Camden’s Care Planning Ambition

Closed 31 Oct 2015

Opened 21 Jul 2015



The Mandate for the Long Term Conditions and Cancer (LTC) Programme sets out clear ambitions for improving the outcomes and quality of life for people living with long term conditions through involving them in the delivery of their own care and embedding personalised care planning. The care planning project will aim to roll out a consistent approach to care planning across Camden with organisational systems and processes reviewed to enable full implementation into general practice and greater access to the care plan across the health and social care system. This work will also aim to agree a more joined up approach to other care plans such as personal budgets.


It is the aim to have one overarching care plan that provides consistency for patients with long term conditions, whether they have one or more LTCs. The LTC care plan will be developed up using the following principles;

•          Two visit ‘Year of Care’ approach

•          Drawn up in partnership with patient

•          Patient goal setting

•          Results section

•          Portable so patient can be handed a copy

•          Accessible to all clinicians involved in care across sectors


Why your views matter


A workshop took place 12th June to engage stakeholders in the plan to fully embed care planning. Guest speakers included two patient representatives and experts in care planning from the Thames Valley Strategic Clinical Network and RCGP.

Feedback from this event will be used to develop the scope to procure training for clinicians in the ‘Year of Care’, goal setting and motivational interviewing and take forward ideas for a new care plan format.

The aim of this survey is to gather feedback from stakeholders about Camden’s ambitions for care planning. We would like to offer the opportunity for stakeholders who attended the workshop to highlight any additional comments and for a wider group of stakeholders (e.g. Community and Secondary Care colleagues) to engage and feedback on the proposal.

Responses will be used to review and assess the proposed approach and findings will be shared on the Camden GP website.


What happens next


  • A service specification will be drawn up for the YOC training programme (early August). Training is expected to start end October/November
  • Developing Care Plan Format with IT team. This will be circulated to all leads for comment and shared with patient reps (end of July)


  • All Areas


  • GP Practice Admin Staff
  • GP Practice Clinical Staff
  • Hospital Admin Staff
  • Hospital Clinical Staff
  • Nurses
  • Practice Manager
  • Consultants
  • Doctors
  • Mental Health Staff
  • General NHS Staff


  • General NHS care
  • Long Term Conditions
  • GP Practices