People suffering with Long Term Conditions sometimes require complex packages of care to maintain their quality of life. Consider John’s situation. He has received long-term care twice a day to maintain his independence at home following his stroke. His sister, who lives some distance away, has provided additional support over the phone, and through occasional visits. Unfortunately, John’s stroke has been extended, threatening his independence, and curtailing his capacity to make decisions. Using a person-centred approach, consider what the next steps might be in his care, and who might get involved in the decision-making process.

As described in the previous section, in a situation such as this, the question of John’s capacity to make decisions becomes an important factor. The input of a multi-disciplinary team provides the basis for a full assessment, and plan of care to meet John’s on-going needs. A meeting between the team and John’s next of kin will help the decision-making process, and family involvement.

Beyond the legal issues of capacity and consent, there are likely to be financial implications around who pays for John’s ongoing care. This complex structure of assessment and planning could fit well within the ‘House of Care’ model described in the chapter, and will likely be affected by local provider structures and how well they integrate their services.