IT templates for long term care plans

GPs and primary care staff will be expected to offer personalised care plans to almost 15m people living with a long term condition by 2010, according to latest guidance.

An IT template, currently being piloted in Yorkshire for patients with diabetes, will be made available across England by the National Programme for IT in the NHS to support the care planning process, the Department of Health says.

The DH guidance says it is also developing an incentive scheme to encourage GP practices to take part and has included care planning as a service specification in the Community Services Standard Contract for 2009-10.

The incentive scheme for GPs will be available via a Primary Care Services Framework, which the DH is still working on, but which PCTs will be able to use to commission care planning as a locally enhanced service.

The requirement to offer all patients with long term conditions a care plan was outlined in Lord Darzi’s Next Stage Review of the NHS, and the guidance says that, as a minimum, the offer should be for an annual meeting between the individual and a health or social care professional.

The meeting is expected to seek information from the individual on their goals, needs and wishes and to identify a ‘plan of care’ to attempt to move the individual towards their aspirations. The plan can either be written or electronically stored. Those with more complex needs may need more regular care planning review meetings.

Care planning is already being implemented through the Diabetes Year of Care programme, which is running pilot sites in North of Tyne, Kirklees and Calderdale and Tower Hamlets in London.

The DH said the aim is to embed the process of care planning rather than creating a bureaucratic system of form filling.

The DH says the average cost of providing a care plan will be £18.61, but claims that overall the NHS will save money as care planning will lead to more self-care and lower use of NHS resources such as hospital apppintments and emergency admissions.

Guidance issued to commissioners highlights work already underway in Yorkshire, where a system of data-sharing for patients with diabetes, using TPP’s SystmOne, has been extended by the local strategic health authority to include a system for recording individual needs. These include their emotional, social, educational, economic and cultural circumstances, as well as biomedical information.

The guidance states: “The IT system will be in use across five primary care trust local health communities throughout Yorkshire and the Humber during 2008-09, before being made generally available within the National Programme for IT.

“If evidence shows the system to be positive the principles of the integrated care planning approach based on the IT tool will be relevant to support all complex long term care processes.”

According to the National Diabetes Support Team, the templates developed by SystmOne have been made available for incorporation or adaption into other systems but is says this “may not be a simple process”.

DH guidance says the information captured in care plans should be used to inform joint needs assessment and commissioning decisions.

It says aggregating information from care plans sould be supported in future by the Summary Care Record and patients having access to their record via HealthSpace.

The guidance adds: “PCTs should be working towards developing information systems to support the systematic sharing of information. In particular, they should be working with their GP practices which can provide them with a rich source of information gathered through their care planning.”

Monitoring of the uptake and quality of care planning will include an evaluation programme and questions in future editions of the GP Patient Survey.

The introduction of care plans is part of the personalisation of health care which includes other DH policies such as the piloting of personal health budgets, included in last week’s Health Bill.

The DH guidance says more detailed practical guidance for NHS staff on care planning will be published soon and it is also developing an e-learning support tool. The DH says it also has plans to procure an external support programme for PCTs to help them implement care planning.