Much of the house is about getting the organisation as well as the culture right. Based on experience of working with 26 communities or programmes (including Year of Care pilot sites) the presence of a local steering group to set up, make local links, monitor progress and make adjustments accordingly is the most important success factor for embedding and supporting personalised care planning.

The most successful local steering groups have included:

  • Commissioning lead for diabetes/long-term conditions
  • Operational Year of Care project lead 
  • A local clinical ‘champion’ of personalised care planning (either from or with a practical understanding of and credibility within primary care)
  • Representative user involvement
  • Individuals with primary care facilitation skills
  • Access to IT expertise
  • Your local trainers, once trained
  • Administrative support

The main functions of the steering group are to ensure momentum behind implementation and roll-out, financial requirements are met, the required infrastructure is in place and an evaluation and monitoring framework exists.

In particular they will need to develop an operational plan to meet strategic objectives, and as part of that plan we suggest they consider the following:

  • Engagement of clinical teams
  • How different ways of working are going to be supported, such as local enhanced services
  • How clinicians are going to be supported to attend training and have facilitated support following training
  • The training of healthcare assistants and administrative teams
  • The role of IT and how individual practice gain support with their clinical systems
  • How users are going to be involved
  • How the programme is going to be evaluated
  • How clinicians signpost to self management services, including social prescribing.