A person-centred approach is underpinned by seeing prevention - engaging and supporting people to live healthier lives - as an on-going activity with people and communities, not a single event or intervention. Taken from Person centred approaches Framework 2020

In 2019 ‘Universal Personalised Care – Implementing the comprehensive model’ was published and is at the heart of the NHS Long Term Plan. It is built using the skills, knowledge and expertise from social care, mental health, children’s services, learning disability and others.

The evidence of the positive impact a personalised care approach has continued to grow. Personalised care also helps to address health inequalities, taking into account people’s different backgrounds and preferences, which mean people from lower socio-economic groups are often able to benefit the most.

Research has shown that people who are more confident and able to manage their health conditions (that is, people with higher levels of activation) have 18% fewer GP contacts and 38% fewer emergency admissions than people with the least confidence. (These figures are based on the tracking of over 9,000 people with long-term conditions across a health and care system.)

The short animation below talks about Bob and why taking into consideration his strengths and interests, and not just his symptoms or conditions, can have a positive impact on his health and wellbeing.

Personalised care is specifically mentioned in a range of Lincolnshire’s transformation programmes:

• Community mental health transformation
• Health inequalities
• Population health management
• Living with Cancer programme
• Maternity services
• Primary care networks
• Personalisation through technology
• Adult care transformation
• Dementia
• Carers
• Personal health budgets

The terms personalised care and person-centred care are often used interchangeably and generally refer to the same approach.

In the video below Kirsteen Redmile, Lead Change Manager - Personalisaton, talks more about the programme and what is already happening across Lincolnshire.

Lincolnshire is embracing the principles and values of personalisation established by Think Local Act Personal ‘Making It Real’ report.

• A sense of belonging, positive relationships and contributing to community life are important to people’s health and wellbeing;
• Conversations with people are based on what matters most to them. Support is built up around people’s strengths, their own networks of support, and resources (assets) that can be mobilised from the local community;
• People are at the centre. Support is available to enable people to have as much choice and control over their care and support as they wish;
• Co-production is key. People are involved as equal partners in designing their own care and support;
• People are treated equally and fairly and the diversity of individuals and their communities should be recognised and viewed as a strength;
• Feedback from people on their experience and outcomes is routinely sought and used to bring about improvement.

The Lincolnshire’s Personalisation Programme has one aim and several ways of making it happen….

To shift the relationship and conversations between people, professionals and the health and care system to one which focuses on their strengths and assets and ‘what matters to them’, providing a positive shift in power and decision making that enables people and those who are important to them to be able to live their best life.

Eight key priorities for 22/23

• Culture and behaviour and workforce development
• Shared decision making
• Supported self-care and self-management
• Strength Based Approaches in adult care and community wellbeing 
• Personalised care and support planning
• Social prescribing
• Personalisation through technology
• Co-production, communication and engagement

 Objectives

The main objective is to make ‘Personalisation’ real for the people of Lincolnshire and our health and care workforce, through: 

1. Collaborative and partnership working with all members of the Better Lives Lincolnshire Alliance.
2. Embedding co-production in service redesign.
3. Using the ‘Making it Real’ framework as our guiding principles.
4. Embedding strength based and person-centred approaches / conversations into workforce organisation development, leadership programmes and all HR processes.
5. Improving information and advice for people so it’s meaningful and accessible.
6. Embedding the Lincolnshire Personalised Care Operating model across the Integrated Care System.
7. Using population health management data to target personalised interventions.
8. Developing an outcome framework and dashboard.
9. Using technology to enable people to live their best life.
10. Contributing to the improvement in health equalities through person centred approaches. 
11. Using Plan Do Study Act (PDSA) continuous improvement

Through co-production and co-design, working with staff and people with lived experience (see section on co-production) to support and shape how we work together.

We will work with you using a continuous improvement methodology called Plan, Do, Study, Act focusing on specific place-based teams which ensures that you can get involved to help design and shape how collectively personalisation becomes real for the people of Lincolnshire.

We will invest and support you to explore, learn and develop new ways of working which put people at the heart of what they do, reshaping process and service delivery models to support strength based and person-centred approaches.

In 2019 The Universal Personalised Care Model was published as part of the NHS Long Term plan, it was co-produced with people with lived experience and has taken a significant amount of learning and evidence from other parts of the care system in particular social care, learning disability, children services and our VCSE.

This should be the framework in which we operate in.

