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Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Personalised Care Planning

The Personalised Care & Support Planning Handbook published by the NHS UK in 2015 details the scope and implementation of personalised care planning (NHS UK, 2015) :


What does it entail ?


The overarching aim of personalised care and support planning is to support people who live with long-term conditions, to develop the knowledge, skills and confidence to manage their own health, care and wellbeing.

People live with their conditions and/or disability every day and make decisions about how to manage them. Over time, they learn what works best for them, what information, care and support they need and how it fits into their life.

As well as helping improve quality of life, this can help improve patient safety and prevent unplanned care, in particular hospitalisations, for these people.

Personalised care and support planning is a collaborative process between equals, whereby people with health and care needs, along with their family and/or carer, work together with care practitioners to discuss:

• what is important to them, setting goals they want to work towards

• things they can do to live well and stay well (and for some people, dying well)

• what support they need for self-management; agreeing actions they can take for themselves

• what care and support they might need from others and how this can best fit in with the rest of their lives

• what good support looks like to them as an individual

• preparing for the future, including making choices and stating in advance preferences for care at the end of their life

(where relevant and appropriate)


The approach of ‘personalised’ care and support planning as a collaborative and person-centred process is distinctly different.

It is:

• not about developing a traditional treatment plan for individual services;

• not a process intended purely to aid health and care practitioners in making decisions about an individual’s care and treatment;

• not about single disease pathways; whilst services might choose to prioritise patients with particular conditions, the care planning discussion should look at all their physical and mental health and care needs, particularly where the individual has more than one


• not solely about traditional medical solutions,

• not a one-off 5 minute conversation;

• not something which can be prepared by the care practitioner and the patient agrees to;

• not a tick box exercise which results in a standardised plan that can be copied an d used for any individual with a particular condition or similar circumstances.



Who is it for ?


Whilst personalised care and support planning is often discussed in relation to people with long-term physical and mental health

conditions, it can be beneficial to anyone with ongoing health and care needs including for example, older people at risk of frailty, people undergoing rehabilitation or reablement, those receiving treatment for cancer, or people with complex needs receiving care and support from a number of different agencies e.g. people with substance misuse problems.

The process can be particularly beneficial to people with multiple long-term conditions by helping to consider the interdependencies between different conditions and the collective impact this can have on their wider health and wellbeing.

Rather than considering each condition in isolation, personalised care and support planning takes a more holistic approach, starting with what is most important to the individual.



Who does it ?


The people involved in care and support planning conversations may vary: sometimes the conversation might be facilitated by a health or social care practitioner such as a GP, social worker, nurse practitioner, occupational therapist or community nurse. Alternatively, the conversation may be with a volunteer, peer supporter, advocate or other non-clinical role who can help the individual to think through what is important to them and prepare them for interactions with care professionals.

The focus of these conversations will likely be influenced by the knowledge, skills and experience of the person facilitating.


The inclusion of unpaid carers, such as family members or friends as the people involved in the individual’s immediate support network, is very important. The practical and emotional support that they provide, as well as their perspective on the individual’s health and care, should be captured in the discussion.

Carers may also have health and care needs that need to be considered.

Care and support arrangements might be dependent on carer’s involvement, particularly where they have a guardianship role or the individual does not have capacity to make decisions, and therefore, the commitment and agreement of carers or parents may be vital to the design and implementation of plans.

The person at the heart of the care plan should give consent for others to be involved, and there should be safeguarding principles embedded to ensure that there is no conflict of interest between the person and the person(s) they wish to involve.



How is it done ?


Four principles should be at the heart of any changes in process, systems, skills, behaviours and attitudes.


1. Prepare

• Starts from the point of view of the person

• Gathers necessary information and makes it available upfront

• Builds in time to reflect and consider options


2. Discuss

• Takes a partnership approach

• Focuses on staying well and living well (and for some, it will also mean dying well)

• Identifies the actions that a person can take

• Identifies what care and/or support might be needed from others


3. Document

• The main points from discussions are written up, included as part of the person’s health and/or social care records, and owned by the person and shared, with explicit consent.


4. Review

• Considers options for follow up and sets a date for review


The Care Act 2014 states that "Local authorities should not develop plans in isolation from other plans...and should have regard to all of the person’s needs and outcomes when developing a plan, rather than just their care and support needs".

The facilitator should attempt to establish where other plans are present, or are being conducted and seek to combine plans, if appropriate. This should be considered early on in the planning process (at the same time as considering the person’s needs and how they can be met in a holistic way) to ensure that the package of care and support is developed in a way that fits withwhat support is already being received or developed."

It also says, "particular consideration should be given to ensuring that health and care planning process are aligned, coherent and streamlined, to avoid confusing the person with two different systems."

Living Well from a GP's perspective

See how a GP practice has worked in partnership with the Voluntary Sector to improve health and care outcomes using Personalised Care and Support Planning

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The Holmside story

See how a GP practice has gone about implementing personalised care and support

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personalised care planning

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Personalised Care Planning

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