Personalised care is about finding out ‘what matters’ to patients and the people you are caring for. It happens when we recognise the person as the most important part of their own care and support them to be an equal and active partner in their health and wellbeing.

A personalised care approach enabled more meaningful and effective conversations, improving outcomes, delivering better results, and helping to reduce demand for services.

It means you can get a fuller picture of someone’s life, so you can build on their strengths and support them to live as independently as they may wish.

This could look like:

  • Practical support to give them more choice and control
  • Building on someone’s knowledge, skills and confidence
  • Finding solutions and breaking down goals into manageable steps
  • Creating care and treatment plans with their life at the centre
  • Talking about the things or outcomes that matter most to them.

For more information on training and events, visit: https://www.bucksoxonberksw.icb.nhs.uk/your-health/personalised-care-training-and-events/

Find out more about the elements of Personalised Care below.

It is important that people know that it is ok to ask questions about their own health and care.

‘Shared decision making’ is a term used by the NHS to describe a collaborative process, whereby health and care professionals work with patients to reach decisions about their care and treatment.

Shared decision making supports people to make better, more informed decisions. It also means you can give the best advice and care.  

During conversations with patients:

  • Ensure they feel a part of the conversation
  • Encourage them to ask their own questions and allow time for them to do so
  • Ask ‘what matters to you?’
  • Write things down or offer clarification
  • Let them know its ok to bring in a family member or friend if they want to
  • Share decision making and help people make choices that are right for them.

There are a selection of decision support tools to assist you working with patients who have certain conditions: https://www.england.nhs.uk/personalisedcare/shared-decision-making/decision-support-tools/

A personal health budget is an amount of money allocated by the NHS to support a person’s health and wellbeing needs. This is planned and agreed between the person (or someone who represents them) and the NHS. It is not about creating new money, but it may mean spending money differently.

It allows people to manage their own healthcare and support, such as treatments, equipment and personal care, in a way that suits them.

Those eligible for a personal health budget are:

  • People receiving NHS continuing healthcare (NHS-funded long-term health and personal care outside hospital)
  • People with mental health problems who are eligible for after care services under Section 117 of the Mental Health Act
  • People who meet the eligibility criteria for a personal wheelchair budget.

NHS England video on Personal Health Budgets: https://youtu.be/LtlYhaTURBQ

Patients may ask you about personal health budgets. Your local wheelchair, mental health and All Age Continuing Care (AACC) services will be able to able to speak to patients about this. Resources from NHS England are also available here: https://www.england.nhs.uk/personalisedcare/personal-health-budgets/

‘Supported self-management’ refers to the different ways that health and care services, including the NHS, can support people to manage their long term physical and mental health conditions.

Supported self-management will look different to everyone, but the intention is to improve health and wellbeing outcomes by giving people a choice over how their care is planned and delivered.

Working with patients to find out their individual strengths, preferences and needs, as well as taking into account inequalities or accessibility barriers, so you can offer specific and relevant support.

This could be:

  • Health coaching: helping people gain and use the knowledge, skills and confidence needed to actively participate in their own health and reach their self-identified goals.
  • Self-management education: formal education or training for people with long-term health conditions.
  • Peer support: bringing together peers and people with similar long-term conditions, to share experiences, grow understanding, and aid self-management or recovery.

People often visit their GP because they are feeling stressed about their work, have money worries, are lonely and isolated, or they are grieving as someone close to them has died. All these things have a big impact on our physical health and mental wellbeing. These problems cannot simply be fixed by taking tablets and a medical approach alone.

Social prescribing aims to provide support that looks at the person as a whole, not just their physical or mental health needs. Considering someone’s physical, emotional, social and spiritual wellbeing and finding solutions to the causes of their problems.

A social prescribing link worker may be part of your General Practice team, under the Additional Role Reimbursement Scheme (ARRS). In most cases, a GP or another member of the practice team will refer a patient to a social prescribing link worker. They support a wide range of people, including teenagers, adults and families, by unpicking issues they may be facing and giving them time to focus on what matters to them.

This often means connecting people to community groups or activities which can provide practical and emotional support, or enable people to take greater control of their health and wellbeing.

Social prescribing can help people who:

  • have one or more long-term condition.
  • need support with their mental health, such as stress, anxiety and low mood.
  • are lonely or isolated.
  • have complex social needs which affect their physical health and wellbeing.
  • visit their GP and hospital very frequently, because they’re not sure who can help them.
  • are not confident to manage their own health and need support.
  • are looking for support, guidance and motivation to make lifestyle changes.

Transformation Partners in Health and Care video on Social Prescribing: https://youtu.be/HkBorjikoJk

It can be frustrating for people to repeat their stories to different health and care professionals or teams – particularly for patients with long-term health conditions or those with complex needs. A personalised care and support plan can help with this.

It is a record from the patient of the things they feel are important to share with you and other professionals. It is a way of summarising what matters to them, such as information on their strengths, values, preferences, or concerns.

The plan moves with the patients, as they go between services and have contact with different people in the system. It tells their story so they don’t have to.

An individual may have a number of plans, all with an ‘About Me’ section. This can help you and your patient by:

  • Ensuring they are at the centre of their own care
  • Helping you get to them through
    • Providing an up to date record of their changing circumstances or wishes
    • Providing a record of their skills, strengths, experiences and relationships
    • Sharing important information on what matters to them

People who would benefit from a personalised care and support plan are those who have a long-term or chronic condition which involves regular contact with health and care services, annual reviews, and/or regular appointments with different organisations.

You can find more information on the benefits and design of a personalised care and support plan at: https://www.england.nhs.uk/personalisedcare/pcsp/