Why care planning for long term conditions and complex needs matters 

The Health Foundation projects that by 2040, 9m+ adults will live with major illness. Many will also develop frailty – the gradual loss of resilience across multiple body systems. These individuals with “complex needs” are more vulnerable to health crises, slower to recover, and become caught in a spiral of deteriorating health and independence.  

A good care plan has the potential to interrupt this cycle. Through structured conversations between patients and their healthcare teams, a personalised health and wellbeing needs plan is created, including action plans for illness, and how this might be prevented or managed in the community. These hope to give patients the confidence to manage their health and care to enable a better quality of life. It’s about helping people live well with complexity, preventing deterioration, pre-empting crisis, and restoring independence after setbacks. This generates a positive impact on system sustainability by reducing the need for expensive secondary care.

So how do you make care planning work within a cohesive model of care? 

Care plans will only be successful when the right plan is executed by all involved (the individual, their families, carers, and all relevant parts of the health and care system). For this reason, effective care planning is a collaboration with the individual and their support network – not a process done “to” or “for” patients. 

Most critically of all, those patients need to be the right patients, and their support should begin, not end, with the creation of their care plan. Therefore, if we want to scale up care planning to deliver impact we need a few critical functions in place, working together as a cohesive model of care.   

These additional key functions are: 

• Intelligent case finding & risk stratification – Systems need to concentrate efforts where they will generate the most value. This needs to be an intelligent, proactive population health approach that predicts with precision the individuals at risk of deterioration. 
• Proactive monitoring and support – Plans create value when they’re acted on. That means structured follow-up, early detection of deterioration, and the ability to intervene early. Increasingly, wearables and remote monitoring should be the focus in intelligent monitoring of at-risk patients. 
• Continuity and shared ownership – Care planning needs to be owned and shared across health providers – necessitating an integrated technology solution. The Government’s vision is that this is a capability of the NHS App – but in the shorter term solutions are needed that provide one plan visible to all and integrated with patient records. 

There’s good evidence that bringing these elements together works. At the Jean Bishop Centre in Hull, personalised care planning and proactive monitoring reduced ED attendances by over 10%, with even larger gains (50%+) for the highest-intensity users. GP appointments fell, problematic polypharmacy dropped, and £100 per patient per year was saved on drugs alone.¹

Function over form

At The PSC, we’ve developed a functional framework to support local teams. Here we are using it to illustrate good practice against the five core functions – but it can be used flexibly e.g. to map existing assets, align improvement plans, or focus efforts where they matter most. It cuts through complexity, helping local leaders design around population need rather than existing organisational structures. 

Delivering a new model & affording the transition 

Care planning is relatively low-cost, and the return on investment is clear. But the transition is expensive. This is because benefits accrue slowly and, whilst proactive care might support downstream disinvestment over the longer term, initial “double running” cannot be completely avoided.  

What can be done about it? We work with our clients to develop local approaches built on three core principles: 

• “Big bang” change is unrealistic here – front-loaded costs are prohibitive in a big bang model, and there is reduced opportunity for learning, experimentation and innovation. Don’t wait for the perfect model. Use strategic pilots to test proof of concept - e.g. a single PCN or a care home population - and scale what works.  
• Avoid pilotitis - A coordinated programme with a joined-up population led approach, oversight, data, and management of risk helps to prevent the proliferation of disjointed, overlapping, and uncontrolled experiments which give  only the illusion of progress.  
• Composite & creative funding is required, with a strong focus on in-year cash-releasing benefits – and minimal reliance on new recurrent funding. In practice this will mean developing a local approach mixing partnership funding (e.g. closer working between NHS and local authorities), cost-neutral elements (e.g. integration of existing teams), disinvestment from downstream services, efficiency and productivity improvements, and system benefits with an in-year element (like reduced drug costs).  

At The PSC, we help NHS leaders move from strategy to delivery. Our work focuses on finding the right place to start, and shaping a practical, affordable pathway to sustainable scale. If you’re grappling with where to begin - or how to move faster - we’d love to talk. 

Sources

1. Murtagh FEM, Okoeki M, Ukoha-Kalu BO, Khamis A, Clark J, Boland JW, Pask S, Nwulu U, Elliott-Button H, Folwell A, Harman D, Johnson MJ. A non-randomised controlled study to assess the effectiveness of a new proactive multidisciplinary care intervention for older people living with frailty. BMC Geriatr. 2023 Jan 5;23(1):6. doi: 10.1186/s12877-023-03727-2. PMID: 36604609; PMCID: PMC9813451.