Partnership working
Transforming care together: The power of four key enablers
When Personalisation, Population Health Management (PHM), Health Inequalities (HI), and Digital Technology work in synergy, they create a transformative force across Lincolnshire's Integrated Care System.
Together they:
Improve outcomes for people by tailoring care to individual needs, enabling self-management, and addressing barriers to access.
Strengthen the workforce by equipping staff with tools, training, and confidence to deliver person-led care.
Enhance the system as a whole by promoting efficiency, reducing avoidable demand, and fostering innovation through data-driven and inclusive approaches.
This integrated approach ensures that care is not only clinically effective, but also compassionate, equitable, and sustainable.
How these four enablers help to embed personalised and strengths-based practice
Together, PHM, Health Inequalities work, and Digital Technology:
- Create a system-wide culture shift towards person-centred care.
- Support staff training and reflective practice, increasing confidence and morale.
- Enable evaluation and continuous improvement, ensuring sustainability.
Frameworks like Our Shared Agreement and the Population Health Management Strategic Partnership Blueprint Guide provide structure and accountability for embedding these practices.
1. Population Health Management: A Data-Driven Foundation
Population Health Management (PHM) enables services to:
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Identify cohorts with specific needs (e.g., frailty, MSK, long-term conditions).
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Target interventions based on real-world data, improving relevance and outcomes.
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Track impact through both quantitative and qualitative measures (e.g., SROI, activation levels).
Impact on personalised practice:
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Supports tailored care by understanding what matters to individuals.
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Enables early intervention and prevention, reducing crisis care.
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Facilitates co-production by involving people in designing services that reflect their lived experiences.
Example:
The Grantham Joint Aches and Pains Hub used PHM data to invite people most likely to benefit, resulting in measurable health improvements and a £1 : £3.71 social return on investment.
2. Health Inequalities: Addressing the Gaps
Health inequalities are often rooted in:
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Socioeconomic status
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Geographic location
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Cultural and communication barriers
Impact on personalised practice:
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Personalisation helps bridge gaps by recognising individual circumstances.
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Strengths-based approaches empower people, especially those from disadvantaged backgrounds.
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Co-production ensures inclusive service design, improving equity in access and outcomes.
Example (COMING SOON!):
Janet and Tony’s story highlights how systemic barriers and poor coordination can exacerbate inequalities. Their turning point came when services began listening and responding to what mattered to them.
3. Digital Technology: Enabling and Scaling Personalisation
Digital tools support:
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Digital Personalised Care and Support Planning (PCSP) to ensure that people only have to tell their story once.
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Technology Enabled Care (TEC) such as remote monitoring and assistive devices to promote independence
Impact on personalised practice:
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Enhances communication and coordination across services.
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Reduces reliance on formal care by supporting people in their own homes.
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Enables self-management and informed decision-making.
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Improves efficiency and productivity, freeing up resources for relational care.
Example:
LCC's Adult Care and Community Wellbeing set out on a journey to explore how technology could help people across Lincolnshire live the lives they want, for as long as possible, in the place they call home.
Working closely with a technology provider, through its Technology Enabled Prevention and Care (TEPaC) pilot, the team offered a range of devices and digital tools for people to try. But this wasn’t just about gadgets or innovation for its own sake - it was about understanding what really makes a difference for real people in everyday life.
The embedding of technology into Lincolnshire’s adult social care strengths-based approach, has resulted in reduced complaints, improved practitioner confidence, and better outcomes for people, including staying at home longer and feeling more in control of their care.
