Local people have told us they want more choice and control over their own health and care. We recognise that personalising care is key to this.
One of our system principles is too 'ensure each individual makes decisions to optimise personal value'. In order to provide the right environment for this to become a reality local health and care leaders will put assurances in place to verify that services are set up so that people are able to make decisions that allow them to maximise the value of that service to them, and are enabled to make decisions that keep them healthier for longer.
We are committed to changing the relationship between people and the health and care system, from one which asks, 'What is the matter with you?' to 'What matters to you?'
Personalised care is fundamental to the changes we are seeking to make over the coming years – to deliver better health and wellbeing for local people in the Black Country and West Birmingham; by supporting people to achieve the outcomes in their personalised care plan, better quality and experience of care that is integrated and tailored around them; and more sustainable NHS services.
By understanding people’s individual needs and personalising their care we can improve their health and wellbeing, reducing dependence/demand on statutory services. By introducing Personal Health Budgets people have more control over the services that they receive and also ensures that patients are supported to be active participants in managing their condition(s) through self-care.
Our aim as a Personalised Care Demonstrator Site is to co-produce the solutions to increasing personalised care.
Our objectives are:
- To develop the workforce in line with the comprehensive training schedule to improve skills, knowledge and experience to deliver personalised care.
- To support service development, in partnership with stakeholders, to ensure the implementation of new approaches to care delivery e.g. Shared Decision Making, Personalised Care and Support Planning, Health Coaching.
- Strengthen peer support through the delivery of facilitation training through the local Community and Voluntary services.
- To work as a system to personalise end of life care to support people to die in the place they have chosen.
People will have more choice and control over their health and care. As we implement the comprehensive model for personalised care, including:
Shared process with health and care professional and the person to help support people to reach a decision about their treatment.
Personalised Care and Support Planning is a series of conversations in which the person (or those who know them well) are involved in discussions about the management of their health and wellbeing within the context of their whole life and family situation. It recognises the person’s skills and strengths as well as their experience and the things that matter the most to them. It addresses things that aren’t working in the person’s life and identifies outcome and actions to resolve these.
Enables people to have choice of provider (who delivers the service) and access to services that better meet their needs. This includes people’s legal rights to choose where they go for an outpatient appointment, and a suitable alternative provider if people are not able to access certain services within the national waiting time standards.
Social Prescribing and Community Based Support helps people to improve their health, wellbeing and social welfare by connecting them to community services which are usually locally run. An example being signposting to dementia support groups, or supporting people to get involved in community activities.
Includes Health Coaching, peer support, self-management, and self-management education. Health Coaching helps people gain and use the knowledge, skills and confidence to become active participants in their care in order to reach their wellbeing goals. Peer support is a range of approaches through which people with similar long term conditions support each other to better understand their condition and aid self-management. Self-management education is any form of formal education for people with long term conditions focused on helping them manage their own health care effectively.
Personal Health Budgets (PHBs) are a way of personalising care based around what matters to people. A PHB is an amount of money to support the identified health care and wellbeing needs of an individual. A PHB enables people to have choice and control over decisions about their care and the budget that is available to meet their needs.
Our Plans include the following:
- Continue to train our workforce in Personalised Care and Support Planning (PCSP) and Health Coaching
- People registered as having a Long Term Condition will have a Personalised Care Plan as part of their annual review
- Deliver “train the trainer” training programme, growing resilience across the system
- The system will release a multi-disciplinary team to engage with the national Shared Decision Making Programme. This team will support the Personalised Care leads with the introduction and spread of Shared Decision Making.
- Increase the utilisation of the Patient Activation Model tool (or approved equivalent) to support the measuring of the impact of Personalised care on an individual’s health and wellbeing.
- We will support the development of a group of Clinical / Professional Champions to promote and engage staff to adopt the Personalised approach.
- We will deliver, along with our Clinical Champions, a number of wide-scale engagement events to promote Personalised Care across the STP.
- Explore PHBs for high intensity users and integrated personal budgets for children and young people with complex needs and Education Health and Care (EHC) plans.
- Expand PHBs for people with Section 117, wheelchairs and High intensity users. We have recently introduced a scheme in conjunction with National Express whereby patients under a S117 can use a PHB to purchase a bus pass, at a negotiated price, to enable them to access services across the area.