Care and support planning with people with long term conditions (LTCs) is about better conversations - emphasising the importance of the care and support planning process itself in achieving outcomes, rather than the written care plan that may emerge at the end. 

Clinicians often have a structured approach to the consultation ‘hard wired’ into their everyday practice. Care and support planning builds on these skills but differs in that the information that the patient can contribute about living their life with their LTCs, what matters to them and their own goals is actively sought and given equal prominence to traditional information about tests and examinations.

Personalised care plans developed during care and support planning with people with LTCs are very different from traditional treatment plans developed by healthcare professionals on behalf of patients.

Year of Care have worked with National Voices to describe the steps of care and support planning in both health and social care.   In particular this emphasises the importance of preparation for both the Health Care professional and the person living with the long term condition.

This diagram shows how this is carried out in general practice using a two ‘contact’ Year of Care approach.

This two stage process is demonstrated in practice with a person with multiple long term conditions in the video below.








For people with some conditions, such as diabetes or chronic lung disease, there may be a need for tests or investigations as part of their routine monitoring.  These would be done at the first contact and the results would be sent to the person a few days later, prior to their care and support planning consultation. This gives them the opportunity to consider their test results, and what these mean to them, along with family and friends as needed.  They will also be provided with agenda setting prompts to help them reflect on life with their LTCs and what they would like to discuss in the consultation.  For other conditions, there may be no need for specific monitoring tests and no results to share.  However people should still be provided with tools to enable their preparation ahead of the care and support planning consultation (including agenda setting prompts, self-assessment or reflective tools)

This emphasises a core principle of care and support planning, which is that everyone should have the opportunity to prepare for the care and support planning discussions in advance to ensure they are in a much better position to contribute fully to the discussions and decisions made.

The second contact is the care and support planning consultation with a healthcare professional trained in partnership working, aiming to help the person identify their priorities, develop personal goals and action plans and identify services available to support these.

The agreed discussions and actions are summarised into a care plan, which is shared with the patient either immediately or subsequently by post or electronically.