How to get going with care planning 

Care planning is about cultural change, and involves changes to attitudes, skills and infrastructure. Chapter 5 (PDF 1.2MB) of the final report discusses some of the discoveries, dilemmas and debates that led to the key learning from the project and Chapter 7 (PDF 1.1MB) describes how these were overcome.

Thus the Year of Care Partnership now has a wealth of experience and learning about the most effective ways to introduce and embed care planning as normal care for people with long term conditions. They can be contacted at enquiries@yearofcare.co.uk and are available to work with organisations who wish to systematically embed care planning within their standard clinical care.

Some of the key messages included

• Philosophy, attitudes and systems must all be addressed together to implement and sustain care planning
• Staff needs to be clear about their role if they are to fully participate in the programme
• There must be clarity over where care planning fits in the local pathway or model of care and be an integral part of the local commissioning agenda
• Local ‘champions’ both clinical and managerial are crucial; ‘right from the top, right from the start, right the way through’; this should include GPs
• Local coordination is essential; to include primary care experience, a facilitative approach and partnership working
• Training which links attitudes, skills and infrastructure change is key for clinical team
• There are start-up costs and extra costs for people with poor health literacy, but potentially significant gains to be made through service re-design and improved service utilisation

Care planning is about cultural change and this takes time; staying in for the long haul delivers; the Year of Care learning now packaged by the Training and Support Team enables new sites to get up and running more quickly.

Since much of this is about getting the organisation right, the Year of Care Programme recommends

A local steering group encompassing

• Commissioning lead for diabetes/long term conditions
• Operational Year of Care project lead 
• A local clinical ‘champion’ of care planning (either from, or with a practical understanding of and credibility within, Primary Care)
• Representative User involvement
• Individuals with Primary Care facilitation skills
• Training
• Administrative support

The main functions of the steering group are to ensure momentum behind implementation and roll-out, financial requirements are met, the required infrastructure is in place and an evaluation and monitoring framework exists.

You may wish to consider a few key questions before you go any further.

How to ensure the right people and the right support to work in the right way is outlined in Information and Guidance about National care Planning Training (PDF 179KB).

Key Questions

• What do you hope to achieve by implementing Care planning?
  
• How does this fit with your local model of diabetes/long term condition care and what is the current quality of care being delivered?
  
• In what clinical settings do you hope to implement Care planning?
  
• How does this link and fit with commissioning?
  
• How engaged are your local clinical teams and who would might be a good local GP champion?
  
• How is the implementation of the care planning going to be coordinated and monitored?
  
• What funding do you have to support the delivery of training and do you need to develop local capacity by training local trainers?
  
• How are individual practice teams going to be supported after training delivery?