Open Access Open Access  Restricted Access Subscription Access

Care planning for long term conditions in primary care: indicators of embeddedness

Monique Lhussier, Natalie Forster, Simon Eaton, Susan M Carr


Rationale, aims and objectives: Healthcare systems are continuously challenged to develop new ways of working to meet the demands of an increasing prevalence of multi-morbid long term illness. Care planning has been proposed as one solution. This analysis used the Normalisation Process Theory as a framework to identify precursors of embeddedness of care planning in 10 primary care practices.

Methods: GPs, Nurses and Practice Managers from the selected practices took part in a series of collaborative learning workshops and a training programme. The data informing this article derive from 15 semi-structured interviews and from observational data collected during 4 collaborative meetings.

Results: A key step in the meetings was collaboratively to differentiate the care planning function from previous practice. Later interviews showed a clear movement towards the generation and implementation of pragmatic solutions. These included the adaptation of pre-existing tools, IT systems, call and re-call procedures and documentation and communication procedures in order to implement care planning for diverse patient needs. Implementing the care planning function entailed a renegotiation of roles between clinicians as well as with patients, the explicit inclusion of practice managers and a consideration of relationships with secondary care and other local services. Participants provided anecdotal evidence of the benefits of care planning and reported having received positive feedback from patients.

Conclusions: The learning collaborative enabled participants to shape care planning to fit their individual practice contexts, in terms of resources, structures and systems as well as in terms of the patient population. It emphasised the need for differentiation from prior practice, individual and communal specification and internalisation and fostered a sense of ownership.

Full Text:



Department of Health. (2012). The Mandate - A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015. London: HMSO.

Department of Health. (2012). Long Term Conditions Compendium of Information - Third Edition. London: HMSO.

Eaton, S., Collins, A., Coulter, A., Elwyn, G., Grazin, N. & Roberts, S. (2012). Putting patients first. British Medical Journal 344, e2006.

Department of Health. (2006). Our Health, Our Care, Our Say. London: Department of Health.

Department of Health. (2010). Equity and Excellence: Liberating the NHS. London: Department of Health.

NHS England. (2013). Transforming participation in health and care. London: NHS England.

Burt, J., Rick, J., Blakeman, T., Protheroe, J., Roland, M. & Bower, P. (2013). Care plans and care planning in long-term conditions: a conceptual model. Primary Health Care Research & Development 15 (4) 342-354.

Hughes, L.D., McMurdo, M.E. & Guthrie, B.G. (2013). Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age and Ageing 42 (1) 62-69.

Guthrie, B., Payne, K., Alderson, P., McMurdo, M. & Mercer, S. (2012). Adapting clinical guidelines to take account of multimorbidity. British Medical Journal 345 e6341.

O'Brien, R., Wyke, S., Guthrie, B. & Watt, G.S.M. (2011). An 'endless struggle': a qualitative study of general practitioners' and practice nurses' experiences of managing multimorbidity in socio-economically deprived areas of Scotland. Chronic Illness 7, 45-59.

Blakeman, T., Bower, P., Reeves, D.& Chew-Graham, C. (2010). Bringing self-management into clinical view: a qualitative study of long-term condition management in primary care consultations. Chronic Illnes. 6 (2) 136-150.

Lhussier, M., Eaton, S., Forster, N., Thomas, M., Roberts, S. & Carr, S.M. (2013). Care planning for long term conditions – a concept mapping. Health Expectations.

Year of Care. Report of findings from the pilot programme. Accessed 10/05/2013.

de Silva D. (2011). Helping people help themselves - a review of the evidence considering whether it is worthwhile to support self-management. London: The Health Foundation.

Coulter, A. & Roberts, A.D. (2013). Delivering better services for people with long-term conditions. Building the House of Care. London: The King's Fund.

Burt, J., Roland, M., Paddison, C., Reeves, D., Campbell, J., Abel, G. & Bower, P. (2012). Prevalence and benefits of care plans and care planning for people with long-term conditions in England. Journal of Health Services Research and Policy 17 (Supplement1) 64-71.

Newbould, J., Burt, J., Bower, P., Blakeman, T., Kennedy, A., Rogers, A. & Roland, M. (2012). Experiences of care planning in England: interviews with patients with long term conditions. BMC Family Practice 13, 71-79.

Kennedy, A., Nelson, E., Reeves, D., Richardson, G., Robinson, A., Roberts, C., Robinson, A., Rogers, A.E., Sculpher, M. & Thompson, D.G. (2004). A randomised controlled trial to assess effectiveness and cost of a patient oriented self-management approach to chronic inflammatory bower disease. Gut 53 (11) 1639-1645.

Zwar, N., Hasan, I., Hermiz, O., Vagholkar, S., Comino, E. & Harris, M. (2008). Multidisciplinary care plans and diabetes: benefits for patients with poor glycaemic control. Australian Family Physician 37 (11) 960-962.

Diabetes UK. (2011). Year of Care: Report of findings from the pilot programme. London: Diabetes UK.

May, C., Murray, E., Finch, T., Ballini, L., Mac Farlane, A., Murray, E., Mair, F., Treweek, S. & Rapley, T. (2010). Normalization Process Theory On-line Users’ Manual and Toolkit. Accessed 23rd January, 2014.

May, C., Finch, T., Ballini, L., MacFaralane, A., Mair, F., Murray, E., Treweek, S. & Rapley, T. (2011). Evaluating complex interventions and health technologies using normalization process theory: development of a simplified approach and web-enabled toolkit. BMC Health Services Research 11, 245.

Lloyd, A., Joseph-Williams, N., Edwards, A., Rix, A. & Elwyn, G. (2013). Patchy 'coherence': using Normalisation Process Theory to evaluate a multi-fasceted shared decision making implementation program (MAGIC). Implementation Science 8, 102.

May, C. (2013). Towards a general theory of implementation. Implementation Science 8, 18.



  • There are currently no refbacks.