Majority of complex patients to have personalised care plan within two years

Almost all patients with complex needs will have a personalised care plan in place within two years under targets set out in the NHS 10-year plan.

By 2027, a new standard will ensure 95% of people with complex care needs will have a personalised and agreed plan in place covering both their treatment and holistic wishes, the Government said.

It will give patients significant ‘choice and freedom’ around their care rather than them being passive recipients of the new neighbourhood health service, also outlined in the plan, it said.

Evidence shows high-quality care plans can improve patient experience but also achieve ‘a return on investment of £3 to the £1 spent on those who use healthcare most often’, the plan states.

But data suggests only about 20% of patients with a long-term condition currently have a care plan in place.

Unpaid carers will be actively involved in care planning, the Government added, with patients having greater control over their care through the expanded NHS App.

‘By 2028, patients will be able to see who is involved in their care, communicate with professionals directly, draft and view their care plans, book and hold appointments and leave feedback’.

It will be accompanied by a dramatic expansion of the use of personal health budgets through which patients can decide with their care team how resources are used.

Currently around 180,000 patients use personal health budgets which the Government said they wanted to see double by 2028 and increasing to a million by 2030.

By 2035, PHBs will be a universal offer for all those who would benefit, the plan states, which will also provide more easy access to end of life care provided by hospices or the voluntary sector.

An evaluation from 2014 found the personal health budgets in England delivered quality of life improvements worth between £1,520 and £2,690 per patient, per episode of care, it said.

It is part of broader plans to shift from hospital to community through a newly formed neighbourhood health service with patient-centred teams made up of nurses, doctors, social care workers, pharmacists, health visitors, palliative care staff and paramedics.

Partnerships with charities will also provide new formal support to help people manage their health conditions.

The focus will be on prevention and keeping patients out of hospital wherever possible.

Groups currently ‘most failed’ will be first to access the neighbourhood health service over the next three years to ease pressure on hospitals and adult social care. This includes:

People with long term conditions who will benefit from joined up neighbourhood teams of GPs, specialists and other care professionals
People living in care homes or with frailty who will have more joined up care supported by ‘wearable’ devices
People near the end of life supported more closely by community teams to die at home if they wish
People with severe mental illness who will get more continuity
Disabled people who will get more ongoing holistic support to reduce poorer life expectancy and inequalities
Children in the early years of life with better support from health visitors

‘Instead of fragmentation and one-size-fits-all -patients will have real choice over the care they receive, real power to steer their care team (including through the NHS App and a care plan), and care will be more personalised,’ the plan states.

Personal health budgets were intended to empower patients with complex, long-term care needs to make decisions about the care and support they wish to receive, but pilots of the scheme to give patients either a ‘notional’ budget or NHS cash to spend were controversial over a decade ago – with some patients found using their budget to buy theatre tickets, ready meals and complementary therapies.

Personalised care plans

We will set a new standard that, by 2027, 95% of people with complex needs will have an agreed care plan

We will expect all care plans to be co-created with patients and cover their holistic needs, not just their treatment. They will align with national standards for high- quality care but, within that, give patients significant choice and freedom

Unpaid carers will also be actively involved in care planning. We will mirror the inclusive practices of family group conferencing, which are meetings where family, friends and carers agree decisions about care together. We will capture information about unpaid carers systematically, to ensure their responsibilities are recognised and supported.

By 2028, patients will be able to see who is involved in their care, communicate with professionals directly, draft and view their care plans, book and hold appointments and leave feedback. For many people, this will mean they can access all they need from their neighbourhood team

We will make personal health budgets a universal offer for all who would benefit from them by 2035

Source: Government’s 10-year NHS plan