Care Planning Project

NCL Wide

The mandate for the Long Term Conditions (LTC) and Cancer Programme sets out clear ambitions for improving the outcomes and quality of life for people living with long term conditions through involving them in the delivery of their own care and embedding personalised care planning. 

For more information about the commissioning of training and the implementation of care planning across Camden, contact itcinfo@camdenccg.nhs.uk

Support an effective approach to care planning:

  • establish supporting IT and other processes
  • embed in new LTC LCS agreement where possible/appropriate
  • facilitate access to the care plan by other clinicians in community and secondary care settings.

Roll out a consistent approach to care planning across Camden, based on a review of existing work:

  • patient centred approach; clinical templates will be reviewed to support goal setting and action planning 
  • work will be done to create a standardised Camden Care Plan 
  • care planning leaflets and materials to be used in general practice.

Identify and train relevant clinicians and staff within practices in the care planning approach:

  • training will involve whole practice teams
  • local champions to support care planning across their area.

The aim is that fully embedding a care planning approach in general practice will improve outcomes for both patients and clinicians by:

  • decreasing the number of unscheduled visits to the GP
  • improving data completeness of care processes
  • increasing the number of patients who feel supported to manage their care (GPPS) 
  • increasing the number of care plans shared with patients in general practice.

The Year of Care two-consultation approach will be delivered for high risk patients registered with COPD or diabetes:

  • a first stage appointment with the patient will take place to address any pre-consultation tests, inform them about the process and to prompt them to start them thinking about their self-care goals
  • notification of any relevant results to the patient will occur (where appropriate)
  • a double appointment (20 minutes) will take place to develop the care plan; using motivational interview techniques, the clinician will explore with the patient motivations and possible goals to support condition management and self-care
  • a portable copy of the patients personal care plan will be generated (electronic or paper options).

Please note: The last two points will only be required for conditions which require an Enhanced Clinical Review (see the Planned Care LES).

Year of Care facilitators will work with GP practices to support efforts to embed care planning into practice and work under the Planned Care LES (Enhanced Clinical Reviews and Year of Care). They will work closely with the Planned Care LES Support teams.

Training for all clinicians in the Year of Care Personalised Care Planning approach will be delivered across Camden.

Work will continue with the IT team to develop materials for care planning and existing clinical templates will be reviewed to ensure they support the care planning approach.


Review date: Saturday, 20 May 2023