Scenario 1: Jim (and his daughter) have the personal care and support planning conversation with his GP
Following the preparatory discussions at home, Jim is clear about what is important to him and what he would like his outcomes to be. These include getting out to church, going on family holidays and having a new cat flap put in, all of which he feels that he can think through himself.
They look at his health and explore rationalising his tablets, deciding to stop specialty appointments and discussing whether he might have another stroke and what he can do to prevent that from happening.
They also discuss whether he would like to make some written directions for treatment and care should he become unable to express his wishes.
Jim and his daughter would also like help with thinking through how best to organise things at home now he has less mobility and have worked out some ideas already.
They talk about the health and social care resources that are available to Jim as a personal budget and begin to discuss how he could use this to achieve his identified outcomes. They discuss who in the practice multi-disciplinary team could help him to do this.
The conversation is continued at home with the team member who is able to support the majority of this.
Scenario 2: Jim (and his daughter) have the personal care and support planning conversation with the social worker
Following the preparatory discussions at home, Jim is clear about what is important to him and what he would like his outcomes to be. As in scenario one, these include, attending church, family holidays and installing a new cat flap.
All of which he believes he can work out himself.
Jim has chosen to have the personal care and support planning conversation at home with the social worker who arranged emergency support and who he and his daughter already know. S/he has all the up to date information from the GP, district nurse, rehab team and hospital discharge.
Jim and his daughter would like help with thinking through how best to organise things at home in the longer term now he has less mobility and they have already worked out some ideas.
The social worker has explained that Jim will now be eligible for a personal budget to help meet his health and social care needs, through the local approach to Integrated Personal Commissioning. They take Jim's ideas as the starting point and make sure everything that is important to Jim is included in his goals and the outcomes.
The social worker talks through Jim's questions about his future health, whether he might have another stroke, what he can do to prevent this and if he can record what he would like to happen if he should become unable to express his wishes. He wonders if stopping some tablets might make his outcomes easier to achieve, if he still needs his specialty appointments and whether the district nurse could call at more convenient times.
The social worker agrees to check these points with the GP and district nurse and link him directly with the team member who can carry on the conversation about how to design and manage his personal budget. They agree to review it all together in a couple of months' time to check everything is working well.
Personal care and support planning can be organised in a number of ways to suit local circumstances.
In the example described here, Jim chose the social worker to discuss all his issues with to continue the established relationship and because he and his daughter felt that issues of daily living would now dominate his life.
The example assumes that the social worker is part of an effective multi-disciplinary team with a good understanding or each other's roles and issues. This makes it easy for her/him to check Jim's list of health issues with the GP, find out the options for his dressings with the district nurse and make sure that the team member, who works with Jim to design his personal budget, has the right skills and understanding.
The aim is to avoid multiple appointments and new people for Jim, while ensuring easy access to the right range of advice within the surrounding team as needed.
Other alternatives are for the social worker to make a separate appointment for Jim with the GP, or for the GP to have the initial personal care and support planning discussion, (Scenario 1) so issues of prognosis and management of the health issues are woven into his thinking and development of his outcomes right from the start.