Tools and resources

3. Co-producing comprehensive care plans that meet people's changing needs

3. Co-producing comprehensive care plans that meet people's changing needs

The guideline and legislation

Section 10.14 of the Care Act 2014 states that people should be in control of their care: "The person [should] be actively involved and have the opportunity to lead or strongly influence the planning and subsequent content of the plan. Joint planning does not mean a 50:50 split; the person can take a bigger share of the planning where this is appropriate and the person wishes to do so." This detailed guidance should provide support in implementing this NICE guideline.

Working with people to co-produce care plans is one of the overarching principles of the guideline (recommendation 1.1.2). Co-production involves engaging and communicating with people and their families to ensure that support is person-centred. The guideline also describes early, focused planning as being a key factor in supporting effective co-production of plans (recommendation 1.37).


Low-cost and simple ideas can make a big difference to ensuring care plans meet people's changing needs.

For example, some people may find it difficult to find ways to occupy themselves after being discharged from inpatient mental health settings, so discharge planning could include information about activities. One of the wards at a hospital in Newham has produced a pack that lists local activities, including sports clubs and drop-in classes. The pack is photocopied and given to people when they are close to being discharged. It is also shared with other settings.

Local learning


Practice, involving people and systems, is important for successfully co-producing care plans that are comprehensive and meet people's changing needs.

At a systems level, a single assessment and care plan that is shared with all members of the multidisciplinary team helps to support co-production. Where health and social care records are held separately, it is important to establish a common approach to assessment.

Feedback from people using services helps future planning, so it is important that good systems are in place for collecting feedback. Feedback should be shared with service providers and with commissioners so that they are aware of providers' performance.

Person-centred support

Focusing on the strengths of the person when assessing their care needs (strengths-based practice) underpins effective co-production. This approach may be new to some practitioners, but they can be supported through supervision to change their practice so that they focus on the person's abilities and what keeps them well and independent.

A default position of recognising the person as the 'expert by experience' also supports co-production. Real, thoughtful co-production requires learning and development for practitioners, so that they feel confident in co-production.

Planning in advance for people who may need crisis support can help to prevent referrals happening at crisis point.

This page was last updated: