Year of Care Partnerships have now worked with a number of organisations to implement care and support planning in a variety of settings and with different conditions. This includes diabetes, multiple long term conditions within a primary care setting and multimorbidity / older people living with frailty.

Year of Care has been working with South West London Health and Care Partnership since spring 2018 on their NHS TestBed project 'You & Type 2'. This implementation of Year of Care care and support planning for people with diabetes across GP practices in the area was accompanied by the design and introduction of supporting technology. This was in the form of software and an app for patients and professionals to access and share information and also personalised video messages sent to people in between their appointments at the practice.

You can hear more about this exciting project in the project launch video here


In July 2017 Lindsay Oliver, Nick Lewis-Barned and Yvonne Doherty went to Singapore to train 30 endocrinologists, general practitioners, nurses, pharmacists and dietitians in care and support planning and a different style of conversation. The intensive two day training at the Division of Endocrinology, National University Hospital (NUH) in Singapore focused on the principles, philosophy and skills of care and support planning and how these could be implemented within their very different healthcare system.

Year of Care also spent time supporting the NUH team to consider how to adapt the programme delivery within the diabetes specialist care setting. The training was attended by GPs from local poly clinics who have since set up a formal study (PACE-D) with support from the Year of Care team and NUH to look at what is needed and the local impact of implementing care and support planning in this community setting.

Please click here to read an article written by the NUH team that covers the success and challenges they faced.


We recently worked with GP Practices in Newcastle to capture stories from a range of primary care staff that detail their personal experience of implementing care and support planning. They have been captured in the document 'Newcastle Practices - Care and support planning stories from the frontline'.

In June 2018 Year of Care jointly presented a poster with Newcastle Gateshead CCG at the Kings Fund event 'Reimagining General Practice' on the fantastic work that the CCG has supported and is continuing to support for people living with long term conditions and multimorbidity. You can see the poster here. The poster describes how collaborative care and support planning has been used to stimulate redesign of general practice care for people living with long term conditions and multimorbidity across the CCG.


In 2016 Carlisle Healthcare embarked upon their implementation of an integrated approach to personalised care and support planning (CSP) for those with multi-morbidity and frailty who would otherwise be unable to attend their usual surgery for routine care. This built on an established approach to care and support planning for people with long term conditions who would usually attend the practice for their care. To read more about this please see The Carlisle Story or watch Dr Robert Westgate describe the approach at Carlisle Healthcare here.


The Holmside Story, Glenpark Story and St Triduana's Story illustrate how three practices have implemented care and support planning for their long term condition population ensuring that individuals who have multiple conditions do not have separate disease specific care planning appointments.

Dr Becky Haines is a GP from Glenpark Medical Centre and delivered a keynote speech at the Year of Care Community of Practice Network Event in June 2016. She discussed how the practice decided to implement care and support planning and the journey they have been on ever since. To see a summary of some of the main points Becky raised please click the link below:

Becky Haines - The Glenpark story – Care and Support Planning in Multi-morbidity


Tower Hamlets was one of the original Year of Care pilot sites.  GP and clinical lead Isabel Hodkinson describes the Tower Hamlets story in this video. 


CSP and Adult Weight Management service

The recommissioning of the tier 3 specialist adult weight management (AWM) service in North Tyneside in 2014 provided the opportunity to redesign a more flexible person centred service that incorporated the principles of preparation for a better conversation in addition to a goal setting and action planning approach as promoted by Year of Care Partnerships (YOCP). Please click here to read about how the service was redesigned to better meet the needs of its users following a care and support planning approach.