Personalised care in practice: a health and wellbeing coach’s perspective

Personalised care works best when information is connected and visible across all services supporting a person, including their GP, hospital teams, community services, social care and local pharmacy. Too often, care plans are stored in separate systems or recorded inconsistently, making it harder for professionals and patients to see the full picture.

Effective personalised care planning depends on systems that can share reliable, standardised, up-to-date information, as well as on equipping people with the right tools and guidance to use them well.

We spoke to Julian Meres, lead health and wellbeing coach for the Hillingdon Confederation, to find out how care planning works in practice across his network.

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Support worker
Julian Meres (left) and his colleagues at the Hillingdon Confederation

“I see myself primarily as a coach rather than a therapist or counsellor. I start from the belief that the answers are already within the patient, and my role is simply to help bring them to the surface. Personalised care, in my view, must be patient-led.

When patients are offered health coaching, they choose how they want to meet. It can be face-to-face, by phone, or online. Appointments are arranged around them wherever possible. I remind them that they’re the ones calling the shots and in control of their care.

Often, what matters most to a patient is different from what a clinician might initially focus on. Someone may be referred for a specific reason, but what they want to work on could be changing habits, improving sleep, managing stress, or addressing behaviours such as overeating or drinking in the evenings. Health coaching looks at these elements together in a non-judgemental way, emphasising motivation, goal setting, and mental wellbeing.

In our network, personalised care has been developing over the past four years and remains a work in progress. I am one of a small team of health and wellbeing coaches in our four practices. Referrals can come through the traditional GP route, but also from others within the surgery, including reception staff. Someone repeatedly attending with minor ailments may be referred for triage, and from there, they might see a health and wellbeing coach, a social prescriber, or sometimes both.

Often patients have multiple long-term conditions such as obesity, COPD, musculoskeletal issues, fibromyalgia, asthma, or low mood. On top of this, they may be dealing with housing, finances, work, childcare, or juggling multiple hospital appointments and prescriptions. While some of these practical issues are handled through social prescribing, my role is to help people find new ways to cope with the everyday challenges they face.

People often think we are there to fix the problems, but health coaching seeks to shift that dynamic, encouraging individuals to take the reins and try to manage some of the challenges themselves. By focusing on key behaviours such as sleep, eating, physical activity, relaxation and sense of purpose, we help individuals build the confidence and skills to improve their own health and wellbeing.

An essential part of all this work is recording and sharing the information so we can all see a person’s care plan. In Hillingdon, an electronic patient record hub has been developed so that information can be accessed across all surgeries. In the early days, there were multiple logins and some confusion between individual practice systems and the hub. Now it’s used far more consistently and is accessible to all colleagues within the Live Well service. However, full integration is still evolving. Different professionals are using different parts of the system without yet seeing the full picture.

At present people don’t routinely access or input into their personalised care plan. I see this as part of the next important stage of development. When patients can access their care plan regularly, for example through an app, and professionals can input and view information seamlessly, the system will begin to feel coherent and connected.

There are challenges. Training and awareness are key. I know I use only a small part of the care planning template, and much more is possible. For the system to reach its potential, staff need to understand what it can do and buy into it.

From my perspective, as someone advocating for the people I support, the benefits are obvious. A shared digital record helps avoid mixed messages about what different professionals are offering. It saves time and makes the whole system work more smoothly. Some days I have eight in person appointments, so I need to write up my notes straight after each session. That means the right people can see what is happening without delay. Whether it is a social prescribing link worker or a GP, we are all working from the same information. That continuity really makes a difference.

Sometimes patients say they feel they are not being heard and that they have to repeat their story but if personalised care plans and digital systems function as intended, that frustration can be reduced.

For me, the goal is clear. Personalised care planning should not be a collection of disconnected documents. It should be a shared, living record that supports holistic, preventative, and person-centred care. With proper training, good data and systems that genuinely connect, care plans can make sure what matters most to someone is visible to everyone helping them. I would encourage anyone sharing this vision and tackling the challenges of an integrated approach to care planning to begin with the PRSB’s Personalised Care and Support Plan Standard and build from there.”

 

Resources

The Personalised Care and Support Plan Standard provides a framework for creating a single, lifelong care plan that can be shared and updated by both the person and the professionals supporting them. By setting out clear ways to record, access, and exchange information, the standard aims to make care plans collaborative, joined-up, and centred on what matters most to each person.

If you want to learn more about how you can use this standard please contact us at info@theprsb.org. Whether you are an NHS organisation looking to improve your systems or a supplier aiming to become conformant, we can help.

 

 

 

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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.”