Personalised Care and Support Plan Standard

Personalised Care and Support Plan Standard

More people than ever are living with long-term physical and mental health conditions in the UK. As a result, there has been a national drive towards developing long-term care plans collaboratively between professionals and people.

Personalised care planning standards will help people manage their own care, with the support of a wide range of services including GPs, hospitals, occupational therapy and social care. This standard will help them and the health and care professionals who support them to get the right information when they need it.

On this page

Current release

Version: v2.0
Release date
December 2021
Release notes
Release notes V2.0
Next release date
TBD
Next release type
Scheduled maintenance update with terminology refinements
The standard
Full standard – PRSB viewer
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Viewer discrepancies: Please read
Full standard – Excel
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Full standard – Json
Download file (Json)
Json file discrepancies: Please read
Supporting documentation
Description/purpose
Information standards notice (ISN)
ISNs are published to announce new or changes to information standards published under section 250 of the Health and Social Care Act 2012.
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This document includes general implementation guidance for all PRSB standards and detailed guidance, specific to the Personalised Care and Support Plan Standard.
Implementation toolkit
A step-by-step guide to help suppliers and organisations implement the standard.
Business rules
Rules for implementation of the standard.
Digital care and support plan final report V1.0
Describes the purpose, methodology and stakeholder engagement for developing the original Digital Care and Support Plan standard, along with the findings and recommendations for further work.
Final report (Community Mental Health update to Personalised Care and Support Plan, 2021)
Describes the consultation process and of testing the existing Personalised Care and Support Plan standard to support people living in the community with ongoing need for help from mental health services.
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Summarises the hazards which could result from implementing the standard.
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Details the potential hazards from implementing the standard with their risk rating and mitigation.
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About this standard

The standard supports personalised care and support planning so that individuals have a single shared personalised care and support plan to which all health and care professionals can contribute. The aim is to avoid what currently happens too often, where separate care plans are created by different professionals or teams of professionals and they are not widely visible, don’t join up, and don’t promote a holistic approach to meeting a person’s care needs.

The plan should be developed with the person themselves and/or with their carer where appropriate, based on the person’s strengths and holistic needs.

The benefits:

  • Improves continuity of care by ensuring people have a single care plan that shares key information to help them to get the right care and support when they need it. 
  • Helps people contribute and feel actively engaged in their own care
  • Provides a single, holistic picture of their needs, goals and actions, enabling them and their family/carers and health and care professionals to provide appropriate support to improve a person’s health and wellbeing.
 
Play Video

Erica, a mental health campaigner has lived with severe mental illness. She talked to PRSB about why a digital personal care plan is essential for her mental health and wellbeing to prevent any relapses.

Scope

The standard is UK wide for use across the whole of health and social care and for anyone requiring a care and support plan, including children, with any health and/or care needs.   

How it works

A personalised care plan should be produced from a conversation between the person (and/or their carer) and a care professional, focusing on what’s important to the person and their holistic needs and goals.

The summary view table below shows the main and supporting sections of the standard:

Main sections:

About Me Information that the person considers important to share with people caring and supporting them and including what matters to them (their needs, concerns preferences and wishes) 
Care and support plan Developed with the person as a single plan to reflect their holistic needs and the goals and actions to support those needs 
Contingency plans The things to do and people to contact, should a person’s health or other circumstances get worse 
Additional support plans For further detailed plans to support for particular conditions or care and support   

Supported by sections for:  

Person demographics Details of the person (name, DOB, gender, NHS Number, address, contact details etc)  
GP practice Details of the person’s GP practice  
Professional contacts Details of the person’s professional contacts 
Personal contacts Details of the person’s personal contacts 
Formulation Only used where appropriate only and usually for people with mental health problems. An account, shared by a therapist and the person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward to support them.  

The standard supports the personalised approach to care and support planning with a single shared care and support plan for all the professionals and people involved in a person’s care, including the person themselves and/or their carers.

It starts with their ‘About Me’ information, then focuses on their strengths and needs, together with their goals, hopes, and aims. It should demonstrate how the person’s aims and goals will be met and who is responsible for delivery of the activities to achieve them. These are the person’s holistic needs (e.g. to recover their mobility or manage anxiety) which may require support from different parts of health and social care.

Additional support plans may be linked to the care and support plan and should be available for others to view. Their format will vary according to the type of plan and can be structured and coded, and some may include diagrams or images. They can be used for detailed plans to support particular conditions such as a dietician’s plan, wound management plan or behaviour support plan, or to set out care plans, for example to support activities of daily living.

Contingency plans, also known as anticipatory, escalation, or crisis plans provide details of how predictable risks associated with health and wellbeing are managed if they get worse’. They are plans of what to do should a person’s health or circumstances get worse and who to contact. 

The diagram below shows how additional support plans and contingency plans fit into the PCSP. Please click on the image for a full size version.

Examples

This example demonstrates how the standard works in practice:

Further resources

  • Standards explained
    PRSB’s guide to standards which sets out the purpose and benefits of using standards and how to support frontline professionals to adopt them.
  • IHRIM record correction guidance
    Despite vigilance when filing information in records, mistakes can occur. The Institute of Health Records and Information Management has guidance to support professionals in making corrections following errors.

Useful links

What is a care plan?
What is included in a care plan?
PCSP supporting care - infographic

Endorsement

The following organisations have endorsed this standard:

  • Royal College of GPs
  • Royal College of Nursing
  • Royal College of Obstetricians