Integrated care and support planning



Integrated care and
support planning

Nilesh Bharakhada

Date: 30th May 2017

In recent years, the UK has witnessed an increase in the number of people living with chronic medical conditions, and treatment options are becoming ever more complex.

To ensure people are getting the best possible care, it’s essential that they have good care planning from different health and care professionals. The complicated nature of diabetes, chronic obstructive pulmonary disease and heart failure to name a few requires a multidisciplinary approach to managing people’s care. Rather than just GP and hospital care, patients receive expertise from a wide range of allied health and care professionals from occupational therapists to physiotherapists, district nurses, community matrons, consultants and adult social care. To facilitate the best possible holistic care, we need a joined-up approach, where relevant information on a patient’s condition can be shared quickly and easily. Integrated care planning allows care to be effectively coordinated, so that multi-disciplinary teams can deliver person-centered care that addresses their preferred treatment plan.

Working in collaboration with the North West London Collaboration of Clinical Commissioning Groups (CCGs) the PRSB has begun developing the Integrated Care and Support Plan Standard to ensure that care plans can be effectively shared between patients, carers and all health and care professionals involved in the person’s care. The standard will also help to support self-care and allow health professionals to deliver person-centred care.

To create a shared care and support plan, we have to agree what information it should contain, what its structure should be and how individual care planning components should be held so they are accessible to care providers. We also need to consider how health and care professionals can update the care plan and how care providers are alerted to any changes specifically relevant to them.

Once the standard is agreed, NHS Digital will develop technical specifications, based on the project outputs. The plan is for these specifications to be incorporated into standard clinical IT system contracts, like GPSoC, to build capabilities into acute hospital, GP, community, mental health and social care systems, with the aim of enabling electronic sharing of care and support plan information. North West London Collaboration of Clinical Commissioning Groups (NWL CCGs) is one of the national integrated care pioneer sites, and this pilot will support implementing a standardised care and support plan across the whole health and social care system.

When a generic care and support plan is agreed, it will be possible to create more specific care plans for a range of conditions including chronic conditions and end-of-life care. Increasingly, patients with terminal conditions are deciding on the care they want, with organisations like Dying Matters advocating open discussions about end-of-life care and patient-led decisions. Whether a condition is chronic or terminal, sharing a care and support plan will ensure that all staff and carers involved in a patient’s care will have access to the right information when they need it, in order to personalise care and improve the experience for the patient, their carer and their families.

The new project will build on existing national and international work on integrated care planning, working closely with members of the RCGP collaborative care and support planning network, the North-West London Collaboration of CCGs, the Healthy London Partnership, NHS Digital as well as national representative professional bodies and Royal Colleges. The PRSB will be working closely with a range of clinicians, professionals, carers and patients across the UK, to develop a standard that is applicable in England, Wales, Scotland and Northern Ireland. At the moment we are gathering evidence and good practice examples and seeking contributions from professionals across health and social care. If you’d like to contribute, please contact us

The second phase of the project will include a consultation process and workshops, before the standard is put together ready for review.

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