The focus of the health action plan is the key action points (whether for the patient, the practice, or other relevant parties involved in the patient’s care) and agreed with the patient and carer (where applicable) during the health check. It should also summarise what was discussed and any other relevant information (e.g. what is important to the patient, what their goals or outcomes are that they want to achieve).
Where the patient has a personalised advanced care plan in place, it is expected that this would also form part of the patient’s health action plan.
It may include health promotion activity, monitoring e.g. weight, referrals to community health and acute services, pain management etc. Other examples include recommendations for sight tests, dental checks, self-management etc.
The patient needs to be given a copy and the practice needs to ensure a copy is scanned into the electronic record.
What other health action plans are available?
Some young people may have an education, health and support plan which you can add information to. For young people the health action plan should consider the move from children’s health services into adult services. You may need to identify which services are currently covered by school or Paediatrics and how these will be met in adulthood. There may not be an automatic transfer and you may need to instigate referrals.
Practices may wish to provide the patient with a post-health check action plan patient letter, written in easy read format.
Sharing the health action plan
Where possible, and if the patient is mentally competent to provide it with their consent, the health action plan should be shared with other relevant professionals and carers who are involved in the care of the patient. Carers are particularly important in regard to the health of people with learning disabilities.
Carers can be consulted but cannot consent or withhold consent on behalf of the adult that they care for (see mental capacity section).
The 12-month challenge (widget symbols) has been developed to help carers and people with learning disabilities consider a healthier lifestyle. The annual health check is the ideal opportunity for the clinician to discuss a healthy lifestyle and issue the challenge as part of the health action plan. Booklets have been delivered to the practices to give to patients. The 12-Month Challenge booklet is also available in photo symbols.
Some web links are below which can help with supportive information regarding different health conditions, tests and procedures.
- NHS Fife accessible information database
Care for people with diabetes and a learning disability
A collaborative team funded by The Health Foundation and the University of Leeds has created a set of evidence-informed, practical resources to improve care for people with diabetes and a learning disability.
Information can also be found below about living with a learning disability and diabetes.