TVSCN > Networks > Long Term Conditions > Patient-centred Care Planning; Patients as the experts of their own conditions

Patient-centred Care Planning; Patients as the experts of their own conditions

The issue

15 million people in England (around 30%) live with long term conditions (LTCs), and the proportion with multiple LTCs is increasing dramatically.

LTCs are the most common cause of death and disability. People with LTCs account for:

  • 70% of the money spent on health and social care
  • 55% of GP appointments
  • 68% of hospital outpatients
  • 77% of inpatient episodes
  • Over half of the overall cost of looking after older people in residential homes

Most people with LTCs spend just a few hours per year with healthcare professionals and more than 99% of their lives managing their conditions themselves. As such, they need to become experts in their own health and will make all the day-to-day decisions which affect their own health.

For healthcare this means the system needs to support individuals to develop the knowledge, skills and confidence to manage their own care

The case for self-management

There is an extensive evidence base for the outcome and cost effectiveness of interventions which support self management. The chronic care model (Wagner, EH, Austin BT, Von Korff, M. (1996) Organising Care for Patients with Chronic Illness) describes how better outcomes for people with LTCs can be achieved when there is partnership working between an ‘engaged’, ‘empowered’ or ‘activated patient’ and an organised proactive healthcare system.

It has been suggested that the most important element of this complex intervention is support for self management. Self care is one of the best examples of how partnerships between the public and health service can work – for every £100 spent on encouraging self care, around £150 worth of benefits can be achieved in return (Wanless D. (2002). Securing Our Future Health: Taking a Long-Term View. Final Report. HM Treasury)

What does this mean for patients?

Patient-centred care planning enables an individual to identify their own goals, action plans and any support they may need through preparation and personal ownership alongside the more traditional element of clinician/patient consultation. This becomes a gateway to providing personalised support, which:

  • Links traditional clinical care with support for self management
  • Signposts to community resources made available as part of wider local commissioning
  • Coordinates health and social care where appropriate.

What does this mean for our partners and organisations in the Thames Valley?

Berkshire West CCGs have already developed a successful patient-centred care planning approach for those patient with Diabetes and TVSCN is working across the Thames Valley to educate, inform and implement this effective way of working to as wide a group of stakeholders as possible.

A number of approaches for support TVSCN are implementing are;

  • Education sessions – we are holding general introductions to patient-centred care planning across the patch over the next 6 months – find out more here
  • Training – we are encouraging and engaging with GP practices across the patch who are introduced in implementing patient-centred care planning to attend a 1.5 training session with our partner training organisation – Year of Care Partnerships at sessions planned in Winter/Spring 2015 and;
  • “The Expert Hub” – a pan-Thames Valley resource of experts available to CCGs and both Acute and Community Providers to assist in developing and building capability to tackle the Long Term Conditions agenda across key areas such as organisational and clinical processes, patient voice and engagement, commissioning and partnership working. A set number of hours free support is being made available for those organisations to access in whichever area they feel advice, support and solutions can be utilised.

What does it mean for GPs?

“The care planning process has resulted in me changing my consultation style; it has brought me back to the way we consulted pre-QOF. By putting the patient at the centre I have found the consultation is far more pleasurable and the evidence indicates far better outcomes.  So its a win-win all round”

Dr Stephen Murphy MBChB MRCGP MBA, Clinical Commissioning Director for Mental Health and Staying Healthy

Training – Supporting Practice Teams to Implement Care Planning

Training is available  primarily aimed at GP’s and Practice Nurses who are interested in implementing Care Planning and are able to influence change within their practice

It focuses on developing the ethos and skills that are at the heart of a partnership approach, using care planning consultation skills and supporting self management.

The overall purpose is to help participants consider the processes and skills that need to be in place to support individuals and their carers to make decisions about managing their long term conditions.

Aims of the one and a half day training:

  • To understand Year of Care and Care Planning
  • To reflect on your own approach / philosophy of care and how this fits with Care Planning
  • To understand the Care Planning consultation framework and the core competencies required
  • To be clear about the organisational requirements for implementing Care Planning in Practices

For further information or to book a place please contact Jennifer on:

Expert Hub

The Expert Hub offer is being scoped at present and further information will be available as to how to request and access the support offered – please check back to for more details.