Dr Peter Standing’s team, joint runner up in the Guidelines in Practice Award 2006, shows how implementing personalised care plans leads to improved results for its diabetes patients

In 2004 at the Minden Medical Centre, Bury, we piloted personalised care plans for the 216 registered patients with diabetes. Concise information was presented with clear guidance based on the GMS contract quality and outcomes framework on why targets for blood pressure, cholesterol levels, and glycaemic control are so important.

Although primarily used as an educational tool, the personalising of clinical results aimed to empower patients to take more responsibility for their diabetes management. The plans have also provided us with a valuable annual clinical record and monitoring tool. Patients contributed to the design of the care plans, and results of a patient survey conducted by questionnaire in May 2006 showed very positive feedback about the usefulness of the plans. By 2006 the practice cared for 244 patients with diabetes who each received the third, and much improved, version of the care plan.


Each year since 1999, our practice at the Minden Medical Centre has produced an annual practice report with the aim of improving the quality of the clinical care provided. The report has focused primarily on critical evaluation of chronic disease management, especially the four 'cardiovascular killers':

  • diabetes
  • coronary heart disease
  • hypertension
  • stroke.

In April 2004, at the end of the preparatory year of the QOF, our diabetes care still showed many shortcomings: for example, only 56% of patients had an HbA1c <7.4% and only 62% had a cholesterol level <5 mmol/l. As previous management had been largely doctor and nurse centred, we decided that the best way to improve care was to involve patients more in understanding and achieving their own targets. We sent each of the 216 patients with diabetes a personalised care plan.

Aims and design of the care plan

The care plan had two objectives:

  • to provide an educational tool spelling out clearly the aims of ideal diabetes care and especially why good control of blood pressure, cholesterol levels, and glycaemia is so important
  • to give personalised feedback on results from the previous year, with the aim of empowering patients to take more responsibility for their own diabetes management.

The design of the care plan was crucial. In order to avoid multiple-paged documents that many patients would never read, we were ruthless in limiting information to a single side of A4. Patients helped to design the first care plan in 2004 and contributed to major improvements in the 2006 version (Figure 1). These improvements allowed for the inclusion of feedback on how each patient's results compared with those from the previous year. This was important because we decided that it was a better incentive to congratulate a patient with poorly controlled diabetes whose HbA1c level has decreased from 13.8% to 10.9% rather than issue dire warnings that a level of 10.9% greatly exceeds the clinical targets advised in the GMS contract.

Figure 1: Example of a personalised diabetes cate plan (for a patient with poorly controlled diabetes)

figure 1

Additional uses and response to the care plans

The clinical result summary in each personalised care plan has provided us with a valuable annual monitoring tool, which is now routinely recorded in the patient's computer record. In some cases, simply preparing the care plans has prompted us to introduce refinements in medication, such as adjusting doses of statins and antihypertensive medications, or initiating aspirin therapy. Care plans are an extra prompt to combat clinical inertia.

In May 2006, we sent out questionnaires with the third version of the care plan to learn what patients with diabetes thought of the initiative. From a 73% response rate (without reminders) patients rated the plan as follows:

  • 'extremely useful and informative' – 34%
  • 'very useful and informative' – 34%
  • 'quite a useful guide' – 16%
  • 'only slightly useful' – 4%
  • 'of no interest or use to me' –2%
  • did not fill in this section of the questionnaire – 10%.

When asked about their understanding of the targets they were aiming for: 80% of patients with diabetes responded that they understood the three key targets for BP, cholesterol levels, and glycaemic control; 6% of them only understood two targets; and 8% did not understand at all (6% left this section blank). The negative responses are in many ways especially helpful, allowing the diabetes nurse to focus on educating this group.

Use of guidelines and success of the care plans

The care plans have always incorporated evidence-based guidelines. In 2004 and 2005, these followed the QOF targets of GMS, but these are now sadly out of date.1

Our April 2006 care plans incorporate the latest, optimal targets of JBS2: a level of total cholesterol <4 mmol/l and BP <130/80 mmHg.2 One beauty of the care plan is that it is simple to update annually.

