Personalised care and support planning

We believe that everyone with long-term conditions should be offered a personalised care plan (also referred to as a person-centred care and support plan). Personalised care plans are an important record of personalised care and decisions. They outline discussions between patients and the professionals who support them. This care planning process changes the focus of how patients are cared for by looking at their current and future needs. This creates a more helpful proactive service – centred on the needs of each individual, rather than a service that comes into effect when something goes wrong.

It helps to focus on what is important to the person and puts them on an equal footing with professionals. It goes beyond clinical treatment, taking a whole-life approach and includes things like peer and community support and support for self-management.

There is no set template for a care and support plan. Instead we recommend a set of principles to help ensure that the process is truly person-centred:

  1. Preparation
  • Start from the patient’s point of view;
  • Gather necessary information and makes it readily available before the planning process starts; and
  • Build in time to reflect and think about all of the options.
  1. Discussion
  • Take a partnership approach, where the patient and professional are equal;
  • Focus on staying well and living well (and for some, it will also mean dying well);
  • Identify actions the patient can take themselves; and
  • Identify what care and/or support might be needed from others.
  1. Record
  • The main points from discussions are written up, included as part of the person’s health and/or social care records. They are owned by the patient and shared only with their consent.
  1. Review
  • Consider options for follow-up and sets a review date.

We have published a series of handbooks for commissioners and care practitioners setting out what personalised care and support planning is and how to deliver it.

NHS Choices has information for patients on how to get a care plan and how it can help to manage your condition.