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Changing practice

Care planning in long term conditions: nurse-led care plans for people with diabetes

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An outline of how a GP practice in Northumberland is piloting nurse-led personalised care planning to support patients with diabetes


Linda Helmore, BA, RM, RN, is practice nurse at Burn Brae Medical Group, Hexham, Northumberland.


Helmore, L. (2009) Care planning in long term conditions: nurse-led care plans for people with diabetes. Nursing Times; 105: 38, early online publication.

This is the second article in a three-part series on personalised care planning for patients with long term conditions. It describes how Burn Brae Medical Group is piloting care planning for patients with diabetes as part of the Year of Care programme. The practice first trialled care planning for this group in 2004.

Keywords: Diabetes, Personalised care planning, Year of Care

  • This article has been double-blind peer reviewed.

Practice points

  • Personalised care planning involves patients making decisions jointly with nurses about their care.
  • A care planning discussion can cover social, psychological and other lifestyle issues that impact on diabetes.
  • The outcome of the planning process is a written plan regularly reviewed by the patient and nurse.
  • Motivational interviewing training helped nurses at the practice support people in setting goals and talking about their concerns.
  • The main barrier to implementing care planning could be administration, for example, sending out letters at the right time.
  • Everyone at a GP practice must support care planning for it to succeed. 


The Burn Brae Medical Group is a GP practice in Hexham, Northumberland. Among the population it serves are 350 patients with type 1 or type 2 diabetes.

The practice, along with West Northumberland and North Tyneside, are piloting and evaluating care planning as part of the Year of Care programme. This is a three year project to examine how routine care for patients with long term conditions, starting with diabetes, can be personalised (NHS Diabetes, 2008).

Here we describe how Burn Brae Medical Group uses personalised care planning to support patients with diabetes and discuss how practice nurses can adopt the approach in their own practice.


According to the Department of Health (2006), care planning is “a process which offers patients active involvement in deciding, agreeing and owning how their diabetes will be managed. It aims to help patients with diabetes achieve optimum health through a partnership approach with health professionals in order to learn about diabetes, manage it and related conditions better and to cope with it in their daily lives”.

In 2004, Burn Brae Medical Group was the first practice in England to pilot personalised care planning by launching a six month study involving 30 patients with diabetes. This pilot was set up after Northumbria Healthcare NHS Diabetes Specialist Team asked for practices to volunteer at one of their annual training events. 

The study aimed to see whether care planning would empower patients to take a central role in their own healthcare by working closely with practitioners to draw up a care plan.

During the initial trial, the practice held a small focus group to gather patients’ views on the concept of care planning and the best ways of implementing processes to help them manage their health more effectively.

Among the suggestions made, Northumbria Diabetes Service recommended that patients should be able to see blood and urine test results before their next review appointment, to give them ample time to think of any questions. Sample forms and letters were drawn up and trialled as part of the study.

The pilot was successful and was rolled out to 320 patients with diabetes managed through the practice’s nurse-led diabetes service. Around 30 patients registered with the practice are managed through specialist services.

Year of Care pilot

In 2008, Burn Brae Medical Group joined the Year of Care pilot in NHS North of Tyne. These pilots are being run at three sites in England – North of Tyne, Calderdale and Kirklees, and Tower Hamlets. The programme includes an evaluation phase, training for pilot sites, and the development of new services to support patients to self-care (NHS Diabetes, 2008).

The Northumbria Diabetes Service, in partnership with Diabetes UK, has provided support, educational sessions and sample templates for practices taking part in the Year of Care pilot.

Each patient with diabetes at the practice has an annual diabetes review. They are also offered an interim review every six months, or every three months if there are concerns about their health. Care planning discussions take place at these reviews.

The diabetes review involves two appointments. The first is a pre-clinic one where an HCA or practice nurse collects data, such as blood and urine samples for testing. The second is the care planning appointment to discuss the results and address patients’ concerns.

Before 2004, patients were not given test results before they arrived at the clinic. They had little time to think about issues raised and the discussion was one-sided. Care planning gives them more time to think because they are sent results one or two weeks before attending the clinic.

Along with their latest test results, patients are sent previous results for comparison, and information on what they mean. They are also sent suggestions for issues to discuss in clinic, such as weight management or medication.

