Care Plans & Care Planning

Care Plans

In 2014, the NHS introduced a service for people who are more at risk of an unplanned hospital admission in an emergency situation. It was felt that such people are likely to benefit from a personally tailored and more proactive support from their GP Practice.

The service involves the invited patients having a named GP and also a named “care co-ordinator” (who could be the same person) at the Practice. These people take overall responsibility for the care/support that can be provided by the GP Practice. Their specific roles are outlined below.

The service involves the Practice working with the patient to develop (and keep up-to-date) a personal  health care plan  to better help them manage their own health & wellbeing.

What is included in a Personal Care Plan?

If you are at risk of an unplanned hospital admission in an emergency situation we will invite you (and your carer if you have one) to meet with us to develop (and, on an ongoing basis, review) your personal care plan. With your agreement, other health or care professionals involved in your care may also be invited to help develop the plan and keep it up-to-date.

This care planning discussion will help us all to think about your health and care needs and with your agreement, your personal care plan will include the following  information:

  • Your NHS number
  • The details of your named GP and care co-ordinator
  • The details of any other health or care professionals who are involved in your care (eg Community Matron, District Nurse)
  • Confirmation that you have agreed to sharing your personal plan with other health and care professionals, if necessary
  • Details of your condition(s) and significant past medical history
  • Any allergies you may have
  • Details of any medication(s) you are taking and plans for reviewing them
  • The actions that you are taking to help manage your health
  • How you can detect any early signs that your health may be worsening and what you should do if this happens
  • Who to contact if you think you need to see a doctor urgently

What is the role on the Named GP ?

The named GP has overall responsibility for the care and support that our surgery provides to you.

What is the role of the Named Care Co-ordinator?

The Named Care Co-ordinator is likely to be the person you see most. They are responsible for sharing information with you and your carer (where applicable) and (if you have agreed to this) with other health and care professionals involved in your care.

Your Care Coordinator will work with you develop your personal care plan and keep in touch with you (usually, at least 4 times a year) to keep your plan up-to-date.

What are the benefits for patients?

Your named care co-ordinator will work with you develop your very own personal health care plan.

Together with your named GP, they will review your health needs as often as necessary and at least every 3 months. They will ensure that you receive support from both the Practice and others to help you manage your health better and reduce your risk of unplanned emergency hospital admissions.

They may also be able to direct you to local community resources that you would find helpful.

And, by taking part in this service, we guarantee that, when you have an urgent health need, you can call the surgery (on the usual number), mention that you have a personal care plan in place  – and either a GP or nurse will call you back on the same day to offer help.


Your personal care plan will only be shared with other health and care organisations (eg hospitals, emergency services or social care) to help coordinate your care – and only with your permission.

If you have any queries about care plans, please ask in the first instance at Reception or email us at