Kate Holliday

Quality Improvement Manager, Deputy LAC LeDeR Programme / Freedom To Speak Up Guardian

NHS North Cumbria Clinical Commissioning Group (CCG)


What change did you make?

Annual Health Checks for people with learning disabilities, which result in the production of Health Action Plans, are incredibly important. A Health Action Plan identifies an individual’s health needs, what will happen about these needs, who will help, and when this will be reviewed. They ensure those with learning disabilities are receiving the very best care, and also help us to address health inequalities. It also summarises what was discussed and any other relevant information (e.g. what is important to the person, what their goals or outcomes are that they want to achieve). 

Reviews which had taken place locally highlighted a lack of use of the Health Action Plan for people with learning disabilities. So in response to this, a project took place to increase the uptake of Annual Health Checks, as well as review and improve the national Health Action Plan in EMIS (the electronic patient record system GP practices use). 

A key ambition of the project was to improve the quality of the Health Action Plan output in terms of making it more holistic and user friendly, easier to complete, and more visual for users. A multi-partner task and finish group was established to review the national Health Action Plan template, and suggestions were made on ways this could be modified. Representation on this group included CCG Learning Disability Lead GP, Specialist Nurses from the Physical Health Team in the Community Learning Disability Team, Primary Care Network Learning Disability Nurse, PRIMIS Informatics Facilitator, and CCG Quality Improvement Manager. This work was co-produced with our local learning disability advocacy group, as well as with a group of young people and their families and carers. 

What happened as a result of the change? What impact did it have on patient care?

As a result of the project, Health Action Plans for people with learning disabilities are now more meaningful to both users and clinicians alike. The plan benefits the individuals, and includes things like goal setting to ultimately improve their health. 

There has been a reduction in time taken by clinicians to produce and populate a Health Action Plan when compared with the previous EMIS template, which has led to more of these being completed. 

On the whole, the individuals now have a more holistic assessment, with a more user-friendly document. It is easier for health professionals to undertake the Annual Health Check and Health Action Plan, as the information automatically populates from the patient record:

How are you making the change stick?

This project can be replicated, and the plan is to roll this out to all of our local GP practices and across the Integrated Care System in the very near future.

‘Teach it forward’! If you would like more information on this improvement, please contact:

Kate Holliday - k.holliday@nhs.net