditions. Diabetes and Primary Care 2012;14:177-81.
15. Davies P. Results to patients' delivers. Diabetes Update 2012;Summer:40-3.
16. Hong YY, Lim YY, Audrey Lim SY, O'Donnell MT, Dinneen S. Providing diabetes patients with personalised written information in the diabetes outpatient clinic: a pilot study. Diabetic Medicine 2010;27:685-90.