NHS England Personalised Care and Support Planning - A Brief Summary Guide
NHS England Personalised Care and Support Planning - A Brief Summary Guide
NHS England Personalised Care and Support Planning - A Brief Summary Guide
Content
Introduction
Who this document is for
What is personalised care and support planning?
Personalised care and support planning: what this looks like for people,
families, and systems
Ensuring equal access
More information on personalised care and support planning
Introduction
This brief summary guide supports integrated care systems (ICSs) to understand
and create the conditions for sustainable implementation of personalised care
and support planning (PCSP) in line with the essential delivery of personalised
care within systems. It is intended to support those involved in the leadership,
design, development and delivery of personalised care and support planning
across all sectors.
ICS’s play a pivotal role in supporting partners to deliver high quality personalised
care, building on best practice, and realising improved outcomes and experience
for those using NHS services. This guide supports collaborative working, offering
strategic guidance to all partners, and those using their services, on how PCSP is
part of the solution to improve outcomes, tackle inequalities and make the best
use of resources.
This guide provides best practice advice, not statutory guidance. However, it can
be used to self-assess and self-assure the quality of local systems
implementation of personalised care and support planning.
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This summary guide is aimed at people who are leading local implementation of
personalised care and support planning within ICSs.
ICSs and integrated care boards (ICBs) have a broad range of responsibilities
that empower them to better join up health, social care, and the voluntary sector
to improve population health and reduce health inequalities. This includes
supporting commissioners and providers collaborating at place level, and through
multidisciplinary teams delivering services and working together across
neighbourhood footprints.
It is also relevant to people with lived experience of care and support, and
voluntary, community and social enterprise organisations.
In personalised care and support planning you start the conversation from a
different point, by finding out what matters or is important to the person in their life
before discussing their health in any detail. This helps to build a picture of how
someone wants to live their life and they are seen through the lens of their
whole life situation rather than being seen through the lens of their condition.
The complexity of a person’s needs, the number of conditions they manage, the
breadth of services they are currently accessing, and their preferences, will
influence the type of support they might receive and the level of choice and
control they have over managing their health and care. This ranges from being
signposted to support for self-care, to people having control over their care
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Personalised care and support planning: what this looks like for
people, families, and systems
NHS England has developed a set of criteria to define personalised care and
support planning and provide strong quality indicators for personalised planning.
This has been done because it is not possible to develop a national template that
would meet the needs of all parts of the system or clinical pathways where
personalised care and support planning may be embedded. These criteria have
been co-produced with people with lived experience and clinicians and
demonstrate what is required from a personalised care and support planning
experience rather than seeking to adopt a one size fits all approach.
The information under each criteria provides clarity on what the process and
resulting plan should look like for people, families and systems. The format
provides a best practice statement including the key elements that should be in
place to meet that criteria and a statement as to when systems could not count a
personalised care and support plan.
The person owns their plan and is central to creating it as an equal partner.
The person is well prepared for the planning
process including understanding the purpose of the plan. They understand
how the process will take place and have been given information in a way
that meets their information needs.
The person is able to choose who will be involved in the planning process,
including family and friends who know them well.
The professionals involved in the planning process are prepared and have
the right information available for the process i.e. test results, information
about eligibility etc.
There are a range of resources available to support the person with
the development of their plan, including resources that support them to
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The person was not involved in writing the plan, didn’t have the opportunity
to involve people they wished to be involved, and/or were given no
information to prepare them for the planning process.
The planning conversation starts with what matters to the person, the things
that make life good. This could include information about important people,
significant routines and rituals and important possessions.
The conversation should also include the things which worry them about
their condition(s) and how they manage them.
The conversation then looks at the support the person needs to manage
their condition(s). This includes what they do on a day-to-day basis to
manage their condition(s), prevent a deterioration of their condition(s), what
to do, and who to speak to if a deterioration occurs.
During the conversation the person is listened to and understood in a way
that builds a trusting and effective relationship taking account of the persons
health literacy, skills, knowledge and confidence.
The conversation does not include a discussion about what matters to the
person and only looks at what is wrong with the person, focusing on their
needs but not within the wider context of their whole life.
It would not be counted if the person does not feel listened to or their health
literacy, skills, knowledge and confidence have not been taken into account.
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Criteria 3 – People agree the health and wellbeing outcomes they want
to achieve, in partnership with the relevant professionals
The plan is not written from the person’s perspective or is written in a way
more aligned with the service or system.
It would not be counted if the outcomes (goals) in the plan did not reflect what the
person wanted to achieve and were written by professionals and not in
partnership with the person.
A clear record of what matters to the person, for example, information about
important people and how they stay connected to them, significant routines
etc.
A clear record of the support they need to manage their condition, including
what they will do for themselves, what family and friends may be able to do,
followed by what other support they require.
A clear record of the agreed outcomes (goals) and actions.
A clear record of contingency plan, risk arrangements and treatment
escalation, where these are relevant.
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There is no clear record of what matters to the person, and the agreed
outcomes (goals) and actions from the planning conversation.
It would not be counted if it could not be shared with all those involved in the
person’s care.
The person was not able to review and edit their plan informally when they
needed to and did not know how to request a formal review.
Promoting equality and addressing health inequalities are at the heart of the
values of personalised care. Throughout the development of the policies and
processes cited in this document, we have:
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Personalised care and support planning is an important tool in helping the NHS,
local authorities, and partners to meet the needs of all sections of the population,
including people who have been poorly served by conventional health and social
care services.
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