Getting people on board

Personalised Care and Support Plan
1.
info icon

About this toolkit

2.
Icon for Diabetes test

Getting to grips with the standard

3.
noun-speaking-people-2808150-FFFFFF

Getting people on board

4.
icon of clip board

Taking stock and planning

5.
icon of health record

Putting the standard into practice

6.
icon of resources

Shared resources and learning

Getting people on board

People often believe that adopting standards for digital information sharing is about ‘getting the tech right’. In fact, getting people on board is a key element of successful standards adoption and the culture change required to make it happen. This part of the transformation initiative demands thorough attention and planning.

To effectively engage people, you should start by understanding their motivations. This includes understanding who you need to get on board and why, and how important their positive involvement will be to your success. 

The case for change

Imagine a GP or hospital appointment where your needs, preferences, and goals take centre stage – that’s the essence of personalised care planning. It’s about providing a unique health and care plan that revolves around you, the person.

Personalised care planning is like tailoring a healthcare experience to fit an individual’s unique needs, all done collaboratively with all the health and care professionals involved in their care, whether it is at their GP, hospital clinic or care home.

What are the benefits?

Having a personalised care plan acknowledges their individuality. It empowers the person to be an active participant in decisions about their health and wellbeing – their voice matters. 

This personalised approach isn’t just about clinical outcomes; it’s about encouraging better adherence to treatment plans and contributing to an overall sense of improved well-being. 

A care plan, that is accessible to all involved in a person's care

A personalised care plan that’s shareable between health and care services ensures a seamless continuity of care, improving communication among professionals across different services.

It also gives people the tools to take charge of their health, encouraging better self-management. By recognising people as key contributors in their care planning, we make sure that the solutions truly matter in the context of their lives. 

Bringing together health and social care during assessment also ensures a more streamlined experience, sparing individuals from repeatedly sharing their stories. The end result is a single, comprehensive care plan tailored just for the person.

Pregnant woman and child

The problem

What is the current situation?

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam eget sem in urna varius egestas. Duis dapibus, magna vel convallis feugiat, nunc libero suscipit elit, id placerat libero libero in turpis. Aenean id luctus nibh. 

Quisque bibendum, dui vitae sagittis luctus, purus urna pretium tortor, ac sollicitudin turpis sapien eu neque. Phasellus euismod porttitor felis non porttitor. Suspendisse potenti. Nulla bibendum euismod augue, non cursus urna pharetra ut.

The solution

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam eget sem in urna varius egestas. Duis dapibus, magna vel convallis feugiat, nunc libero suscipit elit, id placerat libero libero in turpis. Aenean id luctus nibh. 

Quisque bibendum, dui vitae sagittis luctus, purus urna pretium tortor, ac sollicitudin turpis sapien eu neque. Phasellus euismod porttitor felis non porttitor. Suspendisse potenti. Nulla bibendum euismod augue, non cursus urna pharetra ut.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam eget sem in urna varius egestas.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam eget sem in urna varius egestas.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam eget sem in urna varius egestas.

A call to action

Implementation of the standard needs to be delivered as part of a wider change programme. Implementing standards is often viewed as a technical fix but in reality, it is part of a wider service change programme to improve the experience of the individual receiving care and those professionals providing care.

If this change programme is going to be successful everyone involved must understand the purpose of the change and what a successful conclusion might lead to. This works best when the change is framed in the form of a compelling narrative, that connects with people emotionally as well as intellectually. Local health and care systems need to assess the best approach to delivering this change and identify what will motivate clinicians to deliver the change and the benefits to be realised. 

The section below ‘Creating a stakeholder map’ outlines in more detail who needs to be involved and how to get them onboard with the change programme. 

Resources

Briefing your staff

It is critical that your stakeholders are actively involved from the start and have the chance to influence and contribute to the task of implementing the standard.

These slides provide an outline to help you brief staff on the project, the rationale for doing it and how they will be involved. You can adapt them to reflect the specifics of your local situation.

Download the slide pack

Kick off slide deck

Creating a stakeholder map

When starting your implementation project, you will need to identify all the stakeholders that need to be involved in your project. The most useful thing we know from developing the standard is who your key stakeholders are most likely to be and what they are most likely to be concerned about. 

The list below identifies the main stakeholders that should be involved when delivering wound care management change projects.

  • The health and care system clinical leads, including the organisation’s Chief Clinical Information Officer and Chief Digital and Information Officer.

     

  • The governance teams that support the implementation of new systems, clinical safety, and sharing of personal data

     

  • People that support programme and project delivery and will deliver the required change management programme

     

  • Most organisations will be members of the Integrated Care System’s (ICS) existing Wound Care Management Working/Strategy Group. If you have not yet involved this group, it is recommended you do so to reduce the burden of additional meetings on very busy clinical staff. 
Stakeholders

Here is an example list of key stakeholders you may want to include based on our research:

We also recommend using the RACI model – which identifies who needs to be responsible, accountable, consulted and informed.

RACI model

Creating a commitment chart

Once your stakeholder list is complete, filling out a commitment chart can be a useful way to compare current levels of commitment to minimum levels needed from key players for effective implementation. Here is an example of a commitment chart that you might use.


