All patients with long term conditions are to be offered a personalised care plan by 2010. This article details how this approach can benefit both patients and staff
Tracy Morton is senior policy manager in the long-term conditions strategy team, commissioning and system management directorate; Maureen Morgan, MBA, RHV, RN, is nursing officer for policy and practice and part of the chief nursing officer’s professional leadership team; both at Department of Health.
Morton, T., Morgan, M. (2009) Examining how personalised care planning can help patients with long-term conditions. Nursing Times; 105: 37, early online publication.
This is the first article in a three-part series on personalised care planning for people with long-term conditions. This first article describes what personalised care planning is, its benefits for nurses and patients and how nurses can adopt this approach in healthcare settings. It also examines how Department of Health policies and initiatives can help implementation.
Keywords: Personalised care, Long-term conditions, Patient experience
- This article has been double-blind peer reviewed
- Personalised care planning aims to give people with long-term conditions more control over which treatments and services they receive, addressing their full range of needs and supporting them to self care.
- Lord Darzi’s report, High Quality Care for All, committed the NHS to offering, by 2010, a personalised care plan to all 15.4 million people in England with a long-term condition (Department of Health, 2008b).
- Currently, half of those with long-term conditions are unaware of their treatment options and do not have a plan for managing their condition (Opinion Leader Research, 2006).
- Nurses such as community matrons, specialist nurses and practice nurses are developing the right skills, approaches and behaviours for delivering personalised care planning, and they need to build on this.
- Practitioners need to think about their approaches when providing care. Are they really listening? Are they thinking about the wider needs of patients with long-term conditions, such as providing psychological and emotional support? Are they supporting them to self care and make informed decisions?
People with long-term conditions have told the Department of Health that they want services that help them remain as independent and healthy as possible.
They also want quality information to help them understand and manage their conditions better and support wider choice. Patients have also indicated that they want more services delivered safely and effectively in the community or at home, with more proactive and integrated services personalised to them and their needs (Opinion Leader Research, 2006; DH, 2005a).
The DH has responded to this feedback by developing policies and strategies aimed at supporting people with long-term conditions to be more independent and in control of their condition. For instance, The NHS Improvement Plan (DH, 2004) - which builds on The NHS Plan (DH, 2000) - aims to modernise the NHS by putting patients at the centre of care and decision making.
Personalising services and listening to what patients really want has been a major theme of government policy in recent years.
Personalised care planning offers an excellent opportunity to tailor care for those with long-term conditions. However, to be truly successful, care planning needs to be developed with patients, not done to them. This means supporting them to be actively engaged in the process rather than passive recipients.
There are 15.4 million people in England living with one or more long-term conditions. These are defined as conditions that cannot currently be cured, but can be controlled by medication and other therapies (DH, 2008a). Lord Darzi’s report, High Quality Care for All, committed the NHS to offering a personalised care plan to all these people by 2010 (DH, 2008b).
People with long-term conditions are frequent and long-term users of health, social care and community services. They use 52% of GP and 65% of outpatient appointments, but account for only 31% of the population (Office for National Statistics, 2005). Care and services for this group have tended to focus on medical needs and treatments without sufficient attention given to social, psychological and other holistic needs.
Most people with long-term conditions are keen to take responsibility for their health. Over 90% say they are interested in being more active self carers, and over 75% would feel more confident self caring if they had help from a healthcare professional or peer (DH, 2005b).
Despite this, many patients with long-term conditions have limited knowledge of or influence over their care. For example, half are unaware of their treatment options and do not have a plan for managing their condition (Opinion Leader Research, 2006).
Personalised care planning
Personalised care planning aims to put people on an equal footing with health and social care professionals, moving away from “doing to” to “doing with”. A care planning consultation should feel like the “meeting of two experts” - the patient/client and their clinical carer.
It focuses on a discussion with individual patients about goals to support their health and wellbeing, such as returning to work, stopping smoking, improving diet or living independently. The discussion should also focus on supporting them to self care, and finding out what impacts on their health and wellbeing, such as poor housing and emotional and psychological needs.
