Personalised Care

What is personalised care ?

‘Personalised care means people have choice and control over the way their care is planned and delivered. It is based on ‘what matters’ to them and their individual strengths and needs.

This happens within a system that makes the most of the expertise, capacity and potential of people, families and communities in delivering better outcomes and experiences.

Personalised care represents a new relationship between people, professionals and the health and care system. It provides a positive shift in power and decision making that enables people to have a voice, to be heard and be connected to each other and their communities.’ (NHS England » What is personalised care?)

The short animation below further explains what personalised care means for people, professionals and the wider health and care system.

For full details of the personalised care training offers, and how to book, please click here, or read on to find out more about personalised care.

Personalised care is one the five major changes in the NHS Long Term Plan. It is a response to the most pressing issue of the time, health inequalities, enabling delivery of tailored care that better meets the needs of those excluded by a “one size fits all” approach.  

Personalisation is a fundamental shift in our care model in three important (and inter-related) ways

• Broadening the medical model  –  to a bio-psycho-social model, that conceptualises care as more than treatment
• Defining value differently – looking to improve people’s health and wellbeing in ways people value (not in ways the system values)
• Creating Variation – moving away from “one size fits all” pathways and services to diversify delivery models to meet people’s differing capabilities and goals

This shift is founded on a different relationship with patients. In a personalised model there is partnership between patients and professionals. There is mutual respect, openness, joint agenda setting and positive risk taking. The system is designed around this relationship, able to  accommodate differing needs, preferences, priorities and capabilities. Responsibility for creating “health” lies with both patients and professionals and is co-produced together.

The NHSE Comprehensive Model provides a practical framework for delivery. It encompasses 6 implementation workstreams and vital enabling activities that support personalised practice. (clicking on the hyperlinks below will take you through to more information on each point)

1. Shared decision making
2. Personalised care and support planning
3. Enabling choice, including legal rights to choice
4. Social prescribing and community-based support
5. Supported self-management
6. Personal health budgets and integrated personal budgets

Personalised care (NHS England » What is personalised care?):

• improves people’s health and wellbeing, joins up care in local communities, reduces pressure on stretched NHS services and helps the health and care system to be more efficient.
• helps people with multiple physical and mental health conditions make decisions about managing their health, so they can live the life they want to live, based on what matters to them, as well as the evidence-based, good quality information from the health and care professionals who support them
• recognises that, for many people, their needs arise from circumstances beyond the purely medical, and will support them to connect to the care and support options available in their communities.
• brings six different parts of the health system together based on a growing evidence base of what has worked in shared decision making, personalised care and support planning, enabling choice, social prescribing and community based support and personal health budgets and integrated personal budgets.

A fantastic personalised care toolkit can be downloaded for free by any staff in Primary care in Gloucestershire at: https://health-coachingacademy.com/gloucestershire-2022-personalised-care-toolkit/

Why is personalised care important to Primary Care ?

Personalised care is important to the whole system and all our patients and communities, but this is especially true in Primary Care. Around 30% of patients have a long term physical or mental health condition, and these patients account for 50% of all GP appointments.

The Primary Care Network (PCN) directed enhanced service (DES) and the Impact and Investment Fund indicators were designed to support the ‘triple aim’ of:

• improving health and saving lives (e.g. through improvements in medicines safety)
• improving the quality of care for people with multiple morbidities (e.g. through increasing referrals to social prescribing services)
• helping to make the NHS more sustainable.

In all aspects of the triple aim personalised care can support both our patients and our staff. The Impact and investment fund (IIF) domains include further areas which can be directly supported by adoption and spread of personalised care including:

• Improving prevention and tackling health inequalities
• Support better patient outcomes in the community through proactive primary care
• Support improved patient access to primary care services
• Help create a more sustainable NHS

(For full details on IIF please see the following guidance: NHS England » Primary Care Networks – plans for 2021/22 and 2022/23)

Personalised care can be the golden thread to support many of these areas and it is specifically mentioned in the recent Fuller Stocktake report as being of importance in Primary Care, and supporting personalised continuity of care. To view the report please click here. Primary Care has seen the introduction of personalised care roles in the additional roles reimbursement scheme (ARRs) including social prescriber link workers, care co-ordinators and health and wellbeing coaches (for more details on these particular roles please click here. However for personalised care to really be effective it needs to be everyone’s responsibility.

The video below is by Dr Ollie Hart, from Peak Health Coaching, who is also a GP Partner and PCN Clinical director. It aims to bring personalised care to life.

How does personalised care fit within the wider Gloucestershire system?

Personalised care is a system shift. This graphic shows the tiers of activity to make a system work in a personalised way.

It impacts activities across the system- in provider and commissioning organisations including social care and VCSE partners.  People across the system are involved in enabling this shift, embedding a personalisation mindset in their work area whether this is how we use data, design services, develop the workforce, work with communities, or measure value.

This graphic shows the tiers of the work. At the centre is health care professional behaviour, building out to how we design the pathways in which they work.

Ramping up this system shift is set to be a priority for the Gloucestershire ICS.  The programme of work is overseen by the ICS Personalised Care Strategy Board which has membership from partners across the system including primary care.

Aims and objectives of this board include:

• Supporting a co-ordinated and joined approach to personalised care across partners in Gloucestershire
• Develop a strategy to ensure we have the right skills in the workforce to maximise personalised care
• Upskill people to have choice and control over their health and wellbeing Promote the use of the ‘What matters to Me’ (orange folder, see picture below)
• Build leadership capacity around personalisation
• Deliver personalised care to specific populations eg High Intensity Users

Local personalised care initiatives

Below we have highlighted a local initiative called ‘What matters to me’ folder (WM2M) which has been piloted in several PCNs in Gloucestershire, demonstrating how personalised is already being integrated within the heart of Primary Care.

Please find a link to a thought provoking video called ‘Risking happiness’. This was jointly commissioned by the Gloucestershire ICB and Gloucestershire County Council.

What training is available ?

Personalised conversation between professionals and patients is as the heart of the personalisation shift. It is in consultations that partnership relationships are built, and goals agreed that drive tailored care. 

 Ref: Wolever, R. et al, (2013). “A systematic review of literature on health and wellness coaching: defining a key behavioural intervention in healthcare.” Global Advances in Health and Medicine, 2 (4), 38-57

For this reason upskilling the workforce in how to have truly personalised conversations is a priority.

For full details of the personalised care training offers, and how to book, please click here.