Person-centred care is a legal and moral duty — yet only one in five people with a long-term condition have a care plan, revealing a major gap in the health system’s long-term vision.
This article is written by Raje Ballagan-Evans, policy and impact manager at Social Interest Group
In the health and social care sector, we evidence the importance of supporting service users based on the two pillars of person centred care- self-identified needs and aspirations. These form the purpose of our work and indeed are legislated by the Care Act 2014 to uphold dignity and autonomy for service users. However, the 10-Year Health Plan underlines that data evidences only 20% of people with a long term condition have a care plan.
The impact of this on those with long term conditions is clear, advocacy services report that service user needs are overlooked and the bias of professionals dictates treatment. In fact, specialists can hinder the whole picture approach of a person’s health and lead to unmet needs and inconsistent support.
For those with complex needs, this is detrimental and the institutionalised view of disability that still pervades statutory organisations creates barriers that can be insurmountable. The health secretary has rightly pointed out that siloed health services are causing people’s health and wellbeing to deteriorate. A holistic model is essential.
Of course, for care plans to deliver solutions that enable the aims of the 10-Year Health Plan to create interconnected neighbourhood delivery of care in primary, secondary and social settings, they will require more than the just digitisation of data. Whilst digitisation is welcome and important for patient and carer accessibility, care plans and digital passports can only be genuinely empowering if accountability equally informs digital and community pathways to care and treatment.
As currently described in the government’s health strategy, care plans will enable patients and their carers to manage their care better, thus reducing administration by health professionals and therefore significantly reducing costs for health services. However, much like sending professionals out into the community, improvements to care delivery and health outcomes for service users will not automatically occur.
An integrated approach is required amongst professionals, united by an agreed care plan that GPs, social workers, secondary care staff, health and social care professionals all contribute to, enabling peer review and peer informed learning that benefits the service user. The current two-tier approach to care plans being ascribed to patients and care professionals, and doctors and specialists not consulting them, let alone contributing to them, leads to inequalities caused by uniformed assessments and treatments.
When service users with multiple needs describe the stigma and barriers they experience in receiving person centred support and care, a consistent theme emerges; they share their story with professionals, as well as their own assessment of needs and requirements, but the attending professional responds that they can only address one element or need described and that service users ought to reach out to other services to address anything else.
But isolating a symptom without the context of the wider circumstances, patterns and informing factors cannot lead to an efficient outcome? On the other hand, it is in the service users best interest that multiple professionals with expertise and specialisms address each of their needs so live care plans with cross-Trust and partner data sharing present a realistic and efficient solution.
Currently care plan provides succinct information on needs and context and with the addition of a brief medical history, expert opinions and comments from appropriate sources, can become a powerful tool for ensuring informed treatment and support, enabling continuous best practice.
This is a feasible way of integrating care, maximising resources and efficiency in the workforce for the benefit of service users. Integrated care will be more vital than ever for service users as they rely on finding help in the community, the 10-Year Health Plan stipulates service users ‘only using hospitals when it is clinically necessary’ so accessibility and autonomy needs to be enabled.
The word ‘integrate(d)’ features only 52 times in the 171 page health plan. This stands out to me as significant because shifting care into the community is not enough, we must see the fulfilment of fully integrated community services. Isolating secondary care from communities (hospitals are in communities by the way) is concerning because Integrated Care Boards (ICBs) may struggle to fulfil the accountability aspect of their role as strategic commissioners of NHS services, as the new guardians of the neighbourhood health model, due to significant budget cuts and reduced staff size.
A June 2025 report commissioned by the Constitution Society highlights: ‘NHS accountability mechanisms remain largely invisible to the public. A striking 91.9% of survey respondents reported no direct engagement’.
An NHS app won’t fix the deeper structural opacity facing service users and carers. As strategy and governance become ever more centralised, questions of accountability grow louder. What’s needed now is a genuine shift towards multidisciplinary working and live, person-centred care plans—practical tools that could thread together holistic, preventative care without placing unrealistic demands on clinicians. This isn’t just about improving outcomes; it’s about recognising the long-marginalised role of adult social care and delivering on the promise of the NHS neighbourhood health guidelines for 2025/26. Reform can’t wait—nor should it.
Images: Shutterstock and Raje Ballagan-Evans
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