About this tool

This tool is aimed at leaders, commissioners, planners, clinicians and practitioners involved in designing and delivering personalised care and support planning for people with a variety of health and social care needs.

Through a series of case study scenarios, developed with people in the field, clinicians, social care managers, voluntary sector partners and people with lived experience of care, the resource demonstrates what different journeys through personalised care and support planning could look like when delivered through integrated and person-centred arrangements. It also begins to unpack many of the workforce, commissioning and organisational implications.

This is not a blueprint. Many decisions about service design and delivery will rightly be made locally, dependent on local conditions and circumstances, leading to a range of models that may be equally successful.

Rather it is intended to stimulate and inform these discussions, highlight the common principles that should underpin any local approach and demonstrate a variety of possibilities for local adaptation, while encouraging everyone with a stake in this work to aim high in their ambition.

Personalised care and support planning (PC&SP) is part of the different relationship being forged between people with health and care needs and services. It recognises and values lived experience, alongside clinical and professional expertise and empowers and enables people to shape and manage their own care.

Personalised care and support planning is set out as a legal right in the Care Act 2014, alongside personal budgets, for everyone with eligible social care needs, including carers. It is also part of the vision for the future of the NHS in the Five Year Forward View, which describes the importance of people and communities gaining far greater control of their care.

It is a key ingredient in a variety of transformation programmes, grappling with issues of improvement and sustainability across the NHS and local government, including New Care Models, Pioneers and Integrated Personal Commissioning Programmes.

These shifts reflect a shared consensus that current models of health and care are no longer fit for purpose and are incapable of dealing with the changing and increasingly complex needs of the people and communities they serve. Too often they fall short of the expectations people rightly have of a personalised and seamless experience of care.

People often find fragmented services within the NHS and between health and social care and this has to change. Personalised care and support planning is part of the solution.

It can galvanise clinical and professional expertise around the things people need to manage their own health and wellbeing, it can be the organising principle for service redesign and the driving force behind the cultural and structural changes needed to deliver person-centred, coordinated care at scale.

However, holistic and joined up approaches to personalised care and support planning remain rare in practice and the workforce, commissioning and delivery issues can often seem complex.

Despite rich traditions of personalised care planning in social care and in the NHS for people with long term conditions, these approaches have tended to develop in silos, under different policy frameworks, with different language and ultimately with patchy results. Rarely have these worlds come together.

Yet as the Care Act progresses to implementation and the Five Year Forward View moves from vision to action there is an unprecedented opportunity to take the best of what has been tried and learned and to embed it at the heart of health and care reform.

The Care Act encourages a joined up approach to personalised care and support planning and personal budgets, particularly where people have both health and social care needs.

The statutory guidance in support of the Act describes the ethos and practice that should guide a truly personalised approach, stating that:

"The guiding principle in the development of the plan is that this process should be person-centred and person-led, in order to meet the needs and outcomes of the person intended in ways that work best for them as an individual or family...both the process and the outcome should be built holistically around people's wishes and feelings, their needs, values and aspirations."

In addition to the Act reinforcing a general duty of cooperation between local authorities and other statutory partners, including the NHS, the guidance also explicitly encourages this in relation to the personalised care and support planning process for individuals, stating that:

"Local authorities should not develop plans in isolation from other plans and should have regard to all of the person's needs and outcomes when developing a plan,"

"Particular consideration should be given to ensuring that health and care planning process are aligned, coherent and streamlined, to avoid confusing the person with two different systems."

Further, the guidance sets the expectation that a "key area where plans can be combined is where the person is receiving both local authority care and support and NHS health care" and extends this principle to consideration of how personal budgets might also be brought together, so that "other amounts of public money...such as money provided through a personal health budget" are combined to enhance the person's experience and reduce unnecessary duplication.

The Five Year Forward View sets out the vision for the NHS over the course of the current Parliament. The second chapter focuses on the importance of empowering patients and engaging communities, in recognition that harnessing their "renewable energy" will be critical to future sustainability.

The document, developed jointly with Public Health England, Monitor, the Care Quality Commission, Health Education England and the Trust Development Authority confirms the commitment to "do more to support people to manage their own health" and to "increase the direct control that patients have over the care that is provided to them".

To meet these and other commitments to transform the way the NHS works for the future, the Five Year Forward View set in motion several high profile programmes to test and refine new models of care that will address the barriers to "the personalised and coordinated health services people need." These include the New Care Models programme and Integrated Personal Commissioning.

The New Care Models programme is testing a range of new organisational forms to redesign the way whole health and care systems work to better integrate and improve care delivery locally.

Integrated Personal Commissioning is blending health and social care funding for people with the most complex needs, including through the use of integrated personal budgets.

Under the New Care Models Programme, areas testing Multispecialty Community Provider models (MCPs) and Primary and Acute Care Systems (PACS) will be bringing together different clinical and professional expertise from across the system to deliver a far wider range of care to registered lists of patients, some with combined health and social care funding.

In many areas, the coordination of a personalised care plan, drawing on enhanced primary care, nursing, other specialists and social work, is a central component of service transformation plans.

This will require multi-disciplinary teams working flexibly around the person, a shift in organisational cultures and a step change in practice to embed the most effective approaches to personalised care and support planning within new care models. Personal health budgets are also to be made available where people wish to design bespoke arrangements.

As with the new care models programme, this will need to involve multi-disciplinary teams working within and towards a person-centred culture if it is to deliver the transformatory change intended.

The work to develop this tool was commissioned to learn more about the practical implications of personalised care and support planning for people with health and social care needs. The aim was to clarify the stages of the process and show how an integrated approach could work.

It focused on several specified groups:

• people living with one or more long term conditions, multi-morbidity and frailty who have complex needs
• people living with mental health and social care issues
• people living with dementia

We began with a multidisciplinary group of stakeholders including those with lived experience which reviewed the processes and language used within the two traditions of personalised care and support planning in health and social care.

We then developed stories of several fictional people with typical health and social characteristics in order to:

• draw out the key principles, practice and steps of personal care and support planning which will be relevant to all adults with health (physical and mental) and social care needs
• use their experiences to develop an ideal approach through personal care and support planning process

The stories, following a wider consultation, will be used to inform further activity to assess the practice and methods of service delivery within a variety of new models of care.

More information about the case stories used in this tool can be accessed from the home page.