What is personalised care and support planning?

Working with members of TLAP's National Co-production Advisory Group and its equivalent from the Coalition for Collaborative Care, the following statements describes what good personalised care and support planning looks like from their perspective:

• I am trusted to write my own care and support plan, with whatever help I need.
• My care and support plan is about the whole of my life, not just about assessed needs or money.
• I am encouraged and supported to think creatively about ways to achieve my outcomes.
• If I need help to plan, I can choose who supports me and who will help put the plan into practice.
• People who support me to plan, have a flexible, open, honest, positive, solution-focussed attitude.
• I can involve friends and family in the process if I choose.
• I have all the information I need to plan - when I need it, in an accessible way, including signposting to what is available locally.
• I am supported to take risks, and know it is OK to make mistakes and change my mind.
• The process from assessment through to review is transparent and clear. I know what to expect and when to expect it.
• People do what they say they will do.
• My review is person-centred, focused on me and my life, my outcomes and what is working and not working - not just the money.
• Through my review I can contribute my views to improving the system as well.

Care and support planning policy background

Care and support planning (CSP) has had an increasingly prominent place in health policy and was until recently known under the title of 'care planning'. Care planning in physical health was first specifically advocated in National Service Frameworks (NSF) in early 2000's with acknowledgment to the Care Programme Approach (CPA) in mental health (opens new window).

'Our health, our care our say' (opens new window) in 2006 recognised the needs and contributions of all those living with long term conditions (LTCs) and recent policy has emphasised the special issues of those with co-morbidities and the multi-morbidities of ageing and frailty.

'Care plans' or 'care planning' that recognise that people should have a greater say in the management of their care and a greater recognition of their own role in self-managing day by day are included in:

• NHS Constitution (opens new window)
• Mandate from the Department of Health (DH) to NHS England
• Operating Frameworks and most recently
• Five Year Forward View (opens new window)

The work to deliver the National Service Framework in diabetes initiated an extended period of practical development and feasibility testing, which included reviewing the evidence, wide consultation including social care and publication of delivery principles. This work emphasised the importance of the care planning process, rather than the care plan, in delivering improved experience encapsulated as "'it's', the verb not the noun".

The Year of Care (YOC) Programme

In 2006 Department of Health sponsored the Year of Care (YOC) programme (opens new window) hosted until 2009 by Diabetes UK. It was based on learning from the internationally recognised Chronic Care Model (CCM) (opens new window). CCM improved outcomes depend on partnership working between an empowered and activated person working with a proactive system and prepared health care professionals.

The Year of Care programme successfully demonstrated what was involved in care planning at team level - using diabetes as an example for other single and multiple long-term conditions.

Key findings included recognition that if the new 'conversation' was to become a true 'meeting of experts' between those with lived experience and those with technical expertise this would need simultaneous changes to attitudes, skills and clinic infrastructure.

For such conversations to be productive, both practitioner and 'patient' need to be prepared by sharing information before hand and allowing time for reflection. This led to the concept of a specific preparation stage as a key component of effective care planning.

Care and Support Planning - National Voices

National Voices (opens new window) have consulted widely on the nature and purpose of care planning for their members. The consultation highlighted the similarities with support planning in social care and led to a reframing of the process as 'care and support' planning, which provides the language of the Care Act.

They defined care and support planning as, a four step process within a person centred philosophical framework, now included in the architecture of the current work.

A guide for health and care practitioners and local communities (opens new window) hoping to introduce and sustain CSP using this approach has been published by NHS England and the Coalition for Collaborative Care (opens new window).

Preparation

Preparation ensures that both the person with the long term condition, (carers) and the health care professional (called 'care and support partner') are clear about the purpose of the care and support planning process, and their roles within it.

For the person this means

• taking time to think and talk with other people about 'what matters most to you' and what you want to get out of the consultation

For the healthcare professional (Care and Support Partner) this means

• collecting important, individual information from everyone involved in working with /providing care for the person
• sending personal information about health issues (test results and reports) together with explanations and reflective prompts to the person

2. Discussion

With information and tests out of the way this step involves the person and their care and support planning partner working together to:

• making sure the person feels listened to and understood
• identifying what is important to them, their priorities, options and goals
• emphasising staying well and living well
• building on their own strengths (assets)
• talking through an action plan including what the person will do for themselves and what care and support they might need from other people

3. Documentation

• recording the main points from the discussion in a way that is easy for the person to understand, access and use
• acknowledging that the plan belongs to the person and is also part of the main health and care record
• Health care professionals may also need a record (also owned and accessible by the person) to record their treatment plans for professional purposes and to coordinate with colleagues.

