More people than ever are living with long-term physical and mental health conditions in the UK. As a result, there has been a national drive towards developing long-term care plans collaboratively between professionals and people.

Personalised care planning standards will help people manage their own care, with the support of a wide range of services including GPs, hospitals, occupational therapy and social care. This standard will help them and the health and care professionals who support them to get the right information when they need it.

The standard supports personalised care and support planning so that individuals have a single shared personalised care and support plan to which all health and care professionals can contribute. The aim is to avoid what currently happens too often, where separate care plans are created by different professionals or teams of professionals and they are not widely visible, don’t join up, and don’t promote a holistic approach to meeting a person’s care needs.

The plan should be developed with the person themselves and/or with their carer where appropriate, based on the person’s strengths and holistic needs.

• Improves continuity of care by ensuring people have a single care plan that shares key information to help them to get the right care and support when they need it.
• Helps people contribute and feel actively engaged in their own care.
• Provides a single, holistic picture of their needs, goals and actions, enabling them and their family/carers and health and care professionals to provide appropriate support to improve a person’s health and wellbeing.

The standard is UK wide for use across the whole of health and social care and for anyone requiring a care and support plan, including children, with any health and/or care needs.

A personalised care plan should be produced from a conversation between the person (and/or their carer) and a care professional, focusing on what’s important to the person and their holistic needs and goals.

The standard supports the personalised approach to care and support planning with a single shared care and support plan for all the professionals and people involved in a person’s care, including the person themselves and/or their carers.

It starts with their ‘About Me’ information, then focuses on their strengths and needs, together with their goals, hopes, and aims. It should demonstrate how the person’s aims and goals will be met and who is responsible for delivery of the activities to achieve them. These are the person’s holistic needs (e.g. to recover their mobility or manage anxiety) which may require support from different parts of health and social care.

Additional support plans may be linked to the care and support plan and should be available for others to view. Their format will vary according to the type of plan and can be structured and coded, and some may include diagrams or images. They can be used for detailed plans to support particular conditions such as a dietician’s plan, wound management plan or behaviour support plan, or to set out care plans, for example to support activities of daily living.

Contingency plans, also known as anticipatory, escalation, or crisis plans provide details of how predictable risks associated with health and wellbeing are managed if they get worse’. They are plans of what to do should a person’s health or circumstances get worse and who to contact.