The Year of Care team have pioneered an approach and a method of implementing personalised care and support planning that has been developed with grass roots clinical teams, patients and charities and has influenced the development of personalised healthcare policy and approaches. 

The programme was set up in 2007 by the Department of Health with a view to working out the principles, practical application and the components of a personalised care and support planning approach, including the structure and consultations skills within a personalised care and support conversation.  

The initial work in diabetes set out to establish how to introduce personalised care and support planning for self-management as part of routine management for people with long-term conditions (LTCs) using diabetes as an exemplar.

  • The programme recognised the challenge of LTCs and the need to firstly enhance the routine biomedical surveillance and ‘QOF review’ with a collaborative consultation, based on supporting effective self-management via care planning.

  • Secondly to ensure there is a choice of local services available through commissioning that people need to support the actions they want to take to improve their health, wellbeing and health outcomes.

Since this initial pilot programme we have worked with a range of charities and practitioners to work out how the approach works for other single long-term conditions, as well as developing an approach that works for people who live with multiple long-term conditions. 

We successfully demonstrated how to use personalised care planning as a systematic way to make routine contact between the person with the LTC and the healthcare professional more relevant and effective by putting in place 3 core components. 



  • Preparation – to help people understand the personalised care and support planning approach and give them more information up front

  • Collaborative personalised care and support planning conversations with a focus on getting a balance between the patient and professional agenda and the development of a person-centred care plan

  • Support for self-management

Personalised care and support planning enables the individual to identify their own goals, action plans and any support they may need. This becomes a gateway to providing personalised support, which:

  • Links traditional clinical care with support for self-management

  • Signposts to community resources made available as part of wider local commissioning (macro commissioning)

  • Coordinates health and social care where appropriate.  


We also produced guidance on how to commission a wider range of local services to support people with LTCs in the community Thanks for the Petunias – A guide to developing and commissioning non-traditional providers to support the self-management of people with long term conditions: 2011