Personalisation :: Lincolnshire STP

Personalisation is rooted in the belief that people ‘want a life not a service’. It takes a whole-system approach, integrating services including health, social care, public health and wider services around the person.

It provides an all-age approach from maternity and childhood, through living with frailty, older age and end of life, encompassing both mental and physical health and recognises the role and voice of carers. It recognises the contribution of communities and the voluntary and community sector to support people and help build resilience.

Personalised Care is not new. For many people already working in health and care, engaging in a meaningful way with people, families, carers and communities is part of their intrinsic motivation. It is seen in the development of ‘personalisation’ in the social care and voluntary, community and social enterprise (VCSE) sector and is integral to established techniques and approaches such as care and support planning, health coaching, motivational interviewing, shared decision making, self-management support and coproduction.

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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.

Dr Sadie Aubrey, GP and PCN Clinical Director, talks about why Personalised Care is so important.

Liz Reader, Care Co-ordinator talks through her journey to embracing personalised care

Eight key priorities for 23/24

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

Person Centred Approach

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

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.

Aims and Objectives

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….

How will we get there?

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.

Achievements to date

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.