Quality statement 5: Review of health and social care plan

Quality statement

Older people with multiple long-term conditions and eligible social care needs have a review of their health and social care plan at least once a year.

Rationale

An older person's health and social care plan should be reviewed at least once a year, and whenever there is a change in circumstances, to check that it is still meeting the person's needs. It is important to recognise that multiple long-term conditions are associated with changing needs over time, which in turn may have an impact on the needs of carers. Reflecting these changes in the health and care plan will help to ensure the needs of older people with multiple long-term conditions continue to be met, so that they can remain independent for as long as possible.

Quality measures

Structure

Evidence of local arrangements to ensure that health and social care plans for older people with multiple long-term conditions and eligible social care needs are reviewed at least once a year.

Data source: Local data collection.

Process

Proportion of older people with multiple long-term conditions and eligible social care needs who had a review of their health and social care plan within the past 12 months.

Numerator – the number in the denominator who had a review of their health and social care plan within the past 12 months.

Denominator – the number of older people with multiple long-term conditions and eligible social care needs with a health and social care plan for more than 12 months.

Data source: Local data collection. NHS Digital's Adult social care short- and long-term support (SALT) return collects data on the number of people receiving support for more than 12 months who had a review of their care needs during the year.

Outcome

a) Confidence among older people with multiple long-term conditions and eligible social care needs that they can self-manage their conditions.

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 care providers and secondary care) ensure that older people with multiple long-term conditions and eligible social care needs have a review of their health and social care plan at least once a year. The frequency of reviews will depend on individual circumstances and should be agreed with the person.

Health and social care practitioners (such as social workers, GPs, community nurses, geriatricians, occupational therapists, physiotherapists and mental health nurses) carry out a review of the health and social care plan for older people with multiple long-term conditions and eligible social care needs at least once a year. Practitioners should agree the frequency of reviews with the person.

Commissioners (such as local authorities, clinical commissioning groups and NHS England) commission services that carry out a review of the health and social care plan for older people with multiple long-term conditions and eligible social care needs at least once a year.

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 should have their health and social care plan updated at least once a year, whenever their circumstances change, and at other times if they wish. If appropriate, carers should be involved in discussing whether the health and social care plan needs to change.

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 reviewing their health and social care plan. Their health and social care 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 problem may need additional support, such as an advocate, to support them to be involved in reviewing their health and social care plan.

People with deteriorating conditions and those who are likely to be approaching the end of their life may need their health and social care plan to be reviewed more often.