Personalised care and support planning

Personalised Care and Support Planning is a series of facilitated conversations in which the person, or those who know them well, actively participates to explore the management of their health and well-being within the context of their whole life and family situation.

This process recognises the person’s skills and strengths, as well as their experiences and the things that matter the most to them. It addresses the things that aren’t working in the person’s life and identifies outcomes and actions to resolve these.

Personalised Care and Support Planning is key for people receiving health and social care services. It is an essential tool to integrate the person’s experience of all the services they access so they have one joined-up plan that covers their health and wellbeing needs.

What are the benefits to personalised care and support planning?

Valuing people as active participants and experts in the planning and management of their own health & well-being ensures that the outcomes and solutions developed have meaning to the person in the context of their whole life, leading to improved chances of successfully supporting them.

Integrating health & social care at the point of assessment and planning means the person will not have to repeatedly share their story time and time again, as they will have one assessment & planning experience that results in a single integrated personalised care and support plan.

Personalised care and support plans

The personalised care and support plan is developed following an initial holistic assessment around the person about the person’s health and well-being needs. The person, or their family, work hand-in-hand with their health and social care professionals to complete this assessment which then leads to producing an agreed personalised care and support plan.

There is no set template for what a personalised care and support plan should look like but it should reflect the following:

  • a way of capturing and recording conversations, decisions and agreed outcomes in a way that makes sense to the person.
  • should be proportionate, flexible and coordinated and adaptable to a person’s health condition, situation and care and support needs.
  • should include a description of the person, what matters to them and all the necessary elements that would make the plan achievable and effective.

The key features

Perspective – this is a way of ‘seeing people’ and attitude towards them that is fundamental to good Personalised Care and Support Planning.

The changed relationship and different conversation will mean that the person:

  • is empowered and builds knowledge, skills and confidence
  • experiences hope and feels confident that the process and the plan will deliver what matters most to them
  • is central in developing their Personalised Care and Support Plan and will agree who is involved.
  • is seen as a whole person within the context of their whole life, valuing their skills, strengths, experience and important relationships
  • is valued as an active participant in conversations and decisions about their health and well being.

Process – this is the overall process of personalised care and support planning.

A good personalised care and support planning process will mean that the person:

  • has the time and support to develop their plan in a safe and reflective space
  • is able to access information and advice that is clear and timely and meets individual information needs and preferences
  • feels prepared, knows what to expect and is ready to engage in planning supported by a single, named coordinator
  • is listened to and understood in a way that builds trusting and effective relationships with key people
  • is able to agree the health and well-being outcomes (and learning outcomes for children and young people with education, health and care plans) they want to achieve, in dialogue with the relevant health, education and social care professionals
  • has the chance to formally and informally review their personalised care and support plan.

Plan – this is what a good plan looks like.

A Personalised Care and Support Plan:

  • is a way of capturing and recording conversations, decisions and agreed outcomes in a way that makes sense to the person.
  • should be proportionate, flexible and coordinated and adaptable to a person’s health condition, situation and care and support needs.
  • should include a description of the person, what matters to them and all the necessary elements that would make the plan achievable and effective.