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Person Centred and Integrated Care Planning. Claire Whittington Head of Long Term Conditions Department of Health. The commitments. Public Service Agreement (PSA) target:

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Person Centred and Integrated Care Planning

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Person Centred and Integrated Care Planning

Claire Whittington

Head of Long Term Conditions

Department of Health

The commitments

Public Service Agreement (PSA) target:

  • To improve health outcomes by offering a personalised care plan for vulnerable people most at risk, and to reduce emergency bed days by 5% by 2008 through improved care in primary care and community settings.

    Our health our care our say commitments

  • By 2008 everyone with both long term health and social care needs will have an integrated plan if they want one and by 2010 everyone with a LTC will be offered a care plan.

    And underpinned by

  • By 2008 all PCTs and LAs should have established joint health and social care managed networks and/or teams to support those with long term conditions who have most complex needs

Common Assessment Framework

  • A Common Assessment Framework, building on the Single Assessment Process to ensure less duplication across different agencies, avoid fragmentation and facilitate information sharing across health and social care

  • Developing a standard information set for CAF as well as guidance for its use

  • CAF domains based on Outcomes (Independence, Well-being and Choice)

    • For the individual and their carer

    • Aligned to Fair Access to Care Services (FACS)

    • Supports a person centred approach & Self Assessment/Involvement

Why bother ? Current care for those with long-term conditions is not as good as it could be and does not always meet recommended guidelines

  • NSF guidance recommends that patients with diabetes should agree to a care plan to manage their conditions, as the best results are achieved by:

  • patients who are engaged in their own care & empowered to manage

  • Organised diabetes teams that actively seek out people to ensure they get the best care.

  • Partnerships between people with diabetes & healthcare professionals to solve problems/plan care

  • A Healthcare commission survey of patients with diabetes suggests these care plans are not being agreed

Source: Healthcare Commission; Survey of people with diabetes (2006)

Care Planning

  • White Paper commitment to issue good practice guidance

  • Expert Reference Group of key stakeholders held May 2006

  • Assessment and Care Planning Policy Collaborative also shaped its development

  • Linking across to work on Integrated Networks and Teams

Aims of Care Planning Guidance

  • Support delivery of the Long Term Conditions PSA target and the White Paper commitments

  • Promote good care planning leading to improved care/support for people

  • Bring together learning from good practice into one document

  • Describe the key principles for person centred approach

  • Emphasises importance of integrated networks and teams

  • It will not replace or contradict other guidance but rather complement it


  • The agreed principles of person centred care planning

  • How it links with assessment

  • Care coordination

  • Why important for commissioners

  • Benefits – and the impact on different sectors

  • Integrated teams/networks

  • Key actions

Scope of the Guidance

  • Acknowledge and keep in focus the scope of the guidance:

  • To describe an overarching framework for care planning that can be adapted by heath, social care and third sector organisations

  • Avoid too much detail, we can’t describe everything

  • A framework to allow local adaptation

Integrated teams/networks – what will the guidance say ?

  • Effective care planning requires integration of health and social care at individual and strategic level

  • Critical to coordinated, seamless approach to care planning and delivery

  • People with complex needs often require multi-disciplinary/multi-agency support

  • Person-centred care enabler to joint working as ensures all members of team have shared understanding of person’s needs and desired outcomes

  • Maximises combined potential

Individual - Integrated teams

  • Not prescriptive

  • Teams based around user needs

  • Planning and delivering care across organisational boundaries

  • Fixed and/or virtual, but communicating regularly about defined group of individuals

  • Involve support from specialists as appropriate

  • Promotion of where working well and tools to help

Strategic - Integrated networks

  • Commissioning for people with LTC – complex

  • Integrated Networks need to be at centre informing planning and commissioning of care

  • Bring together clinicians, users and managers across health and social care

  • Subgroup of PCT and LA with leading role in identifying priorities and managing cross boundary issues

  • Senior accountable officers from PCT and LA to lead network

  • Reporting to joint commissioning arrangements

Next Steps

  • Publication

  • Further guidance for workforce/patients

  • Links to world class commissioning

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