New guidance to support integrated and person-centred care for people with health and social care needs has just been launched reveals TLAP's Programme Director Dr Sam Bennett.
Personalised care and support planning (PC&SP) is part of a different relationship being forged between people with health and care needs and the services they access. It is set out as a legal right in the Care Act 2014, alongside personal budgets, for everyone with eligible social care needs, including carers and it is central to the vision of the future NHS.
It is also a key ingredient in a variety of transformation programmes, grappling with issues of integration, improvement and sustainability across the NHS and local government, including New Care Models, Pioneers and Integrated Personal Commissioning.
Personalised care and support planning reflects a shared consensus that current models of health and care are no longer fit for purpose and incapable of dealing with the changing and increasingly complex needs of the people and communities they serve. People often find services fragmented 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 TLAP (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 towards 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. The statutory 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.
Similarly, the Five Year Forward View 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". This has 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."
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.
Through Integrated Personal Commissioning, nine demonstrator areas are working with different cohorts of people with complex needs to test a joined up model for redesigning health and social care that prioritises personalised care planning, with access to personal budgets for many more people. The IPC model describes the importance of an evidence based, tailored approach to planning, delivered through a single point of contact and leading to a single, personalised plan, developed through a shared decision making approach.
As with the new care models programme, this will need to involve multi-disciplinary teams working within a person-centred culture if it is to deliver the transformatory change intended.
That's why TLAP has launched a web-based resource that will support these models. It 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 journey's 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.
We are inviting feedback on this beta version ahead of a final version later in the Autumn so please let us know your views. The consultation ends on the 30th October. There will be a series of webinars to showcase the tool. The first of these webinars will take place later this month on 21 October 4-5pm.
6 comments
Comment by termite posted on
Treat folk like real people not objects that need processing, one cover will never fit all!
Comment by Ms Theresa Kimber posted on
If you move sick Elderly people from Hospital to home, you must also let the money follow with them. The transfer home prevents bed blocking and the person still needs a care package to assist full recovery at home. This is the crucial part of individual needs been met and one expects Community services to be prepared for this. Current evidence proves a breakdown in communication has resulted in some Patients being re- admitted to Hospital. More care in the home more money in the community from Hospitals.
Comment by Karl J Womack posted on
I was told by the previous government this was too expensive what has changed?
Comment by Hayley Smallman posted on
This is very much long overdue as the stress of juggling multi services while caring 24/7 can really take its toll. I would really love to see this approach rolled out into children's services Snd for education to vein lauded rather than us having to have a EHCP plus if you want a PHB then you have to do it all over again but excluding education??? Doesn't make sense.
Comment by Mrs Maureen RichardsMBE posted on
The aim has been around for many years to have an integrated person centred plan for people with complex needs.
But although this on paper sounds better for the individual the change from provider to purchaser is where this plan is difficult to perfect, when there is limited care to purchase flexible care for the person to purchase.
This is where there are few options out there, the only way to achieve flexability is for the person to become the employer but this comes with many a headache with advertising, interviews, holidays and sickness cover.
Also when a team is in place in order to keep this team in place is not easy on a limited budget to sustain this plan with wage increases and long term support of the team.
Comment by joyce brand posted on
I am afraid that when it comes down to it the frail, tired, and traumatised just out of hospital person is usually not up to facing the complexity of what is being described and as for teams, the chances of them all being together at a given time is not good. Old fashioned as it will sound I would support the idea of the individual helping person, who ever that should most appropriately be, gathering the essential information - email, internet or even telephone and then putting it into a coherent form and discussing and making change in dialogue with the individual needing the help.