Care Planning Project - The Camden Care Planning Ambition

Under Review — this page was due to be reviewed by 21/01/2022. The information shown here may be outdated.

The mandate for the Long Term Conditions and Cancer (LTC) Programme sets out clear ambitions for improving the outcomes and quality of life for people living with long term conditions through involving them in the delivery of their own care and embedding personalised care planning. 

The aims of the care planning project are to;

  • Support an effective approach to care planning
    • Establish supporting IT and other processes
    • Embed in new LTC Locally Commissioned Service agreement where possible/appropriate.
    • Facilitate access to the care plan by other clinicians in community and secondary care settings.
  • Roll out a consistent approach to care planning across Camden based on a review of existing work in Camden and what works.
    • Patient centred approach - clinical templates will be reviewed to support goal setting and action planning. 
    • Work will be done to create a standardised Camden Care Plan, care planning leaflets and materials to be used in general practice.
  • Identify and train relevant clinicians and practice staff within practices in the care planning approach.
    • Training will involve whole practice teams
    • Local champions to support care planning across their area.


It is the aim that fully embedding a care planning approach in general practice will improve outcomes for both patients and clinicians by;

  • Decreasing the number of unscheduled visits to the GP
  • Improving data completeness of care processes
  • Increasing the number of patients who feel supported to manage their care (GPPS) 
  • Increasing the number of care plans shared with patients in General Practice.

To learn more, see our short three minute video about care planning in Videos.

‘Year of Care’ care planning approach

The ‘Year of Care’ two consultation approach will be delivered for ‘high risk’ patients registered with COPD or Diabetes:

  • First stage appointment with the patient to address any pre consultation tests and inform them about the process and to start them thinking about their self-care goals
  • Notification of any relevant results to the patient (where appropriate)
  • A double appointment (20mins) to develop the care plan - using motivational interviewing the clinician explores with the patient motivations and possible goals to support condition management and self-care.
  • A portable copy of the patients personal care plan is generated (electronic or paper options) 

N.B The last two points only will be required for conditions which require an Enhanced Clinical Review (see the Planned Care LES).

A workshop took place 12th June 2015 to engage stakeholders in the plan to fully embed care planning. Feedback from this event will be used to develop the approach and motivational and take forward ideas for a new Camden Care Plan format. Please see link to Care Planning Report.

Support to embed care planning approach

Year of Care Facilitators

Year of Care Facilitators will work with GP practices to support efforts to embed care planning into practice and work under the Planned Care LES (Enhanced Clinical Reviews and Year of Care). They will work closely with the Planned Care LES Support teams.

What happens next?

  • Training for all clinicians in the ‘Year of Care’ Personalised Care Planning approach to be delivered across Camden.
  • Work will continue with the IT team to develop materials for care planning, existing clinical templates will be reviewed to ensure they support the care planning approach.


For more information about the commissioning of training and the implementation of care planning contact Camden via:

The Long Term Conditions & Cancer Programme at


Care Planning Workshop Video (short)

Care Planning Workshop Video (long)



Care Planning Workshop Report

Care Planning Leaflet 1 (Green) - To print please go to Printer Preferences and select under Binding 'Flip long edge (Left). Orientation should be Landscape

Care Planning Leaflet 2 (Blue) - To print please go to Printer Preferences and select under Binding 'Flip long edge (Left). Orientation should be Landscape

GP Personalised Care Planning for Long Term Conditions Poster

Presentation for Practice TV screens