This provides direct access to main Year of Care documents:

The Year of Care approach: developing a model and delivery programme for care and support planning in long term conditions - The paper, published in BMC Family Practice in November 2019, describes the theory, learning and implementation journey to enable care and support planning to be introduced with high fidelity to the core principles, whilst tailoring it to the unique characteristics of each practice and their population.

Getting to Grips with Year of Care: A practical Guide: 2008 This document was produced at the end of the Year 1. It summarises the background and learning from the first phase of Year of Care (YOC) programme including the key thinking around care planning and commissioning. It introduces and provides an overview of the Care Planning House. It remains a useful introduction to the Programme.

Personalised Care Planning for Diabetes: Policy Lessons from Systematic Reviews of Consultation and Self-Management Interventions. Primary Health Care Research & Development, 10, 210-222Graffy J, Eaton S, Sturt J & Chadick P 2009. This describes the evidence base for the components that were put together to develop a practical approach to care planning.

Partners in Care: A Guide to Implementing a Care Planning Approach to Diabetes Care: 2nd ed. 2010 This is the key Guide to the philosophy and delivery of the care planning consultation and is an important resource for practitioners wishing to reflect on their practice and introduce care planning. It is used in Year of Care training.

Care planning – Improving the lives of people with LTCs; encouraging partnership; increasing the quality of Care: RCGP: 2011 Produced herewith kind permission of the Royal College of General Practitioners this document was produced with the support of key members of the YOC programme. It is a comprehensive account of the rationale for support for self-management in LTCs, the case for change, and practical delivery and monitoring of care planning. It provides practical examples and key tips on how to introduce care planning at practice level by ‘walking around the house’. It provides a detailed ‘how to do it’ manual.

Year of Care report of findings from the pilot programme and Year of Care: Pilot Case Studies: 2011 - This is the formal report on the Programme describing the background, aims and objectives, parallel evaluations, the way the programme was delivered and its impact. Case studies of each of the pilot sites are provided as companion documents. Together they include key learning about implementing the Year of Care approach to care planning and the lessons for commissioning for LTCs. They will be of interest to policy makers, those with broad interests in commissioning and service delivery of personalised care for those with LTCs, and anyone contemplating introducing and embedding a programme of cultural change across the NHS.

Thanks for the Petunias – a guide to developing and commissioning non-traditional providers to support the self-management of people with long term conditions: 2011 This Guide was produced in response to the discovery that there are numerous barriers and lack of experience in commissioning non-traditional community services to support self-management. It outlines these issues and provides a commissioning and delivery model which addresses them. It will be of particular interest to clinical commissioning groups, public health commissioners and Health and Wellbeing Boards.

King's Fund delivering better services for people with long term conditions 2013 - This report summarises the case for change and endorses the use of the Year of Care approach using the House model to demonstrate the essential elements which need to be in place to deliver better services for people with long term conditions. It provides examples of good practice and suggests what organisations need to have in place to deliver care planning and support for self-management more routinely.

Delivering person centred care in long term conditions: BMJ 2015 - This BMJ article describes the need to transform care for people with long term conditions, including support for self-management, and the need for comprehensive reform of health systems which are currently geared to provide acute care. Simon Eaton, Sue Roberts, and Bridget Turner explore the barriers to change, outlining the success of the Year of Care and House of Care approach as a driver for both cultural change and whole system change.


Care and support planning for people with MSK conditions

'Bringing MSK conditions in from the care planning cold - a feasibility study' phase one interim project report - this report comes at the end of phase 1 of a two phase approach designed to tease out the issues of practical delivery and develop the tools and MSK specific resources, so these can be tested and refined as part of a multimorbidity approach to CSP in phase 2. 

'Bringing MSK conditions in from the care planning cold - a feasibility study' Final study report - This Final Report brings together the learning from both Phases of a feasibility study of care and support planning (CSP) for people living with joint, muscle and bone (MSK) conditions.  It builds on the detail and lessons in the Phase 1 Interim Project Report, describes additional learning and highlights dilemmas and further questions which warrant future discussion and investigation.  It also celebrates the successes of the study and describes some of the benefits seen by individuals who live with MSK conditions. We also make recommendations to Versus Arthritis, policy makers and commissioners and professional leaders and training bodies.


