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Enabling personalised care

What are our overall aims by 2028?

Personalised care is embedded at all levels of our system meaning that people accessing health and care services in Coventry and Warwickshire have better experiences and achieve improved health and wellbeing outcomes.

People are consistently empowered to be equal and active participants in their health and wellbeing by having more choice and control over the way that their care and treatment is planned and delivered based on what matters to them and their individual diverse strengths, needs and preferences.

Reduced health inequalities as health and care services are increasingly planned and delivered based on what matters to people, taking account of their circumstances, challenges and assets.  In addition, personalised care approaches are targeted at people living with complex health conditions, often linked to the wider determinants of health, who are most at risk of experiencing health inequalities.

Our local health and care workforce feel equipped to use personalised care approaches in their day to day work.


What’s our starting point?

The Coventry and Warwickshire Personalisation Strategy 2022-2024 sets out our vision and local ambitions for personalised care. The Coventry and Warwickshire Personalisation Programme identifies the practical steps that we will take to embed personalised care in our system, based around the six components of the Comprehensive Model for Personalised Care.

We have a Personalisation Steering Group driving delivery of our Personalisation Programme, while our Population Health, Prevention and Inequalities Board strategically aligns work around health inequalities improvement, prevention and personalised care. 

The Personalisation Programme is supporting a number of “demonstrator projects” across our system.  Through these we will evidence the impact and outcomes of personalised care for patients and staff.  We also have a local Personalised Care Maturity Framework which service leads can use to assess progress and identify opportunities and priorities to embed personalised care in their service areas.


What are some of the key links to other parts of the plan?

Health Inequalities – personalised care is a key delivery model for reducing health inequalities.

Workforce – building personalised care capacity and capability in our workforce will be critical. 

Collaboration and Integration – PCNs have a central role to play in developing personalised care in our system, including through social prescribing link workers, health and wellbeing coaches and care co-ordinators. These professionals connect people to support in their communities, including through VCSE sector organisations, based on what matters to them. 

Digital, Data and Technology – digital tools and solutions can significantly empower people to participate in their own health, wellbeing and care. 

Population Health Management – Population Health Management will enable us to identify people and groups that will benefit most from personalised care approaches.


What will we be focusing on in the next 2 years?

Evaluating ‘demonstrator projects’ to demonstrate impact by population group, PCN and/or Place, sharing learning and assessing scalability.

Developing and delivering plans to embed shared decision making in all services and pathways. Key to this will be driving the roll out of our local Personalised Care Maturity Framework across the system.

Delivering shared decision making training to our workforce to increase their skills and confidence to apply personalised care approaches.

Develop an online repository of personalised care support tools and e-learning resources to support system partners and professionals.

Delivering an “It’s Okay to Ask” public awareness campaign. 

Working across system partners to assess opportunities to embed more proactive, personalised care and support planning for people with more complex needs, including people with learning disabilities and people living with long term health conditions.

In collaboration with the ICB Elective Care Team, scoping opportunities for personalised care and support planning for individuals and carers awaiting elective surgery.

Delivering a public awareness campaign of choice and legal rights in respect of first outpatient appointments.

In collaboration with the ICB Contracts team, ensuring choice and wider personalised care elements are included in contracts.

Through our local Personalised Care Ambassador:
- Delivering a Peer Support Network to support the three personalised care roles in general practice, including by encouraging reflective practice and identifying opportunities to adopt a multi disciplinary team approach to supporting patients;
- Undertaking a survey of staff working in personalised care roles to identify support resources and requirements, and inform further action planning.

Piloting and then formalising a social prescribing/health coaching service in secondary care.

Continuing to develop and embed the role of our local Personalised Care Leaders Network.

Linking with the Health Inequalities Programme Managers to identify opportunities to embed personalised care in projects being delivered through the local Health Inequalities Innovation Fund. 

Personal Health Budgets 

Aligning the Coventry and Warwickshire ICB Personal Health Budget Policy and underpinning operating procedures to the national Personal Health Budget Quality Framework.

Driving an approach that ensures personalised care and support planning is the foundation on which PHBs are developed across the system.

Delivering a system improvement approach that maps PHB processes and addresses access and delays. 

Establishing a Joint Funded Steering Group to include finance and contracting representation – through this group working with both Local Authorities to develop processes for joint funded PHBs.

Designing and delivering an interactive web platform for service users.

Providing ongoing training and support to relevant ICB teams. 

Ensuring that there is an appropriate framework for ICB contracting of external training providers

Key Challenges

Workforce training – having the resources and capacity to support this agenda across the ICS.

Measuring impact – issues relating to coding of relevant activity to evidence impact and progress.

Measuring impact – challenges in tracking benefits and impact in terms of value.

Sustainability of programme resources to maintain momentum.

Commitment of ICB partners to embrace changes in service delivery.

General Practice – uncertainty of ARRS roles and scaling back of commitments in national service specifications may impact on our ability to achieve our overall aims recognising the critical role that PCNs have to play.

Key areas of development such as social prescribing and PHBs require a designated lead in our ICS to drive changes in practice to fulfil our ambitions.

Organisational buy in – how can we support our partners to commit to adopt personalised care whilst dealing with multiple priorities?

Key Metrics and Deliverables

Increased number of personalised care and support plans (PCSPs) recorded/Number of new and reviewed PCSPs.

Improved ratings in PREM (Patient Reported Experience Measure).

Workforce training – number of staff that have completed personalised care training.

Number of settings adopting prepared people/patient resource to support shared decision making.

Referrals to social prescribing link workers.

Recruitment of personalised care roles in general practice, including social prescribing link workers. 

Delivery of agreed PHB trajectory.