The 30 minute appointment focuses on the patient’s most important concerns. The nurse works with them to produce a care plan for managing their diabetes during the coming year. The discussion involves negotiation and joint decision making because it covers both the nurse’s and the patient’s agenda.

The outcome is a written care plan, which is incorporated into the patient’s health record. At Burn Brae, nurses write the plan during the discussion. It is typed later by secretarial staff and sent to the patient. The practice feels the plan has more impact if the patient receives it a few days after attending clinic.

The plan sets out goals the individual patient will work towards, information about self care and an agreement about the services they will use. It could involve them accessing a smoking cessation service, visiting the practice’s dietitian, or seeing a mobility specialist for arthritis.

Patients decide when to come back for another review. At the next review, the nurse and patient revisit and, if necessary, revise the care plan. This gives a focus to the review.

Benefits of care planning

The benefits of care planning at the practice are difficult to quantify because the process is based on patient choice and self management. Benefits will be assessed during the evaluation phase of the Year of Care pilot.

There is anecdotal evidence that care planning is successful, as positive feedback was received during the 2004 pilot. Patients felt more prepared for, and involved in, appointments. Comments about receiving results beforehand included: “It gave me a chance to think about my diabetes and what I could do to improve it.”

When care planning was initially rolled out to all those with diabetes, a few felt it was unnecessary to send results beforehand. These patients are now fully committed to care planning and are among those who ask most questions, and are most involved in joint decision making.

Patients attending clinic take more responsibility for their care. Before care planning was introduced, they attended appointments expecting to be told what to do. Now, the onus is on them to decide on their most important concerns and how they can be addressed.

Supporting people to self-manage and make choices about their condition has reduced the number of unscheduled appointments between diabetes reviews. Patients are having fewer problems between appointments.

Implications for nurses

Personalised care planning moves on from the paternal approach where healthcare professionals set patients’ goals for them. It is person centred, which means it addresses and prioritises an individual’s concerns. 

As patients raise the issues they want addressed, and work with nurses to resolve them, it is easier for practitioners to focus the consultation. It is no longer based solely on nurses’ view of what is most likely to improve someone’s health and wellbeing.

When care planning, nurses also need to take into account patients’ social circumstances. The consultation can cover wider issues that can affect diabetes, such as hypertension and depression.

For example, if a patient is depressed they will not be motivated to go out and be active. They may comfort eat, causing weight gain. Weight management and exercise are key to controlling type 2 diabetes, so tackling depression may be the patient’s main priority.

Resolving non-medical issues involves nurses liaising with other organisations, such as community services and social care. The practice may liaise with the organisation, or provide contact details and information on support and help available.

Supporting people to self-care through information sharing and education is essential to successful care planning. Nurses at Burn Brae Medical Group recommend patients newly diagnosed with type 2 diabetes to attend Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) training.

While the DESMOND course does not suit everyone, it can help people understand their condition better. Held over two afternoons, the course explains what diabetes is and how to prevent complications through diet and other self management techniques (see for more information). After the course, the individual decides which aspects of self care they want to prioritise.

Delivering a personalised service means nurses need to develop new skills so they can support patients to set their own goals. Practitioners have to shift the focus of the discussion away from them to enable patients to voice their concerns.

Nurses at Burn Brae Medical Group found motivational interviewing techniques help with this. They were trained in motivational interviewing by a psychologist during the 2004 pilot, and the Year of Care programme also includes training in this.

Personalised care planning involves everyone in a GP practice so developing good communication and teamwork is crucial. The success of Burn Brae Medical Group is, in part, due to the support of key people in the practice, such as the GPs and practice manager, and the diabetes team who supported the personalised care planning approach.

Receptionists and secretaries must also feel part of the team. They must understand the care planning approach because they fill in and put test result sheets in the post. Probably the biggest challenge to care planning was scheduling appointments to give patients time to think about their results.


Burn Brae Medical Group has offered personalised care planning to patients with diabetes since 2004, and it is a routine part of practice. Nurses and patients have responded positively to the planning process. The practice will evaluate the success of care planning during the Year of Care pilot, and hopes to introduce this approach to other patients with long term conditions in the future.


  • In 2004, Burn Brae Medical Group was the first practice in England to pilot personalised care planning.
  • It is currently participating in the Year of Care pilot programme in the NHS North of Tyne area.
  • The practice offers nurse-led care planning during patients’ regular diabetes reviews. Patients receive their results ahead of their review appointment.
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