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/

Elements of Personalised Care

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/

Case Studies

Nina's story - watch on YouTube

During her first pregnancy, Nina experienced a lot of problems relating to both her physical and mental health. Because of how difficult her pregnancy was, she didn’t think she’d want to have any more children.

Now, after her second child, Nina reflects on how personalised care helped her change her mind.

“With my first pregnancy, I had a lot of physical and mental health problems. If it wasn’t for the personalised care I received after the birth of my son, I don’t think I would have gone on to have another baby.   

“I suffered a lot with my mental health the first time around. Because I didn’t have consistency in who I was seeing, it was quite traumatising to keep repeating my concerns. A few weeks before my baby was due, I developed a fear of giving birth. Whilst I had been reassured that my labour wouldn’t last longer than 8 hours until I was offered a c-section, it actually ended up being 48 hours before someone saw this in my notes.   

“After the birth, I started to experience really intrusive thoughts, really worrying thoughts, probably on the border of psychosis, about harming the baby. I couldn’t hold the baby because every time I did, the thoughts would get worse… I was afraid to speak about what I’d been thinking in case they’d take the baby away and even lock me up.   

“It took about 3 or 4 months for me to actually speak about it. In this time, I’d been discharged from mental health services because I pretended I was okay because of fear of what might happen. I ended up raising it in a routine follow up. That was when I started to receive excellent, personalised care. This changed my whole experience.   

“The mental health team reassured me that my symptoms were normal and helped me understand what I was going through. I didn’t want to take medication right away, which they supported. I ended up doing therapy first. Because of this support, I came to feel comfortable with the idea of being pregnant again.   

“Everything was a lot different from when I had my youngest. I had the same midwife the whole time and felt empowered to ask questions… Afterwards, I didn’t suffer with any mental health like I did before. I believe this is all because I had personalised care … I could speak with someone about what choices I had and we worked it out together.  

“My midwife knew my concerns about gestational diabetes which runs in my family. I believe I had this during my first pregnancy as I gained a lot of weight and suffered with pelvic girdle pain. With my second baby, my first test came back negative, but we did another – and it was picked up this time around. I was able to get treated and didn’t experience the issues I’d had before.   

“I ended up just having a few check-up calls to let my team know everything was fine. Even though personalised care requires a lot of time in the short-term, in the long run I believe it actually saves time. This time around, I got to focus on being a mum and taking care of my baby.’’   

Laura's story - watch on YouTube

Previous mental health support left Laura feeling disheartened and like she had to fight for her care. But recently, she has experienced personalised care for the first time.  

With support from a dedicated team who know her story, Laura is now actively involved in decisions and discussions around managing her mental health – a change which she describes as ‘lifesaving’.  
“I have depression and bipolar type 2, which means I go through extreme mood cycles. This ranges from elation to severe depression,” explains Laura.   

‘’At my very lowest I was very serious about not wanting to be here anymore… Because the depression can be so bad, I just want to be asleep to get away from it.   

“When I moved to my current mental health service, I wasn’t in a good place and needed dedicated support to help me get better. For the first time, I received personalised care that was based on my own needs and experiences. I have been supported by my team to make decisions about treatment and have learnt to understand my mental health a lot better.  

“Whilst it’s important listen to healthcare professions, it’s also important to ask questions about your own health. Previously, I saw a different consultant every time, which meant I’d have to say my whole story again. They didn’t seem to read the notes, which was quite distressing, to have to start again every time. They would all suggest different treatments, different medications.  

‘’Recently, I’ve had very good care, which I’d say is very personalised care… They work together as a team and have discussions, so then we all know what is happening.  

‘’Together, my doctor and I weighed up different medication options and we created a personalised crisis plan for when I’m feeling low at home. It contains the phone numbers of friends, family and services who have helped me in the past. There’s also a plan of what to do when I can’t get out of bed – we figured out really specific steps that work for me.  

“When I’d felt low in the past, I contacted a crisis team for help and they ended up discharging me without my knowing. My depression sometimes makes me feel frozen, with even small tasks seeming impossible. That’s how I felt then. But I still had to fight for a follow up on my own care.   

“Now it’s a lot easier. I feel like I have a safety net, but I rarely actually call on professional help. I can now manage my own mental health because I understand it. Without personalised care, I could have got to a point of hurting myself and would have needed much more intensive support. Lots of people would have had to take care of me. My care has been lifesaving and it’s helped me get to the bottom of things a lot quicker, which actually saves more people being involved.”