You can follow the steps below to determine areas of support and resistance to the project:

  1. Identify the essential individuals or groups for the project’s success and list them as “key players” on the chart.
  2. Review the commitment rating system.
  3. Rate the minimum commitment needed from each key player by placing an “O” in the corresponding box.
  4. Evaluate the current commitment level by placing an “X” in the box that represents their current level. 
  5. Discuss strategies like personal contact, emails, or recommended readings to achieve the minimum commitment level needed for the exercise.

You can then develop a strategy to move everyone to the desired state of commitment. Below is example list of barriers for specific groups and what could be done to engage these stakeholders and get them on board. 

Write your business case

To assist with your implementation, you can download and personalise this example proforma business case which includes hints and tips on the benefits and gains which you can expect. 

Each organisation will need to tailor to their own unique circumstances.

Download the business case template

Business Case

FAQs

In our standard and toolkit development, we gathered many questions and our FAQs have the answers. These FAQ’s will be added to as the standard is implemented widely across health and care systems.

The wound care information standard is not a replacement for existing standards, however it does standardise the information that should be recorded during a wound care episode.

This may require the implementation of a new clinical system (or the development of a template within an existing system) which could replace existing manual form of recording information.

No. The Wound Care Standard is focused on information to support the management of a person’s wound care. It should be used alongside other systems or electronic records to get the wider picture of a person to support wound care.

The standard is one of a suite of information standards that are used in electronic health records.

Information standards are used to support the recording of data in a consistent way so that it can be made available whenever it is needed such as when the community nursing team visits, when we visit our GP, attend a hospital appointment or order medication from the pharmacy.

No, historic data does not need to be updated. Once the new standard is implemented, the new codes can be used but you will need to consider the impact of using the new codes on reporting e.g. for QOF or the National Diabetes Audits.

The standard data entries, where necessary, also include the date the data was recorded. This should be made visible in the electronic systems displaying the wound care information so users can be sure of the latest entry.

Go to

Getting people on board
The case for change
The problem
The solution
A call to action
Briefing your staff
Stakeholder map
Business case
FAQs

PRSB Standards Explained

Why we need standards to record our health and care information in a consistent way so that it can be made available whenever it is needed.

Read More

Making change happen

Transformation programmes need clear goals, the right leadership and engaged staff and stakeholders. Get started by reading our information on transformational change.

Read More

PRSB Support Available

If you have a question for PRSB, please contact our support team. We have an expert team who can help you find the answer, or direct you to the right place.

Read More

Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.

CHAT theory also explicitly addresses five areas which if addressed systematically will help overcome stakeholder differences in pursuit of the common goal:

1. Understanding the artefacts that characterise the group and its activity.
• The artefacts might be clinical settings or the forms and templates used to capture and share information. During the pilot we heard about hard copy Dialog response forms; locally generated templates for collating information from different systems; letters and emails to GPs; images, poems or other non-text artefacts that service users might want to include in their ‘about me’ or care plan.

2. Understanding the multi-views of the group. Such groups are always a community of multiple points of view, traditions and interests. 
• Different participants in the group will have different roles and will bring to the group and their roles their own histories, language, and ‘rules’. During our Stocktake preparations and workshops we worked with psychiatrists, mental health nurses, occupational therapists, social workers, transformation leads and voluntary sector representatives, all professions and interests with their own language, approaches professional ‘rules’ but united in their interest in care plans, care planning.

3. Activity systems (like the ICSs) take shape and get transformed over periods of time. ‘Historicity’ is a term coined to express how the group’s problems and potentials can only be understood against their own history. 

 

• ‘We’ve always done it this way’, ‘that didn’t work before’, ‘it’s always like this’, ‘it wasn’t always like this’, ‘they are changing things again’, are all typical statements that often frustrate those charged with overseeing change initiatives. Without addressing the experiences that lie behind such comments you risk repeating mistakes of the past, alienating your stakeholders or just not understanding the real starting point for your transformation project. This is particularly the case for the implementation of the PCSP standard, the success of which will be largely reliant on point-of-care practices and information protocols as well as having systems which are user friendly and appropriately configured.

4. The central role of contradictions as sources of change and development. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. Collectively addressing contradictions in how policy, practice, culture and technology interact will empower teams to find genuinely novel solutions for apparently intractable challenges, like interoperability and shared care plan/planning. 

This links to the fifth principle that:

5. the possibility of expansive transformations in activity systems. As the contradictions of an activity system are aggravated, some individual participants begin to question and deviate from its established norms. In some cases, this escalates into collaborative envisioning and a deliberate collective change effort. “An expansive transformation is accomplished when the object and motive of the activity are re-conceptualised to embrace a radically wider horizon of possibilities than in the previous mode of the activity.”

“If someone’s been working for a period of time, in a form of therapy, for instance, where there’s an agreed plan for the locality when they may present in an emergency situation … then it’s really important for us to be able to see that that information and be able to act appropriately according to that because, you know, there isn’t and there shouldn’t be a stock response to that. These plans are designed to be individualised and personalised.  All services should be giving that personalised approach to care wherever possible. And a standard such as [PCSP standard] definitely moves us closer towards being able to do that. [Not acting on agreed plans] is a key finding in terms of emergency responses over the years where responses have been inappropriate.” – Mental Health Nurse

“Following a particular plan that’s been put into place will result in much better outcomes and prevent the sort of poor outcome which would otherwise be leading to an unplanned hospital admission.” – General Practitioner