The template is a Word document of text and tables, and the annual care plan for each patient is saved in a secure practice intranet diabetes folder. Personalised plans for the following year are made by 'cutting and pasting' last year's clinical data into the current year's updated template, and then adding the current year's clinical results.

In past years the care plans have not been prepared until after 1 April, but for April 2007 some provisional care plans are being drawn up a few months in advance during the patient consultation. This adds extra responsibilities for motivating patients to go that extra mile to improve their results by April. Once the care plans for 2007 are finalised, they will be added to the patient's clinical record as an attachment.

The production and success of our care plans have involved much teamwork, with valuable contributions from partners, the practice diabetes nurse, medical students, computer staff, and patients. The system used in the practice, where each partner has a personal list of patients, has also made it easy for our attached personal GP receptionists to become involved, and in 2006–2007 they will take charge of much of the updating of the care plans.

Each partner at our practice has a personalised reception desk. Consequently the majority of patients will deal with the same receptionist who will get to know the patients on a partner's list. This system is efficient when it comes to chronic disease management because the personal receptionist gets to know the patients whose care is problematic. We feel that offering continuity of receptionist care is just as important as continuity of GP care.


Disseminating information is fundamental to the aims of our care plans and the system has helped everyone in the practice and patients with diabetes to work together towards achieving the agreed targets. Our care plans have been shared with other local practices and the Tier 2 services for diabetes set up by Bury PCT.

The Government's white paper Our Health, Our Care, Our Say highlights the lack of care plans for patients with long-term conditions or complex health/social needs.3 It is important that these plans do not become so complicated that they fail to provide patients with simple practical guidance.

Our experience has shown that most patients with diabetes will read brief educational material and that they are very interested in personalised feedback. We believe our care plans could provide a model for any national scheme.

Our 2006 results for achieving diabetic management targets (without recourse to exception reporting) are the best ever. Although the QOF has been successful in encouraging GPs to improve the care of their patients with diabetes, rather than focusing on the motivated patients with good clinic attendance records, it must be remembered that the QOF2 clinical targets are only minimum audit standards,1 and are by no means the gold standards for care.

The JBS2 guideline lists the clinical targets that doctors should be aiming for.2 Practices who achieve 100% of their QOF2 points can still improve their diabetes care each year. Some of this improvement in our own figures undoubtedly results from implementation of our personalised care plans.
The future of personalised care plans

Future refinements to the template are likely to include more detailed information on renal function. The laboratories in Bury only introduced estimated glomerular filtration rate (eGFR) testing in September 2006, so our practice is still gaining experience in interpreting and acting on these results.

As a simple rule of thumb eGFRs can be explained as how well the kidney is functioning as a percentage — an eGFR of 59 approximates to 59% of normal renal function. Although this percentage function concept should be easy to explain to patients, many may be alarmed by the result. Therefore, how this information will be incorporated into future care plans will need careful consideration.

Written feedback on body mass index and diet could also be included in the care plans; however, because it is so difficult to achieve weight loss in type 2 diabetes patients, we have deliberately omitted body mass index in our care plans to date.


  • Personalised care plans were introduced at this practice at the Minden Medical Centre to empower patients to take more responsibility
  • The plans incorporate the JBS2 targets, and are used as an educational tool, an annual clinical record, a monitoring tool, and a method of providing personalised feedback
  • Positive patient feedback has been received
  • Following implementation of the plans, achievement of diabetes management targets has improved in the practice


The practice would like to thank its diabetes patients for enthusiastically embracing the personalised care plans, and especially those individuals who helped with early designs of the template.


  1. British Medical Association. Investing in General Practice – The New General Medical Services Contract. London: BMA, 2003.
  2. JBS 2: Joint British Societies' Guidelines on Prevention of Cardiovascular Disease in Clinical Practice. Heart 2005; 91 (suppl v): v1–v52.
  3. Department of Health. Our Health, Our Care, Our Say: a new direction for community services. London: Department of Health, 2006.G