Why personalised care plans should be a norm for long-term conditions

Dr Nilesh Bharakhada, is the Clinical Director for Health and Care at the Professional Record Standards Body (PRSB)

There are over 26 million people in the UK living with at least one long-term condition and 10 million who have two or more1. Many of them are at different stages of their conditions, have different lifestyles and clinical issues that they’re concerned about. Taking a person-centred approach in their care is the way to ensure that people can live their lives and manage their conditions as best as possible. This is what personalised care and support plans help to achieve. 

Diabetes is a good example of how having a personalised care and support plan in place can make a difference and put the person in control of their condition. People with diabetes need to have their blood pressure, weight, foot checks and other measures regularly taken. However, there may be something they’ve noticed, such as changes in their eyesight, that should be raised with their clinician. They’re the experts in their condition, and so actively involving people in their care can improve both self-management and clinical care.  

In the past, people with co-morbidities often had several care plans, each for a different condition, with very condition-specific care plans which attenuated the person’s voice. As a result, people were less likely to actively engage in the self-management of their care, and struggled to make a change in health behaviour that was key to improving their long-term condition and helping them manage it more easily. 

PRSB’s Personalised Care and Support Plan Standard, is a generic care planning standard for recording and sharing person-centred care plans. It is flexible enough to accommodate plans for a person who has multiple long-term conditions without losing significant amounts of detail that are important to health care professionals. The plan focuses on the person’s priorities and grasps how these priorities relate to their care. 

A personalised care and support plan aims to empower individuals, putting them in control of their health, and   used as a reference tool for health and care providers. For example – a nurse or a care home care worker may use it to understand what they need to do if something unplanned happens to the person, or to prevent problems from happening. 

When we developed the Personalised Care and Support Plan Standard, we created a structure which could then be expanded for various long-term conditions, with the personalised care and support plan being the backbone. For example – our Diabetes Record Information Standard includes information that should be incorporated within the person’s personalised care and support plan to ensure its relevant, specific and helpful for a person with diabetes.

However, for this approach to deliver benefits to people, it’s important that we record care planning information in a uniform way, across various care settings. This will enable nursing staff, pharmacists, health coaches, link workers and GPs to provide the best support possible, working in a joined-up way across organisational boundaries. In an ideal scenario, we want a care plan that starts its life in one care setting, recorded in a structured way, so that it can then be retrieved in a different clinical setting, in a different system, and be added to and amended as needed, to reflect people’s care journey. 

Benefits of the person-centred approach to care are also invaluable to the health and care system. In total, 70% of the entire health and social care budget is spent on long term conditions2. Helping people stay in charge of their health helps improve the management of their conditions. Let’s go back to diabetes again – with a personalised care and support plan in place, possible complications, such as strokes, chronic renal failure, and heart disease, can be avoided by taking secondary prevention measures.  

System suppliers have a role to play in making all this a reality. By implementing and achieving conformance against the Personalised Care and Support Plan Standard and Diabetes Record Information Standard, they help ensure that a person’s information flows to everyone involved in their care, allowing for continuity of care across care settings, so that people don’t have to repeat their story to clinicians and carry paper copies of notes with them. 

In essence, we’ve got everything we need to make personalised care and support plans the norm for people with long-term conditions. The standards are an important enabler – but we need the efforts of the whole health and care system to make sure that people benefit from these plans as much as possible. Health and care professionals who would like to proactively develop their personalised care skills, in areas such as Shared Decision making or Personalised Care and Support Planning, can also access a range of high quality, peer-reviewed free training and resources on the Personalised Care Institute website. https://www.personalisedcareinstitute.org.uk/




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