Personalised Care and Support Planning

LTP Priority: Personalised Care

Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service

Type of Interventions: Personalised Care and Support Planning

Major driver of health inequalities in your area of work

Chapter one of the Long Term Plan sets out personalised care as one of the five major changes that will establish the new service model for the NHS. Personalised care means people have choice and control over the way their care is planned and delivered, based on ‘what matters’ to them and their individual strengths, needs and preferences. This happens within a system that supports people to stay well for longer and makes the most of the expertise, capacity and potential of people, families and communities in delivering better health and wellbeing outcomes and experiences. As a result of personalised care, healthcare is tailored to what matters to the individual, in the context of their whole life, such that personalised care can support programmes and systems to address inequalities in access, experience and outcomes.

Personalised care is listed as part of one of the five major, practical changes to the NHS Service Model over the next 5 years: People will get more control over their own health, and more personalised care when they need it.

The LTP sets out that 2.5 million people will benefit from the Comprehensive Model for Personalised Care. This includes the following commitments across six components of personalised care (in addition to a number of other commitments that rely on personalised care):

  • Accelerate roll out of Personal Health Budgets… Up to 200,000 people will benefit from a PHB by 2023/24 (para 1.41)
  • Over 1,000 trained social prescribing link workers by 2020/21 and 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)
  • People have choice of options for quick elective care, including choice at point of referral and proactively for people waiting for six months (para 3.109
  • Support and help train staff to have personalised care conversations (para 1.37)
  • Use decision-support tools (para 3.106) and ensure the least effective interventions are not routinely performed… potentially avoiding needless harm (para 6.17viii))

Below we expand on how each of these commitments can support the approach to reducing health inequalities.

Target groups

People living in deprived areas

Details of the recommended intervention.

Intervention

Personalised Care and Support Planning

Description

PCSP means people have proactive, personalised conversations which focus on what matters to them, paying attention to their clinical needs as well as their wider health and wellbeing. It means health and care professionals tailor their approaches to working with people, based on the person’s individual assets, needs and preferences, as well as taking account of any inequalities and accessibility barriers. The PCSP coordinates access to personalised care and treatment, and actively manages and follows-up on agreed actions.  It differs from Health Coaching primarily in how records are kept and shared, and that its focus is on co-ordination of care rather than self-efficacy.

Evidence

The Year of Care Programme found in 2011 that those in areas of socioeconomic deprivation gained the most from personalised care planning interventions.  This means that unlike many health interventions, care and support planning will narrow the health gap. (Year of Care Partnership. Year of Care report of findings from the pilot programme and Year of Care: Pilot Case Studies. s.l.: Year of Care Partnership, 2011.)

A systematic, independent review has found evidence that people’s well-being, satisfaction and experience improves through good personalised care and support planning. See: Coulter, A. et al. (2015), Personalised care planning for adults with chronic or long-term health conditions, Cochrane Database Syst. Review (3): CD010523

Guidance for Commissioners

FutureNHS from July 2019 as part of the Personalised Care and Support Planning (PCSP) summary guides.