The Department of Health defines care planning as:

"a process which offers people active involvement in deciding, agreeing and owning how their condition will be managed.  It is underpinned by the principles of patient-centeredness and partnership working... It is an on-going process of two-way communication, negotiation and joint decision-making in which both the person... and the health care professionals make an equal contribution to the consultation.

We took the elements of care and support planning that had been widely consulted on within the diabetes community, and working with three very different pilot sites, identified the practical steps that were needed to put these into place in everyday care.  We built on a strong international evidence base which is now supported by a Cochrane Review.  In diabetes this meant changing the annual review which had sometimes become a ‘tick box’ process to fulfil QOF requirements, into a collaborative care planning consultation.

We have now tested and developed this approach for people with multimorbidity in both general practice and community teams.

The Holmside Story 

The Glenpark Story

The underpinning philosophy of care and support planning using our approach is:

  • People with long term conditions (LTCs) are in charge of their own lives and self management of their condition/s, and are the primary decision makers about the actions they take in relation to their diabetes management
  • People are much more likely to take action from decisions they make themselves rather than decisions that are made for them.

This means the healthcare professional has a new role.  Instead of doing things ‘to’ and ‘for’ patients, care and support planning is about doing things ‘with’ people, enabling them to identify their own information needs, goals and action plans, and supporting them to be more effective problem solvers as they live day-by-day with their LTCs. This often requires healthcare professionals to learn new skills as well as new ways of working.