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How to embed PersonalISED Care and Support Planning

 

The 5 criteria for a good Personalised care and support plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(This information has been abridged from the NHSE Personalised Care and Support Planning Checklist and the Think Local Act Personal Toolkit.)

More people than ever are living with long-term conditions in the UK, which include both physical and mental health problems. As a result, there has been a national drive towards providing people with long-term, personalised care plans.

Why do it?

Personalised care planning standards will help to enable people to manage their own care, with the support of a wide range of services including GPs, hospitals, occupational therapy and social care.

Personalised care and support planning is about having a different kind of conversation about health and care, which is focused on what matters to the person as well as their clinical and support needs. This leads to a single plan that is owned by the individual and accessible to those supporting the person. 

Getting personalised care and support planning right is essential for people to gain more choice and control over their life and the support they are receiving.

How to do it

Personalised care and support planning is a series of facilitated conversations in which the person, or those who know them well, actively participates to explore the management of their health and well-being within the context of their whole life and family situation. 

The process recognises the person’s skills and strengths, as well as their experiences and the things that matter the most to them. It addresses the things that aren’t working in the person’s life and identifies outcomes and actions to resolve these.

Below are the five criteria for ensuring that plans meet the definition of a PCSP and provide strong quality indicators for planning. These have been coproduced with people with lived experience and clinicians and demonstrate what is required from a personalised care and support planning experience rather than seeking to adopt a one size fits all approach. (You can find these in more detail further down.)

  1. 1 People are central in developing and agreeing their personalised care and support plan including deciding who is involved in the process.
  2. 2 People have proactive, personalised conversations which focus on what matters to them, paying attention to their needs and wider health and wellbeing. 
  3. 3 People agree the health and wellbeing outcomes they want to achieve, in partnership with relevant professionals. 
  4. 4 Each person has a sharable personalised care and support plan which records what matters to them, their outcomes and how they will be achieved. 
  5. 5 People have the opportunity to formally and informally review their care plan. 

 

Design Principles for Plans

When designing Care and Support Plans it is important to provide a range of people and options for the person to choose during the planning process, making sure there is a balance between overall continuity and effective use of practitioner time and skills.

The following principles will also help to guide the care and support planning process:

  • Everyone involved must understand the care and support planning process, know what to expect and their role in it.
  • No major allocation of resource should be made until the views of the person about what's important in their life and the outcomes they want to achieve have been identified and recorded.
  • Tasks, tests, assessments should be separated in time from discussion on outcomes and what is important to the person.
  • Where relevant and possible assessments should be joint/shared between health and social care. Assessment by itself is not an intervention but could lead to some immediate problem solving and early actions.
  • Care should be organised holistically around the person in ways that connect the NHS, public health, social care and community and voluntary organisations, so people tell their story only once, and the focus is on supporting the person to achieve their outcomes.
  • Care and support planning is a generic approach appropriate to a variety of contexts which should be linked together as they are introduced as routine (one or more long term conditions, recovery model, preparation for ageing, last years of life and dying).
  • People should see the minimum number of different care practitioners, understand the roles of those they see in supporting care delivery and be kept informed during the whole process, in a way that works for the person.
  • Decisions should be made as close to the person as possible.
  • The process should be proportionate to the person's needs and circumstances - there is no one-size that fits all.
  • Where people have a personal budget, they have choice and control over how this is used, and have whatever support they need to decide how to spend it to meet their outcomes.
  • Care and support planning is a continuous process, evolving over time - not a plan that happens only once. The plan is not the outcome.
  • Documentation must be owned and accessible by the person, as well as to health and care colleagues.
  • Practitioners should assume capacity unless otherwise assessed.

 

Designing care plans: what this looks like for people, families, and systems

From the NHS England summary guidance published August 2023:

NHS England has developed a set of criteria to define personalised care and support planning and provide strong quality indicators for personalised planning. This has been done because it is not possible to develop a national template that would meet the needs of all parts of the system or clinical pathways where personalised care and support planning may be embedded. These criteria have been co-produced with people with lived experience and clinicians and demonstrate what is required from a personalised care and support planning experience rather than seeking to adopt a one size fits all approach.

The information under each criteria provides clarity on what the process and resulting plan should look like for people, families and systems. The format provides a best practice statement including the key elements that should be in place to meet that criteria and a statement as to when systems could not count a personalised care and support plan.

The five criteria are:
Criteria 1 – People are central in developing and agreeing their personalised care and support plan including deciding who is involved in the process

Best practice statement – what we should see:

  1. The person owns their plan and is central to creating it as an equal partner.​
  2. The person is well prepared for the planning process including understanding the purpose of the plan. They understand how the process will take place and have been given information in a way that meets their information needs. ​
  3. The person is able to choose who will be involved in the planning process, including family and friends who know them well.​
  4. The professionals involved in the planning process are prepared and have the right information available for the process i.e. test results, information about eligibility etc. ​
  5. There are a range of resources available to support the person with the development of their plan, including resources that support them to develop the plan themselves, and including peer support, where appropriate. 

It should not be described or counted as a personalised care and support plan if: 
The person was not involved in writing the plan, didn’t have the opportunity to involve people they wished to be involved, and/or were given no information to prepare them for the planning process.

Criteria 2 – People have proactive, personalised conversations which focus on what matters to them, paying attention to their needs and wider health and wellbeing

Best practice statement – what we should see:

  1. The planning conversation starts with what matters to the person, the things that make life good. This could include information about important people, significant routines and rituals and important possessions.
  2. The conversation should also include the things which worry them about their condition(s) and how they manage them. 
  3. The conversation then looks at the support the person needs to manage their condition(s). This includes what they do on a day-to-day basis to manage their condition(s), prevent a deterioration of their condition(s), what to do, and who to speak to if a deterioration occurs. 
  4. During the conversation the person is listened to and understood in a way that builds a trusting and effective relationship taking account of the persons health literacy, skills, knowledge and confidence. 
  5. It should not be described or counted as a personalised care and support plan if: 
  6. The conversation does not include a discussion about what matters to the person and only looks at what is wrong with the person, focusing on their needs but not within the wider context of their whole life. 

It would not be counted if the person does not feel listened to or their health literacy, skills, knowledge and confidence have not been taken into account.

Criteria 3 – People agree the health and wellbeing outcomes they want to achieve, in partnership with the relevant professionals

Best practice statement – what we should see:

  1. The person develops health and wellbeing outcomes (goals) in partnership with the relevant professionals. 
  2. The outcomes (goals) are based on what the person wants to change, or achieve, not just what professionals think they should achieve. 
  3. The whole plan is written from a personal perspective that reflects the person rather than in a language more familiar to the service or system. 
  4. The plan reflects a balance between the persons needs in the context of their whole life and the support (clinical or otherwise) needed to manage their condition(s).

It should not be described or counted as a personalised care and support plan if: 
The plan is not written from the person’s perspective or is written in a way more aligned with the service or system. 
It would not be counted if the outcomes (goals) in the plan did not reflect what the person wanted to achieve and were written by professionals and not in partnership with the person.

Criteria 4 – Each person has a sharable personalised care and support plan which records what matters to them, their outcomes and how they will be achieved

Best practice statement – what we should see:

  1. A clear record of what matters to the person, for example, information about important people and how they stay connected to them, significant routines etc.
  2. A clear record of the support they need to manage their condition, including what they will do for themselves, what family and friends may be able to do, followed by what other support they require.
  3. A clear record of the agreed outcomes (goals) and actions.
  4. A clear record of contingency plan, risk arrangements and treatment escalation, where these are relevant.
  5. If the person has a personal health budget or integrated budget, then a budget sheet detailing how the budget will be spent must be included in the plan.
  6. It must be editable and sharable by the person, and relevant others, and available in a range of formats.

It should not be described or counted as a personalised care and support plan if: 
There is no clear record of what matters to the person, and the agreed outcomes (goals) and actions from the planning conversation.
It would not be counted if it could not be shared with all those involved in the person’s care.

Criteria 5 – People have the opportunity to formally and informally review their care plan

Best practice statement – what we should see:

  1. The plan is reviewed on an annual basis, or as required by statutory guidelines.
  2. The person is able to informally review their plan when they want, with those supporting them, and they know how to do this, for example, how to access electronic versions, contacting their care coordinator, etc.
  3. The person knows they can request a formal review if their situation changes and how to do this.

It should not be described or counted as a personalised care and support plan if:
The person was not able to review and edit their plan informally when they needed to and did not know how to request a formal review.

Preparing for a care planning discussion - communication skills, approaches, behaviours

Good communication skills are crucial for optimising a care planning discussion and supporting individuals to self care. It is vital that healthcare professionals have the right skills, approaches and behaviours to deliver high quality personalised services for individuals with long term conditions.

The following questions may prompt healthcare professionals to think about how they interact with individuals: 

  1. Do I communicate effectively? 
  2. Do I listen? 
  3. Do I support individuals to make informed choices? 
  4. Do I support individuals to access appropriate information? 
  5. Do I support individuals to develop skills in self care? 
  6. Do I discuss risk? 
  7. Do I put aside my own health beliefs? 
  8. Do I view the individual in front of me as having expert knowledge in addition to mine? 
  9. Do I see the individual as a whole – not just concentrate on the individual’s medical condition? 
  10. Am I supporting this individual to take control? 
  11. Do I ensure that those with complex needs are receiving coordinated care? 
  12. Do I strive to work across agencies and promote safe information sharing? 
  13. Do I ask individuals what they feel they need to better self manage? 
  14. Do I ask individuals if they have any ideas as to the services they would like to be included in their plan?

Sharing care plans with people, carers and healthcare professionals - the development of digital care plans

The new Personalised Care and Support Planning standard will help citizens and health and care professionals get the right information when they need it, in order to personalise care, and improve the experience for the patient, their carer and their families. Information standards exist to improve the safety and quality of health and social care, specifically to ensure that the right information is recorded correctly, in the right place, and can be accessed easily, by any authorised person who needs it, wherever they are.

The Personalised Care and Support Planning standard provides a framework for standardising the content and sharing of personalised care and support plans between individuals, professionals and systems.

A digitised implementation toolkit has been developed by the Professional Record Standards Body in collaboration with  two mental health trusts who provided insight and specialist knowledge to support the collection and curation of the resources and support materials to help create personalised care and support plans that included mental health.  The materials will support the adoption and implementation of the PCSP information standard across the Integrated Care Systems (ICS). Creating a digital toolkit makes care planning implementation more accessible to all health and care professionals, senior leaders and transformation managers.

 

Implementation steps for making progress in your team, organisation and system - what that might look like:

  1. 1 Implementation of a system of personalised care and support planning for patients in relation to their needs.
  2. 2 Connecting with others across the system so that these plans become one component of a holistic PCSP covering all needs.
  3. 3 Enabling the sharing of these plans so that they can be accessed wherever and whenever they are needed by all those authorised to do so.

 

Training, development and best practice resources: