Personalised care plan

Personalised care plan

Statement 7.1

A personalised care plan should be in place for every IBD patient, with access to an IBD Nurse Specialist and telephone/email advice line.

IBD patients may share a similar diagnosis, but they are all different. So how can healthcare professionals continually ensure that each patient’s care reflects their individual needs and goals?

Developed from an initial holistic assessment of the patient’s health and wellbeing needs, a personalised care plan is an important part of the answer.

This plan can help prepare patients for appointments by giving prompts and questions that will help them focus on what matters to them. It also supports clinicians to open up conversations to include aspects of daily living, including mental wellbeing. This way, they can find out how someone’s IBD impacts on their mood, relationships, employment and sexual health.

Following the conversation, the care plan provides a record of what was discussed, shared decisions about treatment and investigations, goal-setting or next steps. It also includes contact details for an IBD Nurse Specialist and telephone/email advice.

An IBD care plan can be either paper-based or electronic and is preferably integrated into a patient portal. It can also be shared with the GP.

A personalised IBD care plan template is being developed in Scotland. This will be rolled out to patients following testing and evaluation.


I just wish I’d had this care plan to take into appointments when I was constantly having flare-ups of my colitis. There's lots of space to record notes – and it’s easy to track progress.

Edmund, patient participant in co-design workshop

Beyond any biomedical model of self-management, I now understand that patients actually need and want something much broader – and believe all healthcare professionals should take this approach.

Ian, healthcare professional participant in co-design workshop