Islington Directorate, North Central London (NCL) Clinical Commissioning Group (CCG), has adopted a "care planning approach" for people with long-term conditions, which involves them working with health care professionals to make joint decisions about how their condition(s) can be best managed. This creates an oppotunity for patients to feel more in control of their health management: learning to live well with their condition vs having a well-managed condition.
Supporting patients with long-term conditions take both time and huge financial commitment from the health service. A care-planning approach aims to ensure our contacts with patients are as effective as possible for widest possible gain. The aims of the care planning approach are:
People with long-term conditions have an annual review that is a two-part process involving the sharing of results and a collaborative conversation. This is a chance to explore both the patient's and the professional's agenda to come towards a set of shared goals in an action plan for the coming year.
Dr Beth Griggs
Social prescribing via AGE UK
Care planning has been successfully delivered in primary care in Islington for more than five years. Evaluations have demonstrated significant increases in both reach, perceived quality of care plans, and confidence of practice staff with care planning. In light of the growth seen in care-planning provision across Islington, the CCG wants to ensure the quality of care plans is maintained, and that care planning is targeted effectively at those patients who would most benefit from the process.
To ensure high-quality care planning consistently across practices and facilitate sharing and learning from each other, a care-planning quality-review process will be implemented from 2020/21. The following process aims to support patient satisfaction, involvement, activation and positive health and well-being outcomes, over time:
The questionnaire results and care-plan samples will help CCG leads ensure practices are providing quality person-centred care plans and identify particular areas with which practices require specific support.
Please note: Patients with multiple co-morbidities should not be required to have consultations for each of their conditions, but rather a single hollistic care plan review of all conditions.
The following clinicians can refer to this service: GPs, Nurses
Referral methods: Hand to Patient
People with long-term conditions have an annual review that is a two-part process involving the sharing of results and collaborative conversation.