Planned care refers to services for pre-arranged health and wellbeing appointments either in a community setting or in a hospital. 

For the first time, a set of best practice guidelines have been produced about how to deliver planned care in Surrey Heartlands.  These are known as the Planned Care Principles.

Empowered to self-care

Citizens should be supported and empowered to self-care by easily accessing good quality information and local support. This could include signposting to websites or helplines, lifestyle guidance and exercise advice.  Information should be easily available for citizens to ensure support is available to citizens in their own time.

Emotional support and wellbeing

Citizens and carers of all ages should have access to emotional support and wellbeing all the way through the planned care journey, including during recovery.

This should be achieved by working closely with voluntary sector organisations and other local partners.

Specialist practitioner

Citizens should have access to a specialist practitioner in the community and clinicians will have clear referral routes. This means that where clinically appropriate, citizens may not necessarily need to see a GP for a referral when triage and treatment could happen at an earlier stage by another healthcare professional.


Face-to-face and follow-up appointments should be offered when needed and more alternatives will be available if needed. Rather than citizens needing to wait or travel to appointments that may be inconvenient, there should be different options available to ensure patients receive care as quickly and safely as possible.

Improving access

We should reduce health inequalities by improving access to services for vulnerable and higher risk populations.

Health and care professionals across the system should engage with all of our communities to recognise the challenges faced and ensure that access to high quality health and care is universally available to everybody.


We should utilise the available technology to improve health and care by reducing unnecessary delays, including waiting times.

As society rapidly moves into an increasingly digital age, health and care professionals should be exploring innovative enablers such as virtual clinics, online tools, apps and electronic communication rather than solely rely on older methods of communication such as letters and fax machines.

Patient navigators

We should develop patient navigators for complex conditions where multiple specialties are required so everyone is supported through the planned care journey. Citizens with complex or long-term conditions often have to see more than one specialist, which can not only be complicated but also have an emotional impact.  Where possible we should offer dedicated support to provide advice and guidance to ensure citizens are fully supported.

Shared decision-making

Citizens should be empowered and informed of treatment and management options using shared decision-making, all the way through their planned care journey. By bringing citizens to the heart of decision making processes, patients will have an informed choice about their treatment options and have the opportunity to discuss any concerns they may have in detail.

Patient choice

When citizens want to access services we should respect patient choice by offering different access points, flexibility and tailoring care options whenever possible in accordance to the NHS Constitution. We should all recognise that ‘one size does not fit all’ and an intervention that may be beneficial to one citizen, may be detrimental to another, so where clinically appropriate, we should offer our patients as much choice as possible.

A best practice planned care pathway represents an ideal high level journey for each of our citizens. There are five key stages from access to recovery underpinned by a set of ‘building blocks’ that health and care professionals should bear in mind during any pathway redesign.

It is important to understand that the recovery stage is not the end of the planned journey for all of our population, for example citizens with long-term conditions. Therefore, we need to ensure citizens are fully supported throughout a planned care pathway and are given the tools to self-care.

Across all stages: Self-care and support

  • Carers of all ages
  • Long-term condition management
  • Mental health
  • Shared decision making
  • Social
  • Prescribing
  • Patient navigators
  • Well-being

Stage 1: Access

  • Seeing a specialist that may not be a GP
  • Access to information outside appointments
  • Ease and choice of booking appointments

Stage 2: Referral

  • Consistency of referral systems and thresholds
  • Engagements with patient in referrals
  • Enable GP to do a better referral or build up triage
  • Audits and peer reviews on referrals
  • Option of a referral hub

Stage 3: Diagnosis

  • Open up access to records and communication between professionals

Stage 4: Treatment

  • Moving forwards and sideways
  • Remove unnecessary face-to-face appointments
  • Work to best practice guidelines

Stage 5: Recovery

  • Individualised care package
  • Reablement
  • Medication options
  • Reform of face-to-face and follow-up appointment
  • Self-refer to specialist

Citizens have told us that getting through our health and care system can be really complicated and confusing.  Depending on who citizens see first and where they live, different advice may be given or referrals are sent to different people to talk about health and well being issues.  Citizens have also told us that getting an appointment can be sometimes be difficult and traveling into hospital for check-ups can sometimes be a waste of time.

The planned care principles will aim to tackle these issues by:

  • Reducing the amount of time citizens have to wait to see a specialist. This could be by using digital technology or being able to see someone like a physio for muscle pain without seeing your GP first;
  • Reducing unnecessary follow up appointments by respecting everyone’s time and offering alternative ways to discuss after care;
  • By embedding the principles into Surrey Heartlands means everyone is working to the same outcomes. This means a more joined-up approach to when something is improved or changed;
  • Most importantly we hope that these principles and best practice pathway will help to ensure our citizens’ health is improved and those that do become ill can recover quicker. This will be done by sharing good practice across Surrey and ensuring all areas follow the best practice pathways.