4. Review

Checking on how things are going is important to make sure that plans are still the right ones and going well, but also to help reinforce new self-management habits. Review might include:

• self-monitoring (self-review)
• getting support from friends or a community / peer support programme
• more formal review with the care and support partner that helped create a plan

The large body of implementation work which tested for feasibility, sustainability and transferability within the Year of Care programme articulated a number of principles and practical lessons which are incorporated in this work.

House of Care (HOC)

The principles and practical lessons from the Year of Care programme have been described in the House of Care (HOC) (opens new window) developed by the diverse grass roots teams involved.

The HOC provides a engaging checklist of the elements that need to be in place to enable Care and Support Plans to be arranged as the walls, roof and floor of the House; emphasising that all components need to be in place or the structure is not fit for purpose.

It is a transferable framework of fundamental parts which each community can tailor to their own population as they 'build their house of care'. It has enabled the core steps of care and support planning to be tested and validated for those living with multiple co morbidities and frailty and in specialty, community and general practice settings.

Care and support planning barriers

Barriers to care and support planning include the different assumptions that team members bring to their understanding of care plans and care planning. For example many people working in health care settings assume that care plans mean 'treatment plans' which outline the roles and tasks of the professional sometimes for regulation purposes.

It is hoped that as a result of multidisciplinary team working as proposed in this tool people with long term conditions will be recognised for being in charge of their health and that the quality of the care and support planning process centred on the conversation will make the biggest difference rather than the care plan itself.

Personalised care planning has become a central component of government policy for social care. This is demonstrated through the introduction of person-centred planning for people with learning disabilities (Valuing People 2001), and more recently as a core-aspect of the personalisation policy set out in Putting People First (2007).

Building on this, the Care Act 2014 introduces a duty on councils to make sure that everybody eligible has a personalised care and support plan and personal budget. Statutory guidance describes in detail how this should work to put people in control and enable a more holistic approach meeting needs and promoting wellbeing.

In Adult Social Care, the personal budget process starts with an assessment which leads to an indicative allocation. The next step is for the person to develop a care and support plan. This sets out how the person wants their needs to be met, identifies the outcomes important to them and describes how the personal budget will be used to achieve them. The plan is then signed off at team manager level or through a panel and then implemented.

Six stages to developing a support plan include:

1. About me - reflecting on what matters to the person.
2. What do I want to change? - Looking at what is working and not working in the person's life and where they want to be in the future.
3. What do I have? - Looking at the person's assets, relationships and community
4. Ideas - Generating ideas that use the person's assets and budget, to change what is not working, address their needs and move towards the future they want.
5. My decisions - Recording these decisions in the support plan.
6. Make it happen - Implementing decisions and actions.

Department of Health guidance for Putting People First suggested a range of person-centred practices for use in support planning.

Further work identified 12 key principles of best practice in support planning and brokerage which people grouped under the following headings:

Support planners and brokers

1. You choose who you want to support you
2. Qualities of a great support planner

Information before you begin

3. The criteria for signing off plans, and what you can and cannot spend your money on
4. What is available locally and how much things cost
5. Stories and examples of what people have tried and learned locally

Developing the support plan

6. Pay attention to history, hear the person's story
7. The person sets the pace of the planning process and chooses who else to involve
8. Plan for contingencies and be flexible
9. Try different ways to listen to people
10. Focus on what is important to the person (not what is important to staff)

Sharing the support plan

11. Support plans should reflect how the person wants them to look
12. Good communication about next steps and feedback is crucial

In 2014 The Care Act introduced Care and Support Planning and requires a focus on well-being and outcomes. This is what the Care Act and Guidance require in relation to care and support planning: http://www.youtube.com/watch?v=mQue-_fq0Ag&sns=em

[1] Putting People First: Delivering Personalisation though Person-centred Planning (2010)

[2] Putting People First: Support planning and brokerage with older people and people with mental health difficulties (2010)

[3] Personal health budgets guide. integrating personal budgets - early learning (2012) (opens new window)

A range of guidance materials have been published to support further implementation of personalised care and support planning from different parts of the system.

