Care and treatment plans (CTPs) are intended to provide structure, continuity, and person-centred support for people accessing secondary mental health services. In reality, the implementation of care and treatment planning is often inconsistent. Plans can become procedural rather than meaningful, disconnected from people’s needs, and rely too heavily fragmented systems that do not communicate effectively with one another, meaning they are frequently left incomplete.
For people living with severe mental illness, co-occurring or complex needs, poor co-ordination between services can lead to repeated assessments, conflicting information, delayed support, and a lack of clarity around who is responsible for what. Also, people are very often required to repeat the same information to multiple professionals across different services, while carers and family members can remain excluded from conversations about care planning altogether, despite frequently playing a central role in providing support.
As part of our campaign focused on strengthening health and social care across Wales, Adferiad believes CTP should be understood as a key opportunity to improve coordination, early intervention, and long-term outcomes. Effective care planning relies on trust, continuity, and communication between services, professionals, carers, and the person receiving support. Without this, plans risk becoming passive documents rather than practical tools that help individuals navigate recovery and support.
One of the ongoing challenges within the current system is the lack of independent co-ordination. Where responsibility for care planning sits within overstretched statutory services, coordination can become inconsistent and heavily influenced by service pressures or organisational boundaries. Independent CTP co-ordinators based within third sector organisations could help strengthen continuity, advocacy, and communication across agencies while providing a more person-centred approach to co-ordination. Third sector organisations are often well placed to build trusted relationships, identify gaps in support, and work across organisational boundaries in ways that statutory providers can struggle to achieve alone.
There is also growing recognition of the need for a more joined-up “tell us once” approach across health and social care services. Better data sharing and improved communication between services could reduce duplication, prevent delays, and lessen the burden placed on people repeatedly explaining their circumstances at moments of distress or crisis. Co-ordination should simplify access to support rather than add further complexity to already difficult situations.
Care and treatment planning should also better recognise the role of unpaid carers. Carers often hold significant knowledge and insight about the needs, risks, routines, and wellbeing of the people they support, yet many continue to report feeling excluded from decision-making processes. Involving carers meaningfully – while appropriately balancing consent, confidentiality, and safeguarding – can improve outcomes for carers, as well as the person receiving support. Care planning processes should also be recognised as an important opportunity for early identification of carers, ensuring they are connected to appropriate support for themselves as well as those they care for.
All in all, stronger co-ordination, combined with clearer communication and meaningful collaboration would help ensure care and treatment planning functions as a practical process that puts the person at the centre, and supports continuity, recovery, and stability rather than simply fulfilling procedural requirements.
