Hello and welcome to this short series which looks at life planning. I’m Andy Downton and over the next few episodes I’ll be talking to people who are using life planning to really make a difference to people’s lives. Today we’re looking at how life plans are being used in the southwest of England. I’m joined by John Hull, a registered nurse working with the Cornwall and Isle of Scilly Integrated Care Board, and Catherine Pokhara, who’s the Transforming Care assessor and a social worker for Cornwall Council.

But we start with Debbie Reese, who’s the ICC’s clinical review officer for the Transforming Care Programme, who starts by explaining how they’re using life plans in the county. We’re commissioning life plans for individuals who have been in hospital under the Mental Health Act section and actually we’ve commissioned some for people who haven’t been in hospital but following maybe a blue light meeting. So it’s an independent person that is putting together this life plans. They set aside several days to work with professionals who working with the individuals they involve family members and the person themselves and they produce a document that is a really comprehensive document.

So it has a lot of information about people’s life from the start. And that sort of information is often lost I think in clinical records. And it’s, you know, way back and we can’t find information. It’s a way of bringing information across into one document about, you know, what’s happened in their life far, what their hopes and dreams are for their future, what type of support will look like for them. That means it will be good support where they would like to live, what they would like their home to look like and say it’s it’s, it pulls all that information together in a document.

Everyone feeds into that. And, and we use that a lot actually when we’re going out for our procurement process, we’ll cut and paste bits in the life document because people who know the people well are asked to say what’s good about the person. And we often don’t hear that with our cohort of patients. So it’s nice to have those really positive comments about saying those kinds so and so is friendly, so and so wants, you know, whatever it is, it’s really nice information. So when we are sending out information to our provider organisations, although we’re having to put on information around risks, because obviously that’s important information to share, we’re also being able to put some really positive things about the person. And I think it’s being honest and transparent about the time commitments, the people who are quite often are involved with the discharge. So we might be working with a number of people who are being discharged at the same time.

There’s lots of competing factors. When you’re the social worker or you’re the care coordinator, that piece of work actually saves time in that you’ve got this independent person who’s collating all the information that where you might have wanted to do a really good piece of person said to piece of work. You might not have had that time to really do that deep delve into documentation to find all of the history. And it also informs our care plans moving forward because it’s that really open and transparent conversation with the person included about what would your care team look like? Who do you want in your care team? What, what do you find kind of really irritating in a carer? You know, who would you not want around you? And that really that saves time on the, on the support plan as well.

And so it, it is beneficial from a, from a time perspective for the for the care coordinator, but it also makes it more person centred for the individual. As Catherine says, as a social worker, life plans make it all about the person. John, how do they make a difference to your work as a nurse?

I, I’ve been involved in two, one, one was very, very good and one was less good.

So the interesting thing for me is that both individuals, one was able to tell us what they wanted, but actually lacked capacity for, for their current support. So the life plan allowed us to, to, to get their voice to, to hear what they wanted from, from their life within the constraints of the fact that we were going to be taking decisions on behalf of them with, with under the Court of Protection. So, so that, that one was very, very good and, and worked very well. And, uh, continues the, the actual life that’s come from that plan is really good. And I had a message from an individual today telling me how wonderful their life is. And, and they ring me regularly to tell me all the things they’re doing and how great it is. And this is somebody that only that just under two years ago wasn’t going out at all and was being supervised, you know, by by three males all the time. So this person’s now out and about and it’s got a mixed team and he’s doing lots and lots of stuff. So so that’s great. The other person wasn’t able to tell us.

And so it relies then on the people around them. And, and I think that’s then can, can be less effective because what tends to happen with these individuals where they can talk or not, if there is that people seem to take ownership of them. So it could be a parent that does that or it could be one of the, the, the professionals might do that and, and people seem to take ownership off them. And, and at that point, it really depends on the life planner to, to actually sift through that and find the person in all of that. And that’s not always easy when you’ve got strong characters involved in that process. So I think when it’s done well, I, it’s brilliant and we’ve got the evidence of that, but it takes a really good life planner to do it well. So I think it’s, it’s not one of those things that you can just go into a book, read about it or sit there and watch one down and then you can do it. It it, it really takes some scale, I think.

And John, if I can ask, what are the risks of not having life plans in place?