Other Year of Care Publications

Theory and the Real World – What happens in Practice: Introducing a complex intervention into a complex environment: ten challenges and dilemmas from the YOC Programme This brief review from the Year of Care Stakeholder Reviewer is also summarised as Chapter 17 of Year of Care: Report of findings from the pilot programme. It describes some of the real challenges of introducing complex change within a complex organisation like the NHS. It should prove of interest to policy makers, service and project managers and innovation leaders.


Additional summaries and reports

‘The Year of Care’: 2011 A 2 page overview including achievements of the programme, benefits and lessons for wider implementation 

Year of care: 2011: A 4 page summary of key information including details of the Year of Care approach to care planning and the house model 

The Year of Care Programme: Commissioning for Diabetes and other Long Term Conditions: 2011. This two page summary outlines the Year of Care long term conditions commissioning model with examples of increased productivity 

Workforce issues and service planning for people with Long Term Conditions (LTC): 2011. This single sheet clarifies the differing needs of people with LTC and the differing roles of NHS staff that provide care and support


Internal documents commissioned for use by Year of Care Pilot Programme

Year of Care: Evaluation Policy Statement: July 2009


Reports from Tribal Consulting (now Capita)

Evaluating Pilot Sites as they Prepare for Year of Care: 2008

Year of Care: Calderdale and Kirklees Case Study: September 2009 

Year of Care: North of Tyne Case Study: September 2009

Year of Care: Tower Hamlets Case Study: September 2009

Evaluating the delivery and Impact of the Year of Care for diabetes Project: Interim report: November 2009


Reports from Annual Stakeholder Interviews

Wave 1: Stakeholder views on phase 1 of the Year of Care programme and its local and national achievements to date: February 2009

Wave 2: Views and decisions for consideration by Year of Care programme board: Wave 2 interviews with key stakeholders: January 2010 

Wave 3: Year of care: Reflections on introducing a complex intervention into a complex environment February 2011 


Year of Care in Scotland

From fixer to facilitator: evaluation of the House of Care programme in Scotland, 2020 (Cook A, Grant A)

Care and support planning and House of Care: A key enabler of the new GMS Contract: High level 

Care and support planning and House of Care: A key enabler of the new GMS Contract: Practice level


Other resources

Realistic Medicine: Scottish Government 2014-2015

What is the role of voluntary, community and social enterprise (VCSE) organisations in care and support planning? National Voices: 2016 

National Voices – an introduction to care and support planning: 2014 

Gaun Yersel. The self-management for long term conditions in Scotland: 2008 

Enabling people to Live Well. The Health Foundation: 2013 (Entwistle V, Cribb A)

The more you know, the more you realise it’s really challenging to do: Tensions and uncertainties in person centred support for people with long term conditions. Patient Education and Counselling: 2018 (Entwistle V, Cribb A, Watt IS, Skea ZC, Owen B, Morgan HM, Christmas S)

Personalised care planning for adults with chronic or long term health conditions: 2015 (Coulter A, Entwistle VA, Eccles A, Ryan S, Sheppherd S, Perera R)

Improving Chronic Illness Care: Translating evidence into action: Health Affairs: Nov-Dec 2001 (Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A)

Chronic Disease Management: What will it take to improve care for chronic illness? Aug-Sept 1998 (Wagner EH)

Organizing care for patients with chronic illness: 1996 (Wagner EH, Austin BT, Von Korff M)


British Heart Foundation 'House of Care' project

Gateshead BHF House of Care Report

Gateshead experience of the BHF House of Care Project

Hardwick cost analysis case study - this document offers a simple analysis of the differences in routine care and costs, pre and post the introduction of the House of Care - the British Heart Foundation (BHF) Year of Care project. It is intended to complement evidence about how the BHF funded programme impacted on the quality and outcomes of care. ICF, Clare Walker (Hardwick Project Manager) and Year of Care Partnerships, 2017.


Normalisation Process Theory

YOC - NPT - Spreading and embedding complex interventions 

How to ensure your programme is a success