In 2007 the Department of Health sponsored Year of Care Partnerships (hosted by Diabetes UK) to work with grassroots clinical teams to establish how to introduce care planning and support for self-management as part of routine management for people with long-term conditions (LTCs) using diabetes as an exemplar.

  • The programme recognised the challenge of LTCs and the need firstly to enhance the routine biomedical surveillance and ‘QOF review’ with a collaborative consultation, based on supporting effective self-management, via care planning.
  • And secondly to ensure that there is a choice of local services people need to support the actions they want to take to improve their health, wellbeing and health outcomes available through commissioning.

We successfully demonstrated how to use care planning as a systematic way to make routine contact between the person with the LTC and the healthcare professional more relevant and effective. 



Care planning enables the individual to identify their own goals, action plans and any support they may need (micro commissioning). This becomes a gateway to providing personalised support, which:

  • Links traditional clinical care with support for self-management
  • Signposts to community resources made available as part of wider local commissioning (macro commissioning)
  • Coordinates health and social care where appropriate.  

We also produced guidance on how to commission a wider range of local services to support people with LTCs in the community 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