Personalised Care

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According to NHS England Personalised Care:

means people have choice and control over the way their care is planned and delivered, based on ‘what matters’ to them and their individual strengths, needs and preferences

and

will benefit up to 2.5 million people by 2024, giving them the same choice and control over their mental and physical health that they have come to expect in every other aspect of their life. A one-size-fits-all health and care system simply cannot meet the increasing complexity of people’s needs and expectations. Personalised care is based on ‘what matters’ to people and their individual strengths and needs. The NHS Long Term Plan says personalised care will become business as usual across the health and care system and Universal Personalised Care confirms how we will do it.

According to the BMJ Editorial on the new personalised care plan for the NHS Personalised Care:

is much more than "being nice." It describes a fundamental shift towards recognising that people who use health services can also help solve problems and take control.

NHS England has published the Universal Personalised Care: Implementing the Comprehensive Model action plan, which sets out more details and planned actions that were outlined in the Long Term Plan.  Section 2.2 sets out the details of the six components that make up the entire Personalised Care model - see below a summary of the Social Prescribing section.  Importantly, NHSE have stated the commitment to create the balance between specifying a national, consistent standard and enabling flexibility for local adaptation and implementation.   

Also now available is the NHSE The Social Prescribing Summary Guide which outlines what good social prescribing looks like for people, communities and systems, and includes a link worker job description, a check-list for commissioners, and a Common Outcomes Framework.

The Social Prescribing Model Page 21-23

Social prescribing and community-based support: Enables all local agencies to refer people to a ‘link worker’ to connect them into community-based support, building on what matters to the person as identified through shared decision making / personalised care and support planning, and making the most of community and informal support.

Design principles:

A local social prescribing scheme must:

1. Be appropriately funded and supported by local partnerships of commissioners and primary care networks.

2. Receive referrals from all local agencies, including General Practice.

3. Involve a one-stop social prescribing connector service, typically located in primary care, which employs link workers to give people time and personalised support, connecting them to community support, based on what matters to the person

4. Connect people to community groups and voluntary organisations that are supported to receive referrals.

5. Put in place operational protocols about expected priority groups, expected numbers of referrals, workforce, costs, and effectiveness.

6. Have access to a range of community-based approaches providing peer support, advice, increased activity and access to community-based support.

Standard model:

• Social prescribing connector schemes are commissioned collaboratively, with primary care networks, local authorities, CCGs, other local agencies, the voluntary and community sector and people with lived experience all working together.

• There is a clear and easy referral process from GPs, GP practices and other channels, to social prescribing link workers. Self-referral is also supported.

• Link workers are typically located in primary care through primary care networks, as part of a wider network team.

• Link workers receive accredited training and ongoing development to support their role.

• Link workers give people time and start with ‘what matters to you?’ They coproduce a simple plan or a summary personalised care and support plan as per the standard model (see page 19-20), based on the person’s assets, needs and preferences.

• There are up to five link workers per primary care network, supporting up to 3% of the local population, or around one full-time equivalent link worker per 10,000 local population.

• Link workers work with people on average over 6-12 contacts, and hold a caseload of a minimum of 200-250 people per year.

Local areas should have:

• A clear understanding and map of existing communities, community assets, high impact interventions and gaps.

• A whole-system strategy to develop community-based approaches.

If social prescribing and community-based support is delivered according to this standard model, our indicative expectation is:

• 100% of GPs and GP practices are able to involve link workers in practice meetings and making referrals to them.

• 90% of link workers have received accredited training and feel confident in carrying out their role.

• 80% of people take up their social prescription after referral

• There is a positive impact on GP consultations and A&E attendances and wellbeing for those referred, achieving:

o 14% fewer GP appointments

o 12% fewer A&E attendances.