improving care for people

improving care for people with
long term conditions
information sheet 4
assessment of need
and managing risk

an ‘at a glance’ guide for healthcare professionals
assessment of need
and managing risk

improving care for people with long term conditions
About this information sheet
It describes the links between assessment and
personalised care planning and considers the
risk involved in supporting individuals with
complex health and social needs to achieve
their goals and manage their condition(s) better.
Who should read it?
Anyone involved in the delivery of healthcare
to people with long term conditions, including
doctors, nurses, allied health professionals,
those delivering personal health budgets and
health trainers.
How does assessment link to
personalised care planning?
Personalised care planning is a collaborative
process based on an assessment of an
individual’s needs, which determines the level
and type of support required and the objectives
and potential outcomes to be achieved.
Assessment and care planning are therefore
part of one process. Care planning should result
in a care plan being agreed for the individual
who should be supported to participate as
much as they can in the process.
Assessment should:
• be a joined-up process between health and
social care, facilitating joined-up care planning
and delivery of care;
• have a named professional leading the
process and coordinating services;
• be person centred;
• be collaborative;
• be holistic and recognise potential conflicts;
• be based on outcomes;
• simplify the processes.
Existing assessment processes
and care planning
The Single Assessment Process for older
people and the Care Programme Approach in
mental health are person-centred approaches
to assessment and personalised care planning
for adults with complex health and social care
needs. The aim of both is to support agencies
in working together so that assessment and
care planning are effective and coordinated.
It also brings together all the information from
the staff contributing to an individual’s care into
a single overarching care plan, accessible to all
staff involved in the individual’s care delivery.
How does management of
risk support people to make
informed choices?
The management of risk can have a major
impact on individuals achieving their goals
and managing their condition better. Risk
management should be integral to the care
planning process.
Many people want choice and control for
themselves and those they care for, but
sometimes the decisions they make may
seem to others as too risky. Individuals need
to understand the consequences and take
some responsibility for the choices they make.
Healthcare professionals can support individuals
by promoting a culture of choice that entails
responsible and supported decision making.
Risk needs to be considered in the context of
(i) risky behaviours such as smoking; and (ii)
risks associated with goals, such as wanting
to live independently.
improving care for people with long term conditions information sheet 4 assessment of
need and managing risk
Good approaches to choice
and risk
The governing principle behind good
approaches to choice and risk is that individuals
have the right to live their lives to the full as
long as it does not stop others from doing the
same, and does not cause harm to themselves.
However, a fear of supporting individuals to
take reasonable risks in their daily lives can
prevent them doing the things most people
take for granted. What needs to be considered
is the consequence of an action and the likely
harm it may cause.
By taking account of the benefts in terms of
independence, well-being and choice, it should
be possible for an individual to have a care
plan that enables them to manage identifed
risks and to live their life in the way that best
suits them.
Fundamental to providing support for
individuals with long term conditions
is the understanding that they are
responsible for their own actions. It is
the role of healthcare professionals to
discuss risk and inform people of the
possible consequences.
Skills and behaviours to support
choice and risk
Consider communication approaches
and techniques – are they person focused,
empathetic, non-judgmental and supportive?
Approach risk assessments in a way which:
• understands that risk should not be seen as
a reason not to do something;
• understands that some risks cannot be
completely removed or managed, however
much support the individual may have;
• ensures that the right balance is struck
between enabling individuals to lead
independent and dignifed lives and that
procedures for safeguarding are implemented
if there is a need for protection;
• looks for flexible and innovative solutions that
can support people to be independent while
minimising risk;
• ensures that the potential impact of any risks
is fully assessed, and accurate information is
recorded, including the type of risk, its nature
and context, and any actions required/taken
to manage the risk;
• supports individuals who want to make the
choice to manage the risk;
• supports individuals to understand that
with rights come responsibilities and the
implications of their choices, including
any risks;
• ensures that a clear distinction is drawn
between putting an individual at risk and
enabling them to manage risks appropriately;
• works with other healthcare professionals
and across disciplines to develop a common
approach to risk taking;
• works with policies and procedures to
support age appropriate decision making
and risk taking;
improving care for people with long term conditions
information sheet 4 assessment of
need and managing risk
• works with more complex situations to seek
agreed solutions where there are different
views about risk held by the individual, the
family carers and other staff;
• works to achieve a balance between managing
the risks posed to the carer’s own well-being
against the impact of their caring role and the
needs and rights of individuals;
• knows and understands the legal implications
of individuals’ choices and risk taking, and
seeks advice when needed.
Further information for
healthcare professionals
More information on assessment processes
is available at the following links:
Common Assessment Framework
The Common Assessment Framework (CAF) for
Adults is not a new assessment process. Its aims
are to provide a framework that updates the
principles for good assessment, taking account
of the developments in personalisation and in
health and social care, and to support this with
effective approaches to information sharing
between health, social care and the third sector.
The CAF for Adults is currently being developed,
tested and evaluated at 12 demonstrator sites.
Learning from the sites is being shared at
Health needs assessment tool
A health needs assessment (HNA) tool developed
by NHS Kirklees helps healthcare professionals
to identify the needs of the individual and
target resources more effectively, offering more
personalised support to individuals with long
term conditions. For more information on the
HNA tool in Kirklees, please visit
Well-being StarTM
The Well-being Star™ for long term conditions
is another free tool that can support healthcare
professionals in their care planning discussions.
The tool works by encouraging the person to
consider a range of factors that impact on their
quality of life. These are not restricted to health,
but cover a broader range of issues including
lifestyle, looking after themselves, managing
symptoms, work/volunteering/other activities,
money, where they live, family/friends and
feeling positive.
The PDF version of the tool is free to download
and use within your organisation. To register
please go to
Personalised Care Planning and Information
Prescription e-learning toolkits
NHS Employers has produced two e-learning
packages to help develop the skills and
knowledge needed to produce personalised
care plans and Information Prescriptions.

improving care for people with long term conditions information sheet 4 assessment of
need and managing risk
Supporting Self Care e-learning toolkit*
This is designed for healthcare staff supporting
people with long term conditions.
End of Life Care for All e-learning toolkit*
Enhances the training and education of all
those involved in delivering end of life care.
More information on personal health budgets
can be found at:
Publications and other resources on long term
conditions management are available at:
*Please note you will need to register with the site
provider to access these toolkits
The series of information sheets is
available to download at
and covers the following topics:
Information sheet 1:
Personalised care planning
Information sheet 2: Personalised care
planning diagram
Information sheet 3: Care coordination
Information sheet 4: Assessment of need
and managing risk
Information sheet 5: What motivates people
to self care
Information sheet 6: Goal setting and action
planning as part of personalised care planning
Information sheet 7: How information
supports personalised care planning and self care
Information sheet 8: End of life care and
personalised care planning
Look out for further information sheets
covering other relevant topics.
Your feedback is extremely important to us.
Please send your comments/suggestions for
this information sheet, or good examples of
personalised care planning and supported
self care within your area, to
[email protected]
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404557a 1p Feb 11
Gateway ref: 15330 EqIA ref: 1112
Produced by COI for the Department of Health