NHS England Comprehensive model of personalised care: Supported self-management and social prescribing   Gemma Clifford

Objectives To develop an understanding of the Personalised Care comprehensive model and how this relates to the cancer programme To develop an understanding of personalised care and support planning and shared decision making and what tools and resources are available to support the implementation of this locally To explore how this can be implemented in local systems and have the opportunity to share examples of this is practice

What is Personalised Care? Personalised care helps a range people - from people with chronic illness and complex needs to those managing long term conditions and those with mental health issues or struggling with social issues which affect their health and wellbeing.  It helps them make decisions about managing their health so they can live the life they want to live based on what matters to them, working alongside clinical information from the professionals who support them. This is in response to a one-size-fits-all health and care system that simply cannot meet the increasing complexity of people’s needs and expectations.  Evidence shows that people will have better experiences and improved health and wellbeing if they can actively shape their care and support.

Personalised care brings together 6 different components Shared decision making Personalised care and support planning Enabling choice, including legal rights to choice Social prescribing and community-based support Supported self-management Personal health budgets and integrated personal budgets

Comprehensive Model for Personalised Care All age, whole population approach to Personalised Care TARGET POPULATIONS INTERVENTIONS OUTCOMES People with long term physical and mental health conditions 30% Specialist Integrated Personal Commissioning, including proactive case finding, and personalised care and support planning through multidisciplinary teams, personal health budgets and integrated personal budgets. Empowering people, integrating care and reducing unplanned service use. People with complex needs 5% Plus Universal and Targeted interventions Supporting people to build knowledge, skills and confidence and to live well with their health conditions. Targeted Proactive case finding and personalised care and support planning through General Practice. Support to self manage by increasing patient activation through access to health coaching, peer support and self management education. INCREASING COMPLEXITY PEOPLE MOVE AS THEIR HEALTH AND WELLBEING CHANGES Plus Universal interventions Universal Shared Decision Making. Enabling choice (e.g. in maternity, elective and end of life care). Social prescribing and link worker roles. Community-based support. Supporting people to stay well and building community resilience, enabling people to make informed decisions and choices when their health changes. Whole population 100%

NHS LTP: Specific Personalised Care commitments Provide people with a wide choice of options for quick elective care, including choice at point of referral and proactively for people waiting for six months (para 3.109) Use decision-support tools to augment the ability to deliver personalised care (para 3.106), and ensure the least effective interventions are not routinely performed, or only performed in more clearly defined circumstances, potentially avoiding needless harm to people and freeing up scarce professional time (para 6.17viii)) Put in place over 1,000 trained social prescribing link workers by 2020/21 and over 900,000 people referred to social prescribing link workers by 2023/24 (para 1.40) Ramp up support for people to self-manage their own health (para 1.38) Accelerate the roll out of Personal Health Budgets to give people greater choice and control over how care is planned and delivered. Up to 200,000 people will benefit from a PHB by 2023/24 (para 1.41) Support and help train staff to have personalised care conversations (para 1.37)

LTP: other commitments that depend on Personalised Care Significant commitments to support care quality and outcomes, including applying the Comprehensive Model of Personalised Care to end of life care (para 1.42), dementia (para 1.20) and cancer (para 3.64) Enabling more personalised care and choice and control for people with learning disabilities, autism or both (para 3.34), children and young people (para 3.47), and people with mental health conditions (para 3.106) Personalised care and support planning approaches in maternity (para 3.13), CVD (para 3.70) and to support people to manage their condition in work (appendix on health and work) Expand supported self-management for people with long-term conditions (para 2.2), including diabetes (paras 3.79, 5.13), respiratory disease (para 3.85) and MSK conditions (para 3.107) Community pharmacies will also promote and support self-management for people (para 1.10) In addition to the above, personalised care is: Recognised as enabling the shift to digital and vice versa (para 5.8-5.9) Recognised as a practical enabler of integration (para 1.58) To be supported and enabled through the revised QOF (para 1.11)

Supported Self Management Supported self-management: Increasing the knowledge, skills and confidence (patient activation) a person has in managing their own health and care through systematically putting in place interventions such as health coaching, self-management education and peer support. Design principles: 1. Understand a person’s level of knowledge, skills and confidence, using tools such as the Patient Activation Measure (PAM) or equivalent 2. Health and care professionals tailor their approaches to individual assets, needs and preferences, supporting people to increase their knowledge, skill and confidence 3. Interventions are systematically in place: health coaching, self-management education, peer support and social prescribing focussed on, though not limited to, those with low activation to build knowledge, skills and confidence, and take account of any inequalities and accessibility barriers

Supported Self Management Step 1 Peer support in health and care encompasses a range of approaches through which people with similar long-term conditions or health experiences support each other in order to better understand the condition and aid recovery or self-management. It can be delivered on a one-to-one basis, which may be in person or through telephone support, or through a peer support group Self-management education includes any form of formal education or training for people with long term conditions that focuses on helping them to develop the knowledge skills and confidence they need to manage their own health care effectively (RtV 2016). One-to-one support approaches include peer listening, to enable someone to talk through current concerns and offer support.

Patient Activation 40% of people with LTCs have low / no confidence to manage their health and wellbeing 25% of population 15% of population 7% of the population are at level 1 ‘activation’- they tend to have a worse quality of life and have worse outcomes than people at level 4 ‘activation’ More activated people are more likely to: attend screenings, diagnostic tests etc have healthy behaviours have ‘normal’ clinical indicators

Health Coaching Health coaching is a form of coaching that aims to help people to set goals and take actions to improve their health or lifestyle. Health coaching can be done on a one-to-one basis, in pairs or in small groups and can be delivered in person or – for individual coaching at least – by telephone or online. A health coaching role can take many different forms, i.e. built into the roles of existing healthcare professionals, i.e. trained to use these techniques and tools within routine consultations, or delivered in a community setting. Health coaching has some synergies with other SSM approaches. A key distinction, however, between health coaching and some other forms of support, such as SME , is that the health coach is not there to teach, advise or counsel but, rather, to support people to find the answers themselves and plan to achieve their goals.

Key elements of social prescribing in Primary Care Networks

Link workers in Primary Care Networks Social prescribing link workers will be embedded within primary care network multi-disciplinary teams to: provide personalised support to individuals, their families and carers to take control of their wellbeing, live independently, and improve their health outcomes develop trusting relationships by giving people time and focusing on ‘what matters to them’ take a holistic approach, based on the person’s priorities, and the wider determinants of health co-produce a simple personalised care and support plan to improve health and wellbeing introduce or reconnect people to community groups and services evaluate the individual impact of a person’s wellness progress record referrals within GP clinical systems using the national SNOMED social prescribing codes support the delivery of the comprehensive model of personalised care draw on and increase the strengths and capacities of local communities, enabling local VCSE organisations and community groups to receive social prescribing referrals.

Thank you g.clifford@nhs.net