Personalised care and support planning

A personalised care and support plan should be seen as a book with chapters. We all have different chapters depending on what’s going on in our lives.

The plan is about bringing all of the various chapters together electronically so that health and care teams can be aware of this information and share amongst different services.  This means we can better support someone’s needs and not have to ask them to repeat the same story over and over again.

What is a personalised care and support plan?

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

This 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.

Personalised care and support plan is the umbrella term used to describe the many different personalised care and support plans held by various teams and services.  For example, an Advance Care Plan, a Stroke Journal, a Cancer Holistic Needs Assessment (HNA) and the What Matters to Me Plan... are all personalised care and support plans.  All plans must be aligned with the national criteria, as below:

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

Annette Harding, Health and Wellbeing Coach, talks about how What Matters to Me Plans can help to improve outcomes for people.

There are several key parts that come together to form a personalised care and support plan.

Always be relevant
As a peron's life progresses, their 'chapters' and needs will evolve and change. Their personalised care and support plans need to evolve and change with them. It's important that a person's support circle is aware of these changes to make sure that the support given is relevant to the care they need.

The document below is a What Matters To Me plan, which is an example of a personalised care and support plan:

Please click on the sections below for more information.

Key standards

NHS England and Improvement have also worked with partners to co-produce a six-step criteria which must be used to demonstrate that the conversations and plans are of a high standard.  

All six of these criteria need to be in place for it to meet the standards for a personalised care and support plan.

  1. People are central in developing and agreeing their personalised care and support plan including deciding who is involved in the process.
  2. People have proactive, personalised conversations which focus on what matters to them, paying attention to their needs and wider health and wellbeing.
  3. People agree the health and wellbeing outcomes they want to achieve, in partnership with the relevant professionals
  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. People have the opportunity to formally and informally review their care plan.
  6. People have a single plan that is owned by the individual and accessible to those supporting the person.

Family and carers are also considered as an important part of this process, where appropriate. Informal carers may also require their own personalised care and support plan.

These key principles are relevant to any professional/practitioner, or service area that is completing an initial conversation or personalised care and support plan.

If you have a metric about PCSPs then you must be aligned with the criteria. These are the technical criteria for PCSP as a Long Term Plan metric and they should be followed.

What we want to achieve

As a Lincolnshire integrated care system we want to see personalised care and support planning embedded as a way of working across all services. This means:

  • Staff being able to access a range of learning and development approaches which focus on personalised conversations.
  • Embedding the five key standards in care and support planning approaches and creating an effective and meaningful quality assurance processes, which include people with lived experience.
  • Agreeing a methodology for reporting personalised care and support plans.

Since Summer 2021, we have been initially trailing this new approach in the following areas:

  • Grantham and Gainsborough neighbourhoods / integrated place based teams
  • Living with Cancer team
  • Dementia
  • East Lindsey Primary Care Network (Anticipatory care and enhanced health in care homes)
  • Hospital discharge

How will we get there?

We have already taken learning from other service areas and parts of the system who have already implemented personalised care and support planning, including learning disabilities, maternity and adult and children’s social care.Using continuous improvement methodology we are now trying out the approach in specific place based teams and service area to understand how this could work in different areas. This allows as many people as possible to get involved in helping design and shape collectively how these plans become a useful tool for everyone.

What we have done so far

Co-production
Working with people with lived experience we have co-designed a template for personalised care and support plans and the guides for the ‘Initial conversation’. These documents have been produced to make them as simple and easy to use as possible.

Developing the digital record
As part of work to develop a central Lincolnshire Care Portal we have launched online care planning tools, which enable practitioners to create and start to populate care plans or contribute to existing plans. This enables one digital plan to be shared with the relevant people who have access to the Care Portal. You can read more about this work here.

Initial conversation
We are initially rolling out the ‘Initial conversation’ in adult care services at Lincolnshire County Council and testing this approach in community nursing at Lincolnshire Community Health Services NHS Trust. Read more about initial conversations here.

Learning and development programme
A small cohort of staff from the Grantham area have completed an eight session course in personalised care and support planning delivered by EveryOne, a local charity who have a real passion for person centred care. This training includes a more detailed look at why it is important to understand what matters to people, the tools we can use for these conversations, and how we can support people to stay at the centre of their care.

The feedback we have received regarding this course has included:

"Now that I’ve been on this course I’m going to change one of the questions on our assessment that we ask all patients to ‘what matters to you?’ so that we can really understand what the person wants from the assessment"
Ellen Kelly – LCHS Community Nurse

"This approach actually works. It’s an efficient use of time and is much more rewarding. By finding out what’s important to the patient it gets them on the same page as you and stops all the argy bargy.”
Occupational therapist at United Lincolnshire Hospitals NHS Trust

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