NHS England and the Coalition for Collaborative Care published materials on personalised care planning for people with long term conditions (opens new window) in January, while TLAP published practice guidance to support implementation personalised care and support planning under the Care Act.

TLAP's intention with this work was not to replace previous guidance on personalised care and support planning Rather it is to provide a bridge between the two traditions and to suggest practical ways in which learning and evidence can best be deployed in designing an integrated approach for people with both health and social care needs.

The first task was to build on earlier work in health, social care and personal budgets to align the stages.

Here are the stages developed by National Voices, those used in social care and those within personal health budgets.

From this, we created the draft process that is described in this resource.

• Personalised care and support planning doesn't happen by chance. It is based on new relationships and new ways of working and therefore involves particular attitudes to care delivery as well as specific skills alongside new ways of organising day-to-day work.
• This resource starts with what good care and support planning looks like from the perspective of people with lived experience, then identifies what needs to be in place to achieve this. These describe:
  • the attitudes and the beliefs of clinical /social care practitioners which will drive new behaviours
  • the operational principles which need to be at the centre of local co-design of care and support planning.

There are key assumptions/ beliefs that will drive the behaviour of practitioners and those that design services that are essential for this new way of working. These should be at the heart of the training and support programme for staff and need to be the organising principles for local design teams.

These are:

• People are in charge of their own lives and self management of their condition/s and are the primary decision makers about the actions they take in relation to the management of these and their support and services.
• People are the expert in their own lives and aspirations and decide on their own priorities.
• The focus on health and care practitioners is not simply to meet the person's health and social care needs, but enabling the person to achieve their outcomes. Their outcomes are informed by what matters to the person, their aspirations and their needs.
• The person is more likely to act upon the decisions they make themselves, rather than those made for them by a practitioner.
• Practitioners need to recognise people's assets, strengths and abilities, and aspirations not just their needs, and support them to live their lives as well as possible, in a way that reflects what matters to the person.
• People are interested in their lives rather than devices or diseases and care needs to be coordinated around the whole person's needs, aspirations and outcomes.
• The conversation between a practitioner and a person is a meeting of equals and experts.
• Care and support should be focussed on helping people to live in a way that reflects what matters to them as part of their community, stay well, and manage their conditions.
• Where deterioration and death are inevitable this can be a helpful component of a care and support planning conversation.
• The personalised care and support planning conversation (how the care plan is agreed) is more important than the care plan itself.

When designing Care and Support Plans it is important to provide a range of people/options for the person to choose during the planning process; making sure there is a balance between overall continuity and effective use of practitioner time and skills.

The following principles will also help to guide the care and support planning process:

• Everyone involved must understand the care and support planning process, know what to expect and their role in it.
• No major allocation of resource should be made until the views of the person about what's important in their life and the outcomes they want to achieve have been identified and recorded.
• Tasks, tests/assessments should be separated in time from discussion on outcomes and what is important to the person.
• Where relevant and possible assessments should be joint/shared between health and social care. Assessment by itself is not an intervention but could lead to some immediate problem solving and early actions.
• Care should be organised holistically around the person in ways that connect the NHS, public health, social care and community and voluntary organisations, so people tell their story only once, and the focus is on supporting the person to achieve their outcomes.
• Care and support planning is a generic approach appropriate to a variety of contexts which should be linked together as they are introduced as routine (one or more long term conditions, recovery model, preparation for ageing, last years of life and dying).
• People should see the minimum number of different care practitioners, understand the roles of those they see in supporting care delivery and be kept informed during the whole process, in a way that works for the person.
• Decisions should be made as close to the person as possible.
• The process should be proportionate to the person's needs and circumstances - there is no one-size that fits all.
• Where people have a personal budget, they have choice and control over how this is used, and have whatever support they need to decide how to spend it to meet their outcomes.
• Care and support planning is a continuous process, evolving over time - not a plan that happens only once. The plan is not the outcome.
• Documentation must be owned and accessible by the person, as well as to health and care colleagues.
• Practitioners should assume capacity unless otherwise assessed.