New social care standards support more personalised care

New standards for integrating key health and social care information will ensure services can work together better to provide more personalised care.

The new national standards have been introduced to ensure that information is recorded and shared in a clear and consistent way across health and social care. This means professionals will have a full picture of a person’s needs, enabling them to provide safer and individually tailored care.

Sam Bergin Goncalves, citizen lead on the project and mum to 22-year-old Shane – a user of health and social care services – said: “Improved care is where people are listened to, valued and understood. It means goals and health ambitions are taken into account and support is offered to help achieve them.”

The standards have been commissioned and led by NHS Digital and produced by  the Professional Record Standards Body (PRSB).

More than 1,000 people, including frontline health workers, patients and carers, helped develop the new standards as part of a consultation which also involved clinical and professional groups, charities, suppliers and researchers.

The five new standards will ensure important personal details, such as the need for additional social care support after a person’s hospital stay, will be recorded and shared with their care team.

Other important non-medical information can also be included, such as a photo and details about work, family or friends, or the ways a person usually behaves when they are in good physical and mental health. This will provide professionals with a better understanding of the person, not just their illness or condition.

The new standards cover:

  • ‘about me’ – the personal details that a person would like to be recorded about   themselves
  • health and care information shared in care homes
  • information shared by local authorities
  • referrals for community assessments for care and support after a hospital stay
  • the urgent information needed when a person is transferred to hospital from a care home

Professor Adam Gordon, vice president at the British Geriatrics Society and clinical lead on the project, said: “This standardised information will help everyone involved in care to  access the information they need to help people to live the best possible lives they can.

“From crucial information about medication and its effects, right through to daily goals and aspirations, it will help to ensure that everyone can be treated as an individual.”

Sam Bergin Goncalves added: “Shane is loving and affectionate and enjoys gardening, baking, swimming and visiting museums. He has cerebral palsy, a visual impairment and a severe learning difficulty.

“Over the years it has been difficult navigating through a system that is obsessed with labels. We have found that clinicians will record data that they find useful, and the health and social care system will prioritise keeping someone safe, with little room for dreams and aspirations.”

Comprehensive shared information will enable Sam’s son, other service users and their families to get the additional support they need in a way that works for them.

James Palmer, head of the Social Care Programme at NHS Digital, said: “The development of these standards marks a major step forward for social care, supporting better care for service users and wider use of shared digital records across the UK.

“Several areas across the UK have already begun implementing the standards, resulting in improvements to wellbeing and health and care. The learning from these pilots will be shared across the country.”

The development of the standards is part of NHS Digital’s Digital Social Care Pathfinders Programme, in which funding to roll out local digital projects has been awarded to 16 organisations which provide and commission adult social care services.

The pathfinders have previously piloted products and services and are now implementing them on a larger scale, many using these standards to support interoperability.

The new standards for information shared by local authorities and ‘about me’ will be incorporated into the existing shared record standard, known as the core information standard, which was published in 2019.

The other standards will be published separately at www.theprsb.org/standards

 

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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.