This document focuses on people who have long term physical health problems and describes how GPs and the other members of the primary health care team can support them to live their lives more comfortably with their condition.

It is intended that all patients and clinicians who read it can feel more con?dent about how to use Care Planning in their daily practice to achieve better health outcomes, improve the ef?ciency of working together and reduce ‘strain’ on the NHS and social services.

The document makes the case for supporting people to manage their own health through a care planning approach, and describes the evidence that working in this new way is likely not just to improve the experience for everyone, but also to lead to better outcomes and lower costs in the long run.

It looks at why people with LTCs are ‘different’ from people with acute conditions and why support for them needs to be different. It looks at how Care Planning can be a good way to support our patients with LTCs and uses the diabetes Year of Care model as an example.

It outlines some of the experiences of the over 50 general practices who tested the Year of Care model in three diverse pilot PCTs. Teams reported that their experience was that Care Planning is a practical and helpful approach to improving the care of patients with diabetes. It also gave them a good framework to help individuals and teams to re?ect on their attitudes, their current ways of working and to generate ideas for change. The learning from the pilot can be used to support other practices to develop their approach.

Finally it explores different approaches to evaluation which can be used to adjust performance and make improvements to meet externally or internally set standards.