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Our proposals
A care plan
Why it matters
Experience to date of person-centred Care Plans
in some conditions has shown that they can be excellent
if done well. Evidence from the use of Care Plans
in asthma has shown that for every £1.60 spent
on Care Plans, £7.00 is saved in NHS care.(3)
As well as saving the NHS money, Care Plans improve
the quality of patients’ lives and improve
clinical outcomes.
When done well, Care Plans put patients, not professionals,
in the driving seat. However, there is evidence,
particularly from the mental health field, that
where Care Plans are not taken seriously they can
become a box-ticking exercise and, to the individual,
little more than a piece of paper.
Care Plans need to be personalised, negotiated and
holistic, and should ensure that care is tailored
around the needs of the individual and reflects
their personal preferences and choices. The Care
Plan should be a route map for an individual’s
care so they know what they can expect from services
and when. The Care Plan will enable patients to
actively manage their own condition and maximise
the
opportunities for self-care.
Where next
Whilst
we welcome the Government’s target of offering
a personalised Care Plan for vulnerable people,we
believe the aspiration should be that Care Plans
are available to everyone with a long-term condition
who wants one. The Care Plan needs to be jointly
negotiated between the clinician and
individual patient, and their carer and family if
appropriate. The Plan should match the individual’s
particular conditions, personal preferences and
choices with the best services and support available.
In addition, the Care Plan needs to reflect the
patient’s own goals and set out what a person
could do to maximise their own quality of life.
The Care Plan would be given to the patient and
would form part of their electronic patient record,
to be accessed by all health professionals working
with them.The Care Plan would be regularly reviewed,
with any changes made by joint agreement with the
patient. A named individual would be accountable
and responsible for the professional delivery of
the Care Plan to ensure people didn’t slip
through the gaps between different services.Care
Plans should be externally audited to assess them
against clinical best practice and to ensure they
are actually delivered.
There is no one-size-fits-all approach to Care Plans.The
contents of an individual’s Care Plan might
range from agreement about check-up timings and
when to take particular medicines, to a Care Plan
bringing together different services – not
just the NHS, but also other services, including
social care and housing.The Care Plan should be
a person’s evidence of entitlement to services,
that they can take with them if they choose to use
services delivered elsewhere.
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Charlotte
Palmer
Charlotte has moderate asthma that was
diagnosed when she was a baby. However,
due to lack of help from her GP, it is
only in recent years that she has finally
been able to get it under control.
Despite visiting her GP after suffering
an
asthma attack and using a nebuliser three
times, as well as oxygen, to control her
asthma, the GP said that Charlotte now
looked fine and did not require further
help. It took an emergency visit to A&E
before she was referred to an asthma specialist
who then asked Charlotte the history of
her asthma. Together, the specialist and
Charlotte devised a personal asthma action
plan. Her treatments, and the importance
of taking them,were explained to Charlotte
as part of the consultation.
Charlotte now follows her personal asthma
action plan and measures her peak flow
regularly. This helps her to recognise
when her symptoms are getting worse and
helps her to control her condition.
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Charlotte
still has the occasional asthma attack
but these are far less frequent now that
her asthma is under control. Charlotte
says: “I lived for so long with
poorly controlled asthma that it ruled
my life. However, now that I have a personal
asthma action plan, I know how to control
my asthma and recognise when my symptoms
are worsening.Now, I control my asthma
and I feel much healthier and happier
as a result.”
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3) BMJ, Vol. 319, 18 September 1999
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