How personalised care works
Personalised care consists of six components:
- enabling choice, including legal rights to choice
- shared decision making
- personalised care and support planning
- social prescribing and community based support
- supported self management
- personal health budgets.
Enabling choice
Part of enabling choice is to provide patients with information about their condition, in language which can be understood. This will help you recognise the choices you have and how they may it impact on you.
Shared decision making
Shared decision making aims to acknowledge ‘patient knows best’ and allow the health professionals to hear the patient's:
- personal preferences
- values
- beliefs
- circumstances, and
- goals.
In personalised care, the patient has input into the care they receive. There are new roles being embedded within both primary care networks and secondary care, who are there to build a positive relationship with you and explore the goals relating to your health that you both want to achieve.
Health professionals will provide their expertise and advice regarding
- treatment options
- what the evidence suggests
and the risks and benefits of each in language the patient can understand.
By combining the ‘patient knows best’ and the ‘expertise of health professionals’ the professionals and you can make health decisions together.
Personalised care support plans (PCSP)
When you are working with a health professional towards a recognised goal, a personalised care support plan will be created.
This focuses on ‘what matters to me?’ meaning the plan will pay attention to your needs and wider health and wellbeing. A copy of this will be made available to you.
The patient is central in developing their PCSP. Time is given to explore and develop this, considering what goals are to be achieved, for example:
- lose weight
- reduce blood pressure
- increase social relationships.
The PCSP is flexible and unique to each individual.
The plan will include how these goals will be achieved and will be reviewed regularly by yourself and your health professionals. During these reviews, you can reflect on your progress and change your goals if you wish.
Social prescribing and community-based support
The social prescriber's role is to support patients with social factors impacting on their overall wellbeing and quality of life.
Social prescribing link workers, will offer you time to explore goals which will then be reviewed. They can offer ongoing support for approximately six sessions if needed. The aim is to help you to improve your overall quality of life by connecting you with your local community.
Some of the things social prescribers can help with include:
- financial difficulties
- benefits advice
- immigration support
- social isolation
- loneliness
- increasing activity levels
- starting a new hobby
- weight loss
- accessing support groups.
Social prescribers use the personalised care approach to support patients. They offer the time needed to explore your goals and work together with you to create a personalised care support plan (PCSP).
Part of the PCSP will include any community services who are able to offer support needed to help you achieve your goals.
The social prescriber will have extensive knowledge of specialised services within your local community. By focusing on ‘what matters to you’ and using the shared decision making approach they will help you to connect to the right services. This might include introducing you to the service personally, making the referral for you, or simply signposting and providing the details needed.
Social prescribers can be accessed via your GP practice. There may be other roles within secondary care and local community who offer a similar role, such as community connectors, who are based in mental health services and work solely with those accessing the service.
If you wish to speak with social prescriber, please contact your GP practice to self-refer and ask for an appointment.
Supported self-management
Self-management is a term used to include actions taken by individuals to recognise, treat and manage their own health. They may do this independently or in partnership with the healthcare system. The aim being to protect their own health and be able to manage long-term health conditions.
Self-management education is a form of education or training for people with long term conditions, which focuses on helping them to develop the knowledge, skills and confidence they need to manage their own health care effectively. This may be an education programme on diabetes or long-Covid, for example.
Health and wellbeing coaches (HWBC)
If you require additional support in order to change your behaviour, for example increasing activity levels, there maybe support from a health and wellbeing coach who is trained in behaviour change approaches.
An HWBC help can support patients to
- lose weight,
- increase activity,
- leave the house etc.
One of the ways they support individuals is through goal setting and measuring progress. This helps to empower people to take control of their own life choices and so improve their health.
You can speak to a HWBC by contacting your GP practice and asking for an appointment. If your GP practice does not yet have a HWBC your Social Prescriber should be able to offer some support.
Personal health budgets
A personal health budget is an amount of money to support someone’s health and wellbeing needs. This is planned and agreed between you or your representative and the local clinical commissioning group (CCG).
It is not new money, but rather a different way of spending health funding to meet the needs of an individual.
Personal Health Budgets are a way of personalising care, based around what matters to people and their individual strengths and needs. The budget gives disabled people and people with long term conditions more choice, control and flexibility over their healthcare.
Some people have the legal right to have a personal health budget. This includes patients who are eligible for NHS continuing healthcare, those with a learning disability, people eligible for a wheelchair and soon to be extended to those eligible for section 117 aftercare under Mental Health Act.
A personal health budget may be used for a range of things to meet the agreed health and wellbeing goals. This can include therapies, personal care equipment. This may consist of a one off payment or regular payments depending on what it is the person requests. There are however some restrictions in how he budget can be spent, more info can be found on www.england.nhs.uk
To access a personal health budget the patient and their key worker or health professional, will create a personalised care support plan in addition to the PHB application. This will be submitted and the patient will receive a pre-paid card or direct payment with support on how to access the funds. Your key worker, health professional will be able to offer you further advice. In some areas such as CAMHS they are introducing Care Navigators, or PHB advisors to take on this role.