Choice should be stimulated through personalised care planning, which embraces three key components. These are people having:
- Power to shape their pathway through services and keep control over their lives;
- Preferences to choose how, when and what treatments or other services they receive;
- Personalised services organised around their lifestyles.
Care planning should be proportionate to need. For example, for those with a range of complex needs, it is led and coordinated by one professional, such as a community matron or specialist nurse. It follows a health and social care assessment of need and takes more time and is more detailed. There is a strong emphasis on coordinating services and contingency planning.
For those with less complex needs, the planning process must include information about how their condition impacts on their life and support for self care so that each patient can make the best decisions and decide how best to manage their condition.
Providing patients with information such as test results or prompting them to think about questions to ask before the care planning consultation also helps them to reflect and prepare to get the most out of the discussion. It also establishes an equal relationship with their healthcare professional.
The care plan
The care plan records the outcome of the discussion between the patient and healthcare professional and lists any actions agreed. The patient owns the plan, can receive a printed copy, and chooses who has access to it. The level of detail will naturally depend on the complexity involved in their long-term condition.
For example, a care plan for an elderly person with heart disease, diabetes and arthritis will be detailed and would include information about medication, contingency or emergency planning for exacerbations, in addition to detailing their health and wellbeing goals.
At the other end of the spectrum, for someone young and fit with moderate asthma, the care plan could include advice on how to use inhalers, details of websites such as NHS Direct that provide information on self care, a goal to quit smoking and a referral to a quit smoking service.
Benefits of personalised care planning
Many benefits can be gained from personalised care planning. International evidence shows best outcomes are achieved when there are: systematic proactive services; people engaged in their own care; and healthcare professionals and people with long-term conditions working in partnership (Wagner et al, 1996).
People who feel more confident to manage their own health tend to feel more confident in their everyday lives and therefore have a higher quality of life. They also tend to have improved clinical outcomes (Newman et al, 2004). Supporting people to self care through care planning can reduce GP visits by 40% for high-risk groups (Fries and McShane, 1998) and reduce hospital admissions by 50% (Montgomery et al, 1994).
Nurses should see people taking more active involvement in their health and wellbeing, which should lead to them relying less on services. An overall improvement in the management of long-term conditions should free up nurses’ time, allowing them to focus on proactive and preventive approaches.
Another benefit is improved job satisfaction. Community matrons, for example, say they find proactively managing patients with complex needs, using holistic assessment and care planning techniques, hugely rewarding, according to anecdotal evidence. A patient with COPD in Kirklees said: “Without the support from my community matron to stop smoking I wouldn’t be alive now” (from a forthcoming DH case study).
Delivering personalised care planning
Supporting people with long-term conditions requires healthcare professionals to adopt a different role to the traditional “diagnoser and treater”. They must support patients in acknowledging, understanding and adapting to their condition. This is essential since, by definition, long-term conditions are incurable and their effects are permanent and variable.
Healthcare professionals are the “experts” in understanding disease. However, patients will know best whether proposed treatments or support fit into their lives. While they may value help deciding what will work for them, they must make the final decision if the plan is to work.
Adopting a personalised approach involves supporting patients to decide what they need rather than deciding for them. Nurses should consider how they interact and engage with patients. Are they really listening to what they want, providing information, and supporting them to self care?
Guidelines to help nurses develop skills to support patients include Common Core Principles to Support Self Care (Skills for Care and Skills for Health, 2008). Practitioners keen to gain further skills may be interested in learning techniques such as motivational interviewing or cognitive behavioural approaches, which are effective for motivating people to change behaviours.
Linked to the care planning commitment is Your Health, Your Way, formerly known as the Patients’ Prospectus (DH, 2008c). This aims to raise public awareness of what services they should expect to be offered to support self care.
Your Health, Your Way should begin to drive demand for services such as the Expert Patients Programme and peer support networks, or tools and equipment such as blood pressure monitoring devices or handrails.
