Year of Care

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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:

  • to make annual reviews between clinicians and people with long-term conditions truely collaborative
  • to use local services effectively for support self-management.


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.

  • Sharing Results: gives patients the opportunity to reflect on their results in advance, enabling them to be more prepared for their appointment, and more likely to be an equal partner with their Health Care Professional.
  • Care Planning Conversation: this appointment builds on tradition consultation skills but makes room for the patient to contribute their perspective more fuly about living with a long term condition, to explore what matters to them and to ascertain their goals alongside the discussion of tests, examinations and medical management 
  • Supported Self-management: established pathways including social prescribing in Islington enables people with long term conditions to access support from both traditional and non-traditional locally commissioned services that meet their needs within the local community.

Care Planning Team Contacts

Dr Beth Griggs

Social prescribing via AGE UK

Audit Process: 2021/22

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 2021/22. The following process aims to support patient satisfaction, involvement, activation and positive health and well-being outcomes, over time:

  • Annual care-planning strategy and review document: Each practice to complete an end-of-year annual care planning questionnaire to assess current activity and plan for future developments. The questionnaire will cover the following key areas: processes, templates, preparation, capacity building, reflective activities, aims for the next year, support required, feedback for the CCG leads. 
  • Random care-plan sample export: Each practice will also be required to submit a random selection of anonymised care plans from a variety of clinicians and different conditions to CCG clinical leads for review at year end. 

The questionnaire results and care-plan samples will help CCG leads ensure practices are providing quality person-centered care plans and identify particular areas with which practices require specific support.

Eligibility criteria


  • Patients with long-term conditions

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.

How to refer

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.