Quality statement 4: Care planning

Quality statement

Older people with multiple long-term conditions and eligible social care needs have an agreed health and social care plan that includes how their personal priorities and outcomes will be met.

Rationale

A health and social care plan for older people with multiple long-term conditions and eligible social care needs will clarify how their health and social care needs will be met. They should be involved in developing their health and social care plan to ensure it is person-centred and focused on their priorities and outcomes. Ensuring all parties, including the older person, their carers or advocate and care practitioners, agree with and sign the health and social care plan will encourage joint ownership of the plan and confirm agreement with its content. This will help older people and their carers to consider whether the plan meets their needs and will improve their quality of life.

Quality measures

Structure

a) Evidence of local processes to ensure that older people with multiple long-term conditions and eligible social care needs are involved in developing and agreeing their health and social care plan.

Data source: Local data collection.

b) Evidence of local processes to ensure that health and social care plans for older people with multiple long-term conditions and eligible social care needs include how personal priorities and outcomes will be met.

Data source: Local data collection.

Process

a) Proportion of older people with multiple long-term conditions and eligible social care needs with a health and social care plan that includes how their personal priorities and outcomes will be met.

Numerator – the number in the denominator with a health and social care plan that includes how their personal priorities and outcomes will be met.

Denominator – the number of older people with multiple long-term conditions and eligible social care needs.

Data source: Local data collection.

b) Proportion of older people with multiple long-term conditions and eligible social care needs who sign their health and social care plan.

Numerator – the number in the denominator who sign their health and social care plan.

Denominator – the number of older people with multiple long-term conditions and eligible social care needs.

Data source: Local data collection.

Outcome

a) Satisfaction among older people with multiple long-term conditions and eligible social care needs that their health and social care plan reflects their personal priorities and outcomes.

Data source: Local data collection.

b) Health-related quality of life for older people with multiple long-term conditions and eligible social care needs.

Data source: Local data collection. NHS England's GP patient survey includes questions on health-related quality of life.

c) Social care-related quality of life for older people with multiple long-term conditions and eligible social care needs.

Data source: Local data collection. NHS Digital's Personal social services adult social care survey includes questions on social care-related quality of life.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as local authorities, general practices, community health and care providers and secondary care) ensure that processes are in place for older people with multiple long-term conditions and eligible social care needs to be involved in developing a health and social care plan that includes how their personal priorities and outcomes will be met. Providers ensure that the health and social care plan is agreed and signed by all parties, and that the person is given a copy.

Health and social care practitioners (such as social workers, GPs, district nurses, geriatricians and mental health nurses) involve older people with multiple long-term conditions and eligible social care needs in developing a health and social care plan that includes how their personal priorities and outcomes will be met. Practitioners ensure that the health and social care plan is agreed and signed by all parties, and that the person is given a copy.

Commissioners (such as local authorities, and clinical commissioning groups) commission services that ensure older people with multiple long-term conditions and eligible social care needs are involved in developing health and social care plans that includes how personal priorities and outcomes will be met. This includes ensuring that health and social care plans are agreed and signed by all parties, and that the person is given a copy.

What the quality statement means for people using services and carers

Older people with more than 1 long-term condition who need social care services (and their carers, if appropriate) are involved in planning their health and social care. This is to make sure that their care and support reflects what is important to them. They should agree and sign their personal health and social care plan and be given a copy to keep.

Source guidance

Definitions of terms used in this quality statement

Multiple long-term conditions

A long-term condition is defined as one that generally lasts a year or longer and impacts on a person's life. Examples include arthritis, asthma, cancer, dementia, diabetes, heart disease, mental health conditions, stroke, and hearing and sight loss. Multiple means a person has more than 1 condition. The impact and symptoms of these conditions can fluctuate, and people may or may not need to take medicines for their conditions.

[NICE guideline on older people with social care needs and multiple long-term conditions]

Eligible social care needs

Local authorities have a duty to meet people's social care needs that fulfil the criteria in the Care Act 2014. When determining a person's eligibility for social care, local authorities must consider 3 conditions:

  • Condition 1: The adult's needs for care and support arise from or are related to a physical or mental impairment or illness and are not caused by other circumstantial factors.

  • Condition 2: As a result of the adult's needs, the adult is unable to achieve 2 or more of the following outcomes:

    • managing and maintaining nutrition

    • maintaining personal hygiene

    • managing toilet needs

    • being appropriately clothed

    • being able to make use of the adult's home safely

    • maintaining a habitable home environment

    • developing and maintaining family or other personal relationships

    • accessing and engaging in work, training, education or volunteering

    • making use of necessary facilities or services in the local community, including public transport, and recreational facilities or services

    • carrying out any caring responsibilities the adult has for a child.

  • Condition 3: As a consequence of being unable to achieve these outcomes, there is, or there is likely to be, a significant impact on the adult's wellbeing.

[The Care and Support (Eligibility Criteria) Regulations 2014]

Health and social care plan

Health and social care plans should be tailored to each person, giving them choice and control, and recognising the inter-related nature of multiple long-term conditions. When developing or reviewing a care plan, the person should be offered the opportunity to:

  • address a range of needs including medical, psychological, emotional, social, personal, sexual, spiritual and cultural needs, sight, hearing and communication needs and environmental care needs

  • address palliative and end-of-life care needs

  • identify health problems, including continence needs and chronic pain and skin integrity, and the support needed to minimise their impact

  • include any requirements for managing medicines, for example, the importance of dosage and timing, and the implications of non-adherence

  • identify the help they need to look after their own care and support, manage their conditions, take part in preferred activities, hobbies and interests, and contact relevant support services

  • include leisure and social activities outside and inside the home

  • address mobility and transport needs, adaptations to the home and any support needed to use them.

[NICE guideline on older people with social care needs and multiple long-term conditions, recommendations 1.2.5 and 1.2.7]

Equality and diversity considerations

People with communication difficulties or hearing or sight loss should be offered support to enable them to be involved in developing and agreeing their health and social care plan. The plan should be provided in a format that suits their needs and preferences and meets the requirements set out in NHS England's Accessible Information Standard.

People with limited independence as a result of a physical disability or mental health condition may need additional support, such as an advocate, to support them to be involved in developing and agreeing their health and social care plan.