Newcastle Gateshead Clinical Commisioning Group

Care and Support Planning for Long Term Conditions

We have been working with GP practices in Newcastle and Gateshead to change the way they organise appointments and provide support for people who have long term conditions. This new way of working is called care and support planning.

Information for patients

When you have a long term condition this needs regular follow up. To organise this GP practices are required to include you on a long term conditions register.  This will help you to make sure you receive effective care at the right time for your condition.

Everyone with a long term condition should expect to receive a yearly review  in their General Practice to monitor their  condition and help them manage it, alongside this, they will have a review of any medications they take.

If you don’t think you have been having this review then contact your practice to find out if you should receive one and how this works in your practice.

What is care and support planning?

You will have an appointment for any checks or test that are needed to help you and your GP, or Practise Nurse, to monitor your condition, such as blood pressure and blood tests. Your results will be sent to you with an explanation and a preparation sheet so that you have time to think about anything you’d like to discuss with your GP or Practice Nurse, before you meet them. People who do not require any checks or tests  will still be sent a preparation sheet and any other useful information which will help  them to manage their condition. 

Working in this way makes sure that you are given as much information as possible before you see your nurse or doctor, so you can get the most from your appointment.

It should help you to talk about:

• What is important to you
• What you can do to look after your health and stay well
• What support you may need

Who is it for?

GP practices have started working in this way with patients who have one of a number of long term conditions, such as diabetes, heart disease, COPD, asthma and circulatory disease.  To find out if your GP practice is using care and support planning you can visit their website or contact the practice directly.

We are asking for feedback from patients to help us to understand how you are experiencing the care and support planning process.

There is also a leaflet which provides more information. Click here to download a copy.

Information for clinicians

In Gateshead, the development of this approach was funded by the British Heart Foundation as part of their national House of Care programme (April 2015 to March 2018), with support from the Year of Care Partnerships.

The focus of the project was to implement a new approach to the management of long term conditions – the year of care approach. The aim was to enable patients with CVD and their carers to be engaged, informed and empowered to better care for themselves, and to enable health professionals and voluntary sector to support self-management.

The project has used a partnership approach across Gateshead with support from local stakeholders, and we are grateful to all involved for their continuing hard work and support.

As part of this project we have completed an evaluation report, case study and key messages. These are available here:

• Gateshead House of Care Project summary
• Gateshead Key evaluation messages
• Learning from our experience key messages
• Gateshead House of Care Evaluation Report
• Case Study – Our Experience of the Gateshead House of Care Project

This approach has now been rolled out across practices in Newcastle and is delivered under a Care and Support Planning for long term conditions local improvement scheme.