About personalised care and support

Personalised care and support planning is a is a collaborative process between equals, whereby people with health and care needs, along with their family and/or carer, work together with care practitioners to discuss what matters to them and what they want to achieve, identifying objectives that are personal to them as well as meeting health needs. This can include working out the best treatment, or care and support option as well as things the person can do themselves to manage their needs better.

A personalised care planning process should reflect people’s whole life needs, preferences and self-determined outcomes, while incorporating the clinical and professional expertise needed. The approach is essential to better supporting people living with long term physical and mental health conditions to develop the knowledge, skills and confidence to manage their own health, care and wellbeing. Personalised care and support planning should be a planned and continuous process, not a one-off event.

Person-centred care and support planning is mandated in the Care Act, including the provision for combining plans across health and care. The statutory guidance describes the guiding principle in the development of a plan being that the process, “ should be person-centred and person-led, in order to meet the needs and outcomes…built holistically around people’s wishes and feelings, their needs, values and aspirations.”

Personalised care and support planning is also central to the “House of Care” model, which describes the full range of supporting conditions that need to be in place to ensure a systemic approach for people with long term health conditions.

Learning from implementation in a variety of settings suggests that to be most effective personalised care and support planning should:

  • Be supported by good prior information for people and professionals about what is involved and the intended benefits.
  • Involve the right people, which could mean a carer, family member, peer or advocate, a health professional, social worker, voluntary sector planner, or independent broker.
  • Focus on outcomes and leave room for creativity in how they are met, not beginning from assumptions about the services people need.
  • Cover everything the person needs to live a good life, not just the treatments or services they draw upon.
  • Take an enabling approach to risk and how it is managed, making clear contingencies where necessary.
  • Where developed as part of a personal budget process, start with an indicative allocation already identified.
  • Produce a plan that is owned by the person, reflecting them as an individual. This should build on existing services, including within social care, general practice and education.

The Year of Care programme demonstrated that where personalised care and support planning is embedded in practice it is highly valued by healthcare professionals, leads to improvements in clinical outcomes and is cost effective. The Cochrane Review on personalised care planning found that personalised care planning plus appropriate follow-up support leads to improvements in certain indicators of physical, psychological, and subjective health status, and people’s capability to self-manage their condition. Evaluation of the Year of Care and Co-Creating Health Programme’s also highlighted a number of benefits to commissioners, including:

  • Greater value for money, as services provided meet individual needs, deliver improved health outcomes and reduce medicine wastage
  • A measurable assessment of an individual’s needs or goals to guide commissioning of appropriate services
  • A positive impact on other local and national drivers, e.g. reducing acute admissions and improving the patient experience

A means of recognising the renewable energy that patients, carers and communities can bring to supporting long-term conditions care.