1. NHS England Comprehensive model of personalised care : Personalised Care and Support Planning
Gemma Clifford

2. 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

3. 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.

4. 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

5. 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%

7. 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)

8. 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 )
Recognised as a practical enabler of integration (para 1.58)
To be supported and enabled through the revised QOF (para 1.11)

9. Personalised Care and Support Planning
On your table or in pairs can you discuss what you think a personalised care and support plan is?

10. PCSP Key Features
People who have a personalised care and support plan will:
Be central in developing their personalised care and support plan and agree who is involved
Have the time and support to develop their plan in a safe and reflective space
Feel prepared, know what to expect and be ready to engage in planning supported by a single, named coordinator
Be able to agree the health and wellbeing outcomes they want to achieve, in dialogue with the relevant health, social care and education professionals
Have opportunities to formally and informally review their care plan
Experience a joined-up approach to assessment, care and support planning and review, resulting in a joined-up personalised care and support plan which takes account of all of their needs

11. PCSP Counting Criteria
People are central in developing an agreeing their PCSP including deciding who is involved in the process
People have proactive personalised conversations which focus on what matters to them, paying attention to their needs and wider health and wellbeing
People agree the health and wellbeing outcomes they want to achieve in partnerships with the relevant professionals
Each person has a sharable PCSP which records what matters to them, their outcomes and how they will be achieved
People are able to formally and informally review their PCSP

12. Bradford and Personalised Care
Pilot programme with Cancer Support Yorkshire, Macmillan, Bradford CCG, Bradford Royal Infirmary, West Yorkshire and Harrogate cancer alliance
Testing out the additional 6 questions in the Macmillan eHNA, PAM, Social Prescribing and Supported self management
ALS with professionals and people who have been involved in the pilot
Training for the staff in personalised care and PCSP
Wider development with Leeds, Calderdale and the WY&H STP

13. There are 2 key principles to personalised care and support planning….
I start this section with talking about 2 key principles that apply to PCSP and also things like shared decision making, patient activation etc. Its about a different conversation, one that is based on finding things that matter to the person as well as what we need to do to address their clinical needs. Key to this is starting the conversation from this point.
Its about a different conversation, starting from a different place….. and

14. ……. seeing people as equal partners in the process
The second principle is that we see people as equal partners in the planning process, recognising the experience, gifts and talents they bring.
……. seeing people as equal partners in the process

15. What is important to a person includes only what people are “saying”: .
What is important to a person includes only what people are “saying”:
-with their words
-with their behaviour
When words and behaviour are in conflict, listen to the behaviour.

16. How best to support … to be healthy and safe
Important for
This includes only those things that we need to be mindful of regarding issues of health or safety and fulfilling potential.
Think about……..
How best to support … to be healthy and safe
What others need to know or do … . .

17. Guess
Write
You can repeat these questions until you find a solution which will work add jos slide
Ask?

18. We think you can develop one page profiles in six questions (with some sneaky sub questions)
Explain they have come from the FINK cards and invite them to look at the card packs on their table but ask them to please not take them away.
Explain that you are now going to ask them to develop their own one page profile. It is a requirement of the The Learning Community for Person Centred Practices that people do not use these tools with others unless they have experienced them for themselves. Sharing your own one page profile can be a lovely way to introduce yourself to a child and their family. Impress on people they do not need to share any thing of a personal nature that they do not want to share with people.
They will do the profile as home work so remind them to write down as much as possible so they can draft it later.

19. There are a couple of sub questions that it is also useful to ask here, like how often do you see people, what would you do with them?
Ask them to work on pairs or small groups and ask each other this question. Record their own answers. Give them 5 minutes to do this. Tell them this would then be recorded in the important to section using the detail we talked about earlier.
Who are the most important people in your life? How often do you see them and what do you like to do together?

20. What would make a good day for you and what would make a bad day?
For the purpose of the exercise ask participants to think of 3 things that make it a good day and three things that make it a bad day at work. Once they have identified these you need to talk them through the following:
Firstly, ask them to look through the lists and identify if anything on the lists tells them about something that is important to them about their work. They need to develop a sentence about this and record this under the important to section on their one page profile.
Secondly, they need to look at the bad day list and ask the question ‘Is there anything you need people to know and/or do to support you with this issue. This would be recorded in the support section of the one page profile
What would make a good day for you and what would make a bad day?

21. This question helps gather information for the support section of the profile. Ask participants to identify the things that make them stressed or unhappy and then identify what people need to know and do to support them with this.
What makes you stressed, unhappy or upset and what can people do to help you with that?

22. You are looking for routines here and things that people do that they would miss if they didn’t do. These are usually things that are important to them and would be recorded in the important to section of their profile.
What do you usually do during the week that you would miss if you didn’t do?

23. What would you never leave home without in your bag or pockets?
You are looking for information here about important possessions. People usually say their phone but ask them to think deeper than that. this would be recorded in the important to section.
What would you never leave home without in your bag or pockets?

24. Here you are looking for one word descriptions of people’s qualities and characteristics.
What would your family or best friend say they love and admire about you?

25. The three most common mistakes we make with outcomes….

26. …embedding the solution in the outcome

27. …not being specific enough
The other one is that we are not specific enough with our outcomes, which makes it hard to measure them
…not being specific enough

28. Is something that a person wants to change or achieve
Is written from a personal perspective and describes how the person wants their life to be
The person or those around them must have some control or influence over it
It can address something that isn’t working or can move the person towards their desired future
It is measurable and specific

29. Some examples of how not to write outcomes and what to write instead
Instead of this
Write this
Increasing mobilisation at home
Jane is confident walking from the lounge to the kitchen and bathroom every day
This isn’t well written because:
it’s not specific or measurable and the use of language isn’t personal to the person
3 homecare visits a day for medication administration
Joan has the right support at home to ensure she takes the correct dose of her medication at the right time of day
the solution is embedded in the outcome
Maintain oxygen saturation at 96% whilst out
For Heather to go out and meet her friends at Costa coffee twice a week and whilst out maintain her oxygen saturation at above 96%.
It only focuses on the person’s health condition and is not linked to anything that matters to the person.

30. PCSP Key Features
People who have a personalised care and support plan will:
Be central in developing their personalised care and support plan and agree who is involved
Have the time and support to develop their plan in a safe and reflective space
Feel prepared, know what to expect and be ready to engage in planning supported by a single, named coordinator
Be able to agree the health and wellbeing outcomes they want to achieve, in dialogue with the relevant health, social care and education professionals
Have opportunities to formally and informally review their care plan
Experience a joined-up approach to assessment, care and support planning and review, resulting in a joined-up personalised care and support plan which takes account of all of their needs

31. PCSP Counting Criteria
People are central in developing an agreeing their PCSP including deciding who is involved in the process
People have proactive personalised conversations which focus on what matters to them, paying attention to their needs and wider health and wellbeing
People agree the health and wellbeing outcomes they want to achieve in partnerships with the relevant professionals
Each person has a sharable PCSP which records what matters to them, their outcomes and how they will be achieved
People are able to formally and informally review their PCSP

32. Thank You G.clifford@nhs.net

33. My family and friendships are what define my life
My family and friendships are what define my life. Spending time with them and staying in contact is very important to me.
For people to respect my decisions - if I am ok to work I will, if not I won’t but keeping things normal at home and work are important to my recovery.
Be sensitive if I come in wearing a scarf! I am not sure how I will deal with this yet - I may be fine or I may be self conscious. Take your lead from me I will let you know.