An information booklet for healthcare professionals was recently published, alongside a range of online practical tools and resources. Further national tools are currently being developed, including e-learning modules for care planning and information prescriptions (DH, 2008d).
Delivering personalised care, listening to patients, and putting them at the centre of their care requires a cultural shift from “doing to” patients to “doing with” them. Nurses may feel they are familiar with the concept of care planning, but true personalisation takes this to a new, more dynamic level. The care plan itself can also be a vehicle for patients to hold important information, a significant step in shifting the locus of control.
Finally, no amount of good intentions will change practitioner behaviour if the working environment is not supportive. If the timing of appointments is wrong, if patients do not have the information or understanding to take part, if working practices are geared to tick boxes and if commissioners measure the number of care plans rather than involvement in the new process - things are unlikely to change.
The DH has responded to feedback from patients and the public by developing health policy that is more patient centred. Personalised care planning is among the latest of these policies. It is initially being offered to people with long-term conditions because they will benefit most, but the principles should apply to all those receiving health and social care services.
Successful personalised care planning will ensure that those with long-term conditions receive care shaped around their needs, preferences and lifestyles. It will promote support for self care and information to support choice.
Nurses have a huge role to play in delivery, using and developing skills to make a difference to the thousands of patients with long-term conditions with whom they come into contact each day. However, the scale of cultural change required across the whole of the NHS workforce should not be underestimated. Nurses will benefit from this policy by being able to address the wider needs of those with long-term conditions, which should lead to improved outcomes and patient satisfaction.
Box 1. Useful resources for nurses and patients
The seven common core principles are:
- Ensure patients are able to make informed choices to manage their self care needs;
- Communicate effectively to enable them to assess their needs, and develop and gain confidence to self care;
- Support and enable patients to access appropriate information to manage their self care needs;
- Support and enable them to develop skills in self care;
- Support and enable patients to use technology to help self care;
- Advise patients how to access support networks and participate in the planning, development and evaluation of services;
- Support and enable risk management and risk taking to maximise independence and choice.
Your Health, Your Way - Your Guide to Long-term Conditions and Self Care (guide for patients)
Department of Health (2008a) Raising the Profile of Long-term Conditions Care: a Compendium of Information. London: DH.
Department of Health (2008b) High Quality Care for All: NHS Next Stage Review Final Report. London: DH.
Department of Health (2008c) Patients’ Prospectus - ‘Your Health, Your Way - a Guide to Long-term Conditions and Self Care’. London: DH.
Department of Health (2008d) Information prescriptions.On-line resource.
Department of Health (2005a) Independence, Well-being and Choice: Our Vision for the Future of Social Care for Adults in England. London: DH.
Department of Health (2005b) Public Attitudes to Self Care - Baseline Survey. London: DH.
Department of Health (2004) The NHS Improvement Plan: Putting People at the Heart of Public Services. London: DH.
Department of Health (2000) The NHS Plan: a Plan for Investment, a Plan for Reform. London: DH.
Fries, J.F., McShane, D. (1998) Reducing need and demand for medical services in high-risk groups. The Western Journal of Medicine; 169: 201-207.
Montgomery, E.B. Jr et al (1994) Patient education and health promotion can be effective in Parkinson’s disease: a randomised controlled trial. TheAmerican Journal of Medicine; 97: 5, 429-435.
Newman, S. et al (2004) Self-management interventions for chronic illness. Lancet; 364: 9444, 1523-1537.
Office for National Statistics (2005) Results from the General Household Survey (GHS). London: ONS.
Opinion Leader Research (2006) Your Health, Your Care, Your Say - Research Report. London: DH.
Skills for Care, Skills for Health (2008) Common Core Principles to Support Self Care: A Guide to Implementation. London: DH.
Wagner, E.H. et al (1996) Improving outcomes in chronic illness. Managed Care Quarterly; 4: 2, 12–25.