Title: Care planning in policy
1National Framework for NHS Continuing Healthcare
and NHS funded Nursing care Thoughts for the
Week - Monday 6 August 2007
Welcome! We want to help you get ready for
implementation from 1 October and there are
now only 8 weeks to go !!!! (but dont
panic). Remember, there will be a national
training pack to support you (to be launched at
the beginning of September). DH is working with
SHA and CSIP colleagues to arrange a series of
regional events in September and October. Do
talk to your PCT, LA or SHA leads to find out
more, including who should be attending from your
organisation. Those events will provide an
opportunity to focus on final preparations needed
in your area. We will try and tailor events to
what you need we are publishing a self
assessment form this week on this website to
help you start those discussions in your area.
This is the fourth of our little weekly
notes. Theme for this week Care planning Like
several of the other notes, this has a much wider
significance than just Continuing Care. This note
draws your attention to some of the things to
think about and some resources that are there to
help you when planning packages of care, wherever
it is being delivered.
Care planning in policy The National Framework
focuses very much on the process for determining
eligibility for NHS Continuing Healthcare and has
less detail around care planning. There are wider
commitments within DH to look at care planning,
which were set out in the White Paper, Our Health
Our Care Our Say for example, that everyone
with both long term health and social care needs
will have an integrated care plan if they want
one. There will be guidance out later in the
year, and in the meantime you might want to look
at existing approaches to planning care and
support (e.g. Person Centred Planning) NHS
Continuing Healthcare is not about a particular
service or a particular care plan, its about
funding the care that people need, and so the
same principles apply to care planning here as in
other areas of health and social care. Effective
care planning takes on an additional dimension as
someone approaches the end of their life the End
of life Care Strategy is working to address
relevant issues comprehensively in due course but
there are already resources available (see links
below).
- General principles. Person centred and integrated
care/support planning is essentially a process of
delivering care that - Puts the person, their needs and choices at the
centre of the process - Is planned, anticipatory and proactive, including
effective emergency/crisis planning as opposed to
unplanned and reactive - Promotes better management of risk, which also
supports choice and control - Has contingency planning to prevent crisis
episodes - Ensures that people, especially those with more
complex needs receive coordinated care packages,
reducing fragmentation between services - Provides support and information to assist joint
decision making by the person and the
professional to self care/self management,
empowering people to manage their conditions
better and prevent them deteriorating for
example through the delivery of information
prescriptions - Facilitates joined up working between different
professions and agencies, especially between
health and social care
2National Framework for NHS Continuing Healthcare
and NHS funded Nursing care Thoughts for the
Week 6 August 2007
- REMEMBER
- Person centred care/support planning is a
continuous process not a product regular
reviews need to be built into the system - The person should be encouraged to have an active
role in their care, be offered options to allow
informed choices, and empowered to make their own
decisions with adequate information or
signposting all within a framework of managed
risk (see link below) - Self care and self management is an essential
element of good care/support planning and should
be supported wherever possible (for more
information, see the Long Term conditions website)
Care and support options People coming through
the National Framework process might conceivably
be supported in a variety of ways. The process of
assessment and deciding on eligibility will have
identified needs and started to indicate ways to
address those needs. The next step is deciding
how and where the identified needs can best be
met. Given the current emphasis on tailoring care
to suit peoples needs, there is a move away from
the traditional institutionalised models of care
and within each type of care package there needs
to be as much flexibility as possible. Depending
on circumstances, NHS Continuing Healthcare can
be provided in any setting. Joint packages
range from minimal support from community health
services at home, to requiring substantial
contributions from both NHS and LA. These
include, but are not limited to, NHS funded
Nursing Care in a care home with nursing there
are also many other types of joint packages,
again in any setting, and in some cases the NHS
will need to provide additional healthcare
services over and above the need for registered
nursing care.
Commissioning Given the range of care and support
options, effective commissioning which provides
continuity and familiarity is obviously a
challenge, not just in NHS Continuing Healthcare
but across the board. Good links between agencies
are essential. Theres a separate note coming on
commissioning in a few weeks, but for now, the
key messages are mainstreaming the
commissioning of NHS Continuing Healthcare and
other substantial health and social care
packages, and working together within and across
agencies see the Commissioning Framework for
Health and Wellbeing for more information.
What can I do to ensure better care
planning? Rather than setting a little exercise,
were going to leave you with a question. If you
work at a PCT, would your mainstream care
planning and commissioning services be sufficient
to successfully and efficiently arrange a range
of NHS Continuing Healthcare packages? If you
work for a LA, what expertise might you be able
to share with your local PCT(s)?
What next? links for further information The
Long term conditions team have a range of
resources that might be helpful. Links are
available from http//www.dh.gov.uk/en/Policyandg
uidance/Healthandsocialcaretopics/Longtermconditio
ns/index.htm White paper for policy
context http//www.dh.gov.uk/en/Policyandguidance
/Organisationpolicy/Modernisation/Ourhealthourcare
oursay/index.htm Risk http//www.dh.gov.uk/en/Pub
licationsandstatistics/Publications/PublicationsPo
licyAndGuidance/DH_074773 Commissioning framework
for Health and Wellbeing http//www.dh.gov.uk/en/
Publicationsandstatistics/Publications/Publication
sPolicyAndGuidance/DH_072604 End of life
care http//www.dh.gov.uk/en/Policyandguidance/Or
ganisationpolicy/Endoflifecare/DH_4106262 http//w
ww.endoflifecare.nhs.uk/eolc, especially
http//www.endoflifecare.nhs.uk/eolc/acp/ Thats
it for this week. Next week the Discharge
process. If you have any queries or comments,
drop a line to national.continuing.care_at_dh.gsi.gov
.uk, active until 1 October.