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Care plan use among older people with functional impairment: analysis of the English General Practice Patient Survey

Alice Shiner, John A Ford, Nicholas Steel


Objectives: Care plans may improve health when patients are involved in the care planning process. They are recommended for primary care.  This study aimed to identify characteristics of older patients with functional impairment (age ≥75 years with problems completing daily activities) who report having a care plan and who are involved in care planning.

Methods: The General Practice Patient Survey (individual-level dataset) 2015-16 in England was analysed. Logistic regression was used to estimate associations between having a care plan and being involved with care planning and age, gender, ethnicity, deprivation, multimorbidity, interpersonal relationship with general practitioner (GP) and other variables, clustered at practice level.

Results: Three point five percent of GPPS respondents and 14.4% of older people with functional impairment reported having a care plan; however, only a quarter of the latter were involved with the care planning process. Involvement with care planning was associated with seeing own GP (odds ratio (OR) 1.88, 95% confidence interval (CI)1.48 to 2.38) and factors reflecting a positive interpersonal relationship with the GP, including having confidence in the GP (OR 5.92, CI 2.38 to 14.77). Respondents involved with care planning reported greater confidence in managing their own health.

Conclusions: Few older people with functional impairment report having a care plan and fewer report involvement in the care planning process. This may reduce the ability of care plans to deliver health benefits and person-centered care.


Care plans, collaborative goal setting, frailty, functional impairment, long term conditions, multimorbidity, patient activation, patient engagement, person-centered healthcare, self-efficacy, self-management, shared decision-making, social care

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Coulter, A., Entwistle, V.A., Eccles, A., Ryan, S., Shepperd, S. & Perera, R. (2015). Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database of Systematic Reviews (3): CD010523.

Lhussier, M., Eaton, S., Forster, N., Thomas, M., Roberts, S. & Carr, S.M. (2015). Care planning for long-term conditions - a concept mapping. Health Expectations 18 (5) 605-624.

Bower, P., Reeves, D., Roland, M. et al. (2013). Care planning in the treatment of long-term conditions: final report of the CAPITOL project. Available at: (accessed 18 Dec 2017).

Lenzen, S.A., Daniëls, R., van Bokhoven, M.A., van der Weijden, T. & Beurskens, A. (2015). Setting goals in chronic care: Shared decision making as self-management support by the family physician. European Journal of General Practice 21 (2) 138-144.

Boyd, C. & Fortin, M. (2013). Future of Multimorbidity Research: How should Understanding of Multimorbidity Inform Health System Design? Public Health Reviews 32 (2) 451-474.

National Institute for Health and Care Excellence. (2016). NG56 Multimorbidity: clinical assessment and management. London: NICE.

NHS England. (2015). Personalised care and support planning handbook: the journey to person-centred care. Available at: (accessed 7 March 2018).

NHS England. (2015). Enhanced service specification. Avoiding unplanned admissions: proactive case finding and patient review for vulnerable people 2015/16. Available at: (accessed 7 March 2018).

Garin, N., Koyanagi, A., Chatterji, S., Tyrovolas, S., Olava, B., Leonardi, M., Lara, E., Koskinen, S., Tobiasz-Adamczyk, B., Ayuso-Mateos, J.L. & Haro, J.M. (2016). Global Multimorbidity Patterns: A Cross-Sectional, Population-Based, Multi-Country Study. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 71 (2) 205-214.

Burt, J., Rick, J., Blakeman, T., Protheroe, J., Roland, M. & Bower, P. (2014). Care plans and care planning in long term conditions: a conceptual model. Primary Health Care Research & Development 15 (4) 342-354.

Ipsos MORI. (2016). GP Patient Survey. Available at: (accessed 7 March 2018).

Reeves, D., Hann, M., Rick, J., Rowe, K., Small, N., Burt, J., Roland, M., Protheroe, J., Blakeman, T., Richardson, G., Kennedy, A. & Bower, P. (2014). Care plans and care planning in the management of long-term conditions in the UK: a controlled prospective cohort study. British Journal of General Practice 64 (626) e568-e575.

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 & Policy 17 (Supplement 1) 64-71.

Ipsos MORI. (2016). GP Patient Survey - Technical Annex 2015-2016 annual report. Available at: (accessed 7 March 2018).

StataCorp. (2013). Stata Statistical Software: Release 13. College Station, TX: StataCorp LP.

Bouillion, K., Kivimaki, M., Hamer, M., Sabia, S., Fransson, E.I., Singh-Manoux, A., Gale, C.R. & Batty, G.D. (2013). Measures of frailty in population-based studies: an overview. BMC Geriatrics 13, 64.

Vermunt, N.P.C.A., Harmsen, M., Westert, G.P., Olde Rikkert, M.G.M. & Faber, M.J. (2017). Collaborative goal setting with elderly patients with chronic disease or multimorbidity: a systematic review BMC Geriatrics 17, 167.

Blakemore, A., Hann, M., Howells, K., Panagioti, M., Sidaway, M., Reeves, D. & Bower, P. (2016). Patient activation in older people with long-term conditions and multimorbidity: correlates and change in a cohort study in the United Kingdom. BMC Health Services Research 16 (1), 582.

Patient activation measure. Available at: (accessed 7 March 2018).

Parsons, S., Winterbottom, A., Cross, P., et al. (2010). The quality of patient involvement and involvement in primary care. London: The King’s Fund. Available at: (accessed 7 March 2018).

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.



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