Care and support planning for people with diabetes

Year of Care report of findings from the pilot programme and Year of Care: Pilot Case Studies: 2011 - This is the formal report on the Programme describing the background, aims and objectives, parallel evaluations, the way the programme was delivered and its impact. Case studies of each of the pilot sites are provided as companion documents. Together they include key learning about implementing the Year of Care approach to care planning and the lessons for commissioning for LTCs. They will be of interest to policy makers, those with broad interests in commissioning and service delivery of personalised care for those with LTCs, and anyone contemplating introducing and embedding a programme of cultural change across the NHS.

Partners in Care: A Guide to Implementing a Care Planning Approach to Diabetes Care: 2nd ed. 2010 This is the key guide to the philosophy and delivery of the care planning consultation and is an important resource for practitioners wishing to reflect on their practice and introduce care planning.

Getting to Grips with Year of Care: A practical Guide: 2008 This document was produced at the end of the Year 1. It summarises the background and learning from the first phase of Year of Care (YOC) programme including the key thinking around care planning and commissioning. It introduces and provides an overview of the Care Planning House. It remains a useful introduction to the Programme.


Care and support planning for people with MSK conditions

'Bringing MSK conditions in from the care planning cold - a feasibility study' phase one interim project report - This report comes at the end of phase 1 of a two phase approach designed to tease out the issues of practical delivery and develop the tools and MSK specific resources, so these can be tested and refined as part of a multimorbidity approach to CSP in phase 2. 

'Bringing MSK conditions in from the care planning cold - a feasibility study' Final study report - This final report brings together the learning from both phases of a feasibility study of care and support planning (CSP) for people living with joint, muscle and bone (MSK) conditions.  It builds on the detail and lessons in the phase 1 Interim Project Report, describes additional learning and highlights dilemmas and further questions which warrant future discussion and investigation.  It also celebrates the successes of the study and describes some of the benefits seen by individuals who live with MSK conditions. We also make recommendations to Versus Arthritis, policy makers and commissioners and professional leaders and training bodies.


Care and support planning for people living with frailty  

Using care and support planning to implement routine falls prevention and management for people living with frailty: A qualitative evaluation - this Year of Care publication from October 2022 details a qualitative evaluation aiming to understand the barriers and success criteria involved in incorporating falls assessment and management into the CSP process.

See also the newsletter we produced on the topic of CSP and falls here.

Falls, frailty and care and support planning - Care and support planning (CSP) has proven to be a flexible framework to deliver personalised proactive care to people with LTCs, including people with multiple conditions and frailty. This report details an evaluation of a successful pilot project to include falls detection and prevention as an element of frailty within the CSP process.

Falls, Frailty in Care & Support Planning: A feasibility study in Newcastle & Gateshead CCG - This document provides a short summary of the main falls report.

Care and support planning for people with frailty. British Journal of Primary Care Nursing - with frailty 


British Heart Foundation 'House of Care' project

Gateshead BHF House of Care Report

Gateshead experience of the BHF House of Care Project

Hardwick cost analysis case study - This document offers a simple analysis of the differences in routine care and costs, pre and post the introduction of the House of Care - the British Heart Foundation (BHF) Year of Care project. It is intended to complement evidence about how the BHF funded programme impacted on the quality and outcomes of care. ICF, Clare Walker (Hardwick Project Manager) and Year of Care Partnerships. 2017


Year of Care in Scotland

Scotland's House of Care project is based on the Year of Care programme and in this podcast hosted by the Scottish National Users' Group (SNUG) Lindsay Oliver and Dr Graham Kramer present details. They are joined by Alison Fox, Practice Manager of St Triduana's practice in Edinburgh who explains how care and support planning works for them before, during and after the pandemic.

From fixer to facilitator: evaluation of the House of Care programme in Scotland, 2020 (Cook A, Grant A)

Alliance HOC Learning Report 2016 - Scotland’s House of Care Learning Report (2016).  A summary of shared experiences from adopter sites, implementers, practitioners and people living with long term conditions across Scotland.

Care and support planning and House of Care: A key enabler of the new GMS Contract: High level 

Care and support planning and House of Care: A key enabler of the new GMS Contract: Practice level


Scotland's House of Care celebration event - past, present and future

This event marked the closure of Scotland’s House of Care Programme and to celebrate, reflect and learn from what had been achieved. The event was hosted and organised by the Health and Social Care ALLIANCE with support from Dr. Graham Kramer (clinical lead) and Year of Care Partnerships. It brought together many members of Scotland’s House of Care community who had helped pioneer care and support planning.

A short summary of the event and a recording of the main sessions is here.


Year of Care in Singapore

The Year of Care team have been supporting the implementation of personalised care and support planning (PCSP) in Singapore as part of a multidimensional partnership over the last 7 years. The Singapore health system is very different from the UK, it is publicly subvented and the population is under the care of 3 health clusters. Year of Care have visited Singapore on 4 occasions delivering training and train the trainers, and consultancy and support in thinking through staff engagement and system implementation.   

This paper published in BMC Primary Care in 2023 aimed to investigate health care professionals’ perspectives on PCSP to inform future developments.

A further paper has also been published in BJGP Open that focuses on the views of people living with diabetes on personalised care and support planning, which resonates with findings from UK implementation programmes.