- For many social care practitioners personalised care and support planning is now a familiar way of working. This is less so in healthcare settings and demands new philosophies of practice, different consultation/conversation skills and a greater understanding of the overall care and support planning process and the practitioner's role within it, so they can support the person though the process, and work as a team.
- The core concept is that people however frail and with however many physical, psychological or social issues are in charge of their lives and the main decision makers about the outcomes they want to achieve.
- Supporting people to achieve this requires a complex mixture of skills and expertise brought to bear in the right way , and at the right time to enable
- The approach to be proportionate to the person's needs
- Decisions to be taken as close to the person as possible
- Continuity of relationships
- All parts to be transparent, consistent and joined up
- The right person with the right skills to be involved in the right way - linked with everyone else.
- This work has identified a number of key roles (with related competencies) which must all be available, but could be provided in a number of different ways, by staff with a variety of background (e.g. professional and non-professional) . This will be partly determined by the overall pathways and models of care determined for a local health and social care community.
- The input needed in the first personalised care and support planning cycle may be very different to subsequent ones; when core information has been collated, the person's overall outcomes are clear, there is feedback from previous care and support planning cycles and the person has become clear about their preferences for the practitioners or volunteers they would like to work with.
- An overriding conclusion is that to obtain this level of proportionality, joined up working and flexibility these roles need to be based within active multidisciplinary teams across health and social care, and with key voluntary sector involvement where individuals work together and most importantly train together to deliver a coordinated and systematic approach.
- There are a number of emerging exemplars of personalised care and support planning approaches which could turn organisational integration into a holistic service truly led by the outcomes that people want to achieve. Such teams need to make sure they include physical and mental health and social care expertise alongside supported link workers and volunteers, and coordinators.
- Team members may need to develop a generic set of skills which include expertise beyond their traditional roles and work in pairs / or other partnerships.
In addition, aspects of local workforce context will depend upon the way in which personalised care and support planning is delivered locally and for which groups of people, e.g.
Local pathway design and administration (use of risk tools, registers, audit and monitoring and reporting)
Local accountability for quality assurance and reporting for the population registered for personalised care and support planning
Joint PCSP: Key roles
What does the workforce need to know?
- Everyone should understand the whole personalised care and support planning process; including the philosophy, and be able to explain the purpose and process to the person, and their own role
- Everyone involved in personalised care and support planning needs to be trained to support their role. A key conclusion of this work is that training is best undertaken within each team - to ensure the flexibility of roles and functions that are needed by people with complex needs.
- Knowledge and skills in person-centred practices, for example one-page profiles.
- Learning about what works needs to be provided using methods which model the personalised care and support planning approach itself i.e. solution focussed, recognising assets and strengths of the learners and local community
- It is the responsibility of the practitioner to reflect on their style of consultation / conversation and assess how it is supporting the person
- Embedding new habits / skills takes time and support for self refection and reinforcement needs to be provided using a facilitation approach
Models of learning delivery
- A variety of models could incorporate these principles
- E.g. Blended learning providing e-learning about person-centred thinking and face-to-face sessions to embed attitudes and practice skills.
As roles become flexible, decision making is delivered closer to the person and specialist skills become spread - formal arrangements within teams for supervision and support will become more important.
Using a person-centred approach within a supervision model and embedding person-centred principles and practices is an essential component of changing the underlying philosophy of care delivery.