In 2013, NHS England specified that:
‘... every person with a long-term condition or disability has a personalised care plan supporting them to develop the knowledge, skills and confidence to manage their own health’.1
Around 40% of the UK population experience a long-term condition while 65% of people aged 65–84 years have two or more.2 This is an all-time high, with figures set to rise. This places significant personal, social, and economic burden on individuals, their families, and the community.
The use of care plans to manage multiple long-term conditions — by assessing individual behaviour, setting joint goals, supporting self-management, and ensuring proactive follow-up — is based on Wagner’s Chronic Care Model.3 The model takes into account the need to provide support and structure to patients, and the fact that all long-term conditions have common challenges.
Care planning has received extraordinary interest in the NHS. Policymakers endorse care planning as a way of containing high costs, encouraging a more person-centred approach, improving quality of life, and reducing mortality rates and emergency admissions to hospitals. But are care plans effective in this regard and what challenges do GP practices face in implementation?
EVIDENCE FOR CARE PLANNING
Systematic literature reviews on the impact of care planning show that it leads to only limited reductions in admissions and small improvements in patients’ physical health.4 However, …