We need to identify our local populations – through business intelligence, practitioner judgement and local knowledge as this will enable informed and targeted interventions. Our population will benefit from an initial conversation that can happen anywhere in our health and care system. Some people may just require a one off intervention but have engaging and meaningful conversations to ensure that they are informed to be able to seek support and help early enough to prevent a crisis or a reactive response. Others may recognise the need to connect back with their local community or join it for the first time with the support of a social prescribing link worker. There will also be some people who may need some support in developing knowledge, skills and confidence to manage their own health and wellbeing. Approximately 30% of people and carers may require a more detailed conversation, around personalised care and support planning. 

The focus remains the same on what matters and what's important, and looks at all the resources and connections that are around them. This is the point when multi professionals become involved or when a small percentage of individuals would benefit from a direct payment or personal health budget (PHB).

In order to drive this change we must acknowledge;

1. It will take time. This is a generational change
2. We must do this with people through true co-production and co design
3. We must invest in supporting our workforce, the people we work with and the public to make the shift in relationships

50 leaders from Lincolnshire signed up to do the NHS Leadership for Personalised Care programme was a great achievement and proves the commitment and motivation we have in Lincolnshire to make personalised care real and meaningful.

The personalisation message is now being heard and starting to be understood in Lincolnshire with colleagues from across Health and Care coming forward to get involved in a whole range of activities such as leadership programmes, monthly personalisation huddles, action learning sets, presenting at regional events and working with people with lived experience through our co production groups.

Co-production

Is really starting to thrive in Lincolnshire with a range of co-production groups working across our system supporting service redesign and transformational change.

• Living with Cancer
• Hospital Discharge
• Palliative and End of Life
• Personalisation
• Mental Health and Wellbeing Transformation

Secured additional funding through NHSE to support the Personalisation funding which is being used for the following;

• To recruit to a Social Prescribing development Lead for the Lincolnshire Integrated Care System
• To recruit to a Workforce development lead who will be developing a strength based person centred curriculum for Lincolnshire health and care workforce.
• Working with Lincoln County Hospital and partners to embed strength based person centred discharge conversations between staff and patients and families.

Workforce Learning and Development

• 220 staff are completing the Coaching for Health and Wellbeing course
• 10 Coaching for Health and Wellbeing Champions completing the accredited course.
• 105 staff are completing the Personalised Care and Support Planning training
• 23 staff will be completing social prescribing qualifications
• 60 staff have completed the eLearning modules on the PCI website
• Strength Based approached being rolled out across LCC services

Personalised Care and Support Planning

• The comprehensive role out of the Lincolnshire Initial conversation and strength based approaches across Lincolnshire County Council – with a particular focus on adult care and frailty and the customer service centre. A similar approach is now being tested out with community nursing teams in LCHS.
• LCHS, LPFT and the community mental health transformation teams are embedding personalised care and support planning in their operating models.
• Quality assurance framework has been developed
• A range of teams are starting to explore the e care planning functionality on the Care Portal eg;
  • Stroke services
  • Hospital Discharge
  • Neighbourhoods, integrated place-based teams and PCN’s
  • Cardiac Rehabilitation

Social Prescribing

• A new Customer relationship management system (CRM), Social RX is being implemented with all our Social Prescribing providers which will have a direct interface with Primary Care clinical systems. Go live date – mid October
• A new role coming in to link up the VCSE sector and population health management work. 
• Over 40 social prescribing link workers are working across Lincolnshire’s PCN’s and integrated place based teams.
• Working with Voluntary Engagement Team and Lincolnshire County Council on developing the strategy for a more sustainable and robust relationship with communities and the VCSE.
• Developing a bid with NHS and VCSE partners to access NHS Charities together funding for people with long covid and Carers.

Using tailoring tools

The Cardiac rehab team in LCHS have successfully supported 20 people using tailoring tools which enables the professional to understand the individuals level of confidence and motivation to look after their own health and wellbeing, and how to tailor the response appropriately.

Communication, Engagement and Marketing

• Launched the ‘its all about people’ website
• Developed the first citizen panel survey to understand how people connected in with their communities and what they thought about their relationships with health and care professionals.

We’re now looking for personalisation champions / advocates who are keen to get involved in this exciting transformation programme. You need to be prepared to be available for colleagues who might just want to talk through the best way to start a person centred conversation and or exploring different options and approaches that they could use.

For more information please contact:

Lead Change Manager for Personalisation (ICS) – Kirsteen.redmile1@nhs.net

Project Manager for Personalisation (ICS) – Emma.Townend@nhs.net

www.england.nhs.uk/personalisedcare

www.thinklocalactpersonal.org.uk/makingitreal

www.personalisedcareinstitute.org.uk

www.kingsfund.org.uk/publications/social-care-360

www.kingsfund.org.uk/audio-video/putting-personalised-care-practice

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	TLAP Making it Real report	155.83 KB
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