The risk for me would be they’d lose their voice. So it’s about that person centeredness. What life plan does is it allows us to, to, to find the individual in this. And generally, as Debbie said, these individuals are, are people that have been through the system all of their lives and have not yet managed to to have their voice heard properly because of their condition, because of their behaviours, because of everybody else’s viewpoint on who they are. So, so the life plan helps us to, to find their voice. When you asked on that question, I am just thinking about some of the more complex discharges that we’ve had over recent years. And I can’t imagine being able to do those discharges without the life plan. Actually, they have been such valuable documents that has informed every step of the process to make sure we get it right for the person. We, you know, we make sure we update the life plan. So they are have been really useful documents to send into the court protection as part of our sort of bundle of papers that goes in. I would struggle to see how we could have affected such good discharges for people without those documents. I think they give a focal point to the team, so where we all work on different recording systems and each of us might have a piece of that person’s journey, but not maybe the entirety.

The life plan brings that all together with a shared document about that person’s, their history and their goals that we can all use and refer ourselves back to when we’re all off doing our individual pieces. I think that’s what helps with the discharge and and makes it so useful. I think the other thing for me is I’ve, I’ve attended a lot of training and, and really trying to learn about families experiences and trauma experiences around having a loved one who’s in who’s under a section.

And again and again I hear families saying they weren’t involved in the process or they didn’t feel like their voices were heard. Now obviously we always need to be mindful that the person is at the centre to the family’s voice doesn’t overtake the person’s voice, but I think the life plan and a particularly a skilled life planner does a really great piece of work around family. We’re meeting with you, What do you remember? What do you want for the person’s future? And then does the same piece of work with the person so everybody feels heard and valued. And with your point there, Catherine, this is so much more than just yourselves in social care working with the NHS teams like Debbie and John, isn’t it?

I think if you just think about the sheer number of people involved in the discharge, you know you’ve got adult social care, you’ve got maybe the the foundation trusts, you’ve got the commissioning boards, you’ve got families, you’ve got the individual, you’ve got care providers, you’ve got hospital staff, maybe multiple different hospitals.

You know there might be four or five different recording systems within that as well. And so I think if you think about the number of people that get coordinated to enable a complex discharge to happen, it’s no wonder we need a life plan to pull us all together. I suppose the other thing with life plans that that that I think is really important not to lose as it safeguards the person’s life.

Often we as professionals will move on. So you might have professionals that know what this person wants and, and are really key to keeping that person safe and, and help in the community. But we move on or we retire, some of us at some point. And, and, but, but, but that life plan will live. And because it lives in everybody’s systems, it acts as a little sort of safeguarding the backstop really to protect that person’s life story and, and their life plan. And I think we do have a group of individuals that we work with, certainly me and John, who can’t tell their own story, who don’t have the ability to tell their own story. And maybe their families aren’t around to tell their story either. So additionally to what John said, it adds that safeguard for those who can’t tell us without that extra bit of support. So listening to that, it sounds like life planning is really making a positive impact on many lives across Cornwall. Debbie, what would your message be to other Icbs and the wider health and care systems across the country who maybe haven’t looked and aren’t looking at life planning in the same way as you have?

I would just be strongly encouraging people to be commissioning life plans, you know, as cat cats data. You know, although you’re saying, you know, yeah, they’re quite a lot of work in the initial instance, they save a lot of work in the long run. They ensure that we’re always working in a person centred way and it they always paint a nice picture of the person and that is often lost with our documents. You know, it’s the risk this it’s our care. None. Often our guys don’t look very good on paper, but you know, the life sounds paint a really lovely picture of who that person really is, and I think that often gets lost. So yeah, they’re they’re just very valuable documents. I would really be encouraging people to use them.

I guess I’m just mindful that I have had some conversations with other areas where they’ve said that they haven’t found life planning helpful. My thoughts on that would be areas have those negative experiences, are they sure they’ve commissioned the right people to do that work and has it been thorough? Because I would struggle to see a a discharge scenario where it wouldn’t bring benefit if done properly.

The only scenario is if it’s completed and shoved in someone’s filing system somewhere and not used. Maybe that’s about the buy in to using it as a document shared across the agencies once it’s completed and not letting it go. So personally I every individual I work with who has a life plan, I embed it in my needs assessment rather than doing the work twice. Although I’ll review if it’s out of date, but I’ll embed it in my needs assessment and it gets embedded in the health documents as well. So the same story is starting to play out in all recording systems rather than 10 different versions.

And we’re always referring back to it when we’re looking at discharges. We’re always going back to life plan. Is this an accurate or are we, are we creating what is an accurate reflection of what that person saying they would like? Debbie, John, Catherine, thank you so much for your time. In our next episode, which will be our final episode, we’re going to be hearing from someone at the heart of a life plan and how much of a difference it has made to their life.