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personalisation in professional codes and workforce development


Policy Drivers

The Policy background to Personalised Care includes:

•The NHS Long Term Plan describes Personalised Care as one of the five major practical changes needed to achieve a new Integrated Care Service model for the 21st Century. Proactive Care is a NHS Long Term Plan commitment that aims to provide proactive and personalised health and care for a targeted subset of individuals living with multiple long-term conditions including frailty (MLTC) who could benefit most, delivered through multidisciplinary teams (MDTs) in local communities.

•The Elective Recovery Plan requires all organisations to monitor and improve both waiting times and patients’ experience of waiting for first outpatient appointments; and to provide personalised, accessible support to patients whilst they wait, improving outcomes and reducing inequalities in health outcomes.

•Personalised care is an essential element of the C&W Integrated Care Strategy, to ensure we deliver care that is meaningful and valued by those that access and receive support, and because personalisation is so integral to tackling health inequalities.

The ICS’s Integrated Health & Care Delivery Plan (to be published summer 2023) includes legislative requirements to promote the involvement of each patient, ensuring the comprehensive model of personalised care is implemented across community health services, in particular, and wider health care delivery.

•The 23/24 System Planning Briefing for community health services asks if consideration has been given to embedding personalised care and support planning in mental health, Enhanced health in care homes, CYP, Maternity, Cancer, Dementia, Elective and Inclusion Health groups.

•The May 2022 Fuller Stocktake report requires personalised care for those who need it: people should be able to access more proactive, personalised support from a named clinician working as part of a multi-professional team….this model of care should offer greater shared decision-making with patients and carers and maximise the role of non-medical care staff, such as social prescribers, so people get the care they need as close to home as possible.

Professional and Legal Drivers

It is a legal requirement for health professionals to take “reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments”. (Health and Social Care Act 2012, Medical Protection Society 2015, Montgomery v Lanarkshire Health Board (Scotland) 2015 UK Supreme Court.)

But it's also intrinsic in the professional codes of clinical colleagues.

Decision Making and Consent - GMC

Doctors must try to find out what matters to patients so they can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action.

Good Medical Practice - GMC

32. You must give patients the information they want or need to know in a way they can understand.

49. You must work in partnership with patients, sharing with them the information they will need to make decisions about their care

Nursing and Midwifery Council - The Code

2 Listen to people and respond to their preferences and concerns

To achieve this, you must:

2.2 recognise and respect the contribution that people can make to their own health and wellbeing

2.3 encourage and empower people to share in decisions about their treatment and care

Standards of Conduct, Performance and Ethics - HCPC

1.2 You must work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other services to be provided.

1.3 You must encourage and help service users, where appropriate, to maintain their own health and well-being, and support them so they can make informed decisions.


Workforce Framework Drivers


Advanced Clinical Practice Nurses working in Primary Care

Core Capabilities Framework for Advanced Clinical Practice Nurses Working in General Practice Primary Care in England

ACP (Primary Care Nurses) take account of individuals’ preferences, priorities and needs, to guide the care and treatment they offer. They respect individuals’ expertise in their own life and condition and empower and support them to retain control and to make choices that fit with their goals. Avoiding mechanistic practice, they apply their knowledge and skills in a person-centred way.


Care Coordinators

Workforce development framework for care co-ordinators

Care co-ordinators are personalised care roles. They focus on what matters to individuals and support people from diverse backgrounds, including those with a range of conditions and disabilities. They co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They are skilled in personalised conversations, assessing people’s needs, facilitating joint working, ensuring the effective flow of information, monitoring needs and responding to change.

Care co-ordinators work in different settings across health and care, including but not limited to primary care, hospitals and secondary care services, end of life care, children and family services, community health services and care homes. They offer significant benefits to individuals they support and the health and care system, for example freeing up clinical capacity and reducing the likelihood of the need for acute or crisis care.


First Contact Practitioners and Advanced Practioners in Primary Care

Roadmaps to practice:

Dietitian: Roadmap to Practice

MSK: Roadmap to Practice

Occupational Therapist: Roadmap to Practice

Paramedics: Roadmap to Practice

Podiatry: Roadmap to Practice


Health and Wellbeing Coaches

Workforce Development Framework for Health and Wellbeing Coaches

Health and wellbeing coaches are non-clinical, personalised care roles. They work with people with physical and/or mental health conditions, people with long-term conditions and those at risk of developing them. They focus on improving health related outcomes by working with people to set personalised goals. Health and wellbeing coaches offer people support to increase their self-efficacy, motivation and commitment to make changes to their lifestyle and improve their health. Health coaches are experts in behaviour change, working in a person-centred way – they are not directive or prescriptive and they do not give advice. Evaluations show that health coaching can produce positive effects on adoption of healthy behaviours, improving physical activity, weight management, body mass index (BMI), blood glucose levels (HBA1c) and dietary fat, along with improving patient satisfaction and quality of life.


Social Prescriber Link Workers

Workforce development framework: social prescribing link workers

SPLWs give people time over several sessions to offer a person-centred conversation based around asking, “what matters to you?” They: 

  1. Are part of an all-age, whole population social prescribing approach and work with people who are lonely, have complex social needs, low level mental health needs and long-term conditions
  2. Help people to identify issues that affect their health and wellbeing, and co-produce a simple personalised care and support plan
  3. Support people by connecting them to non-medical community-based activities, groups and services that meet practical, social and emotional needs, including specialist advice services and the arts, physical activity, and nature
  4. Use coaching and motivational interviewing techniques to support people to take control of their own health and wellbeing
  5. Support accessible and sustainable community offers by working with VCSE organisations, local authorities and others to identify gaps in provision and deliver activities and groups to meet population needs.

SPLWs provide support to tackle issues caused by the wider determinants of health, alongside colleagues providing conventional medical interventions. SPLWs and their PCN work in partnership with local agencies to proactively reach out to populations who might benefit from social prescribing, taking a preventative approach. People can be referred to SPLWs from a wide range of local agencies including NHS services, local authority services, pharmacies, emergency services, job centres, housing associates, VCSE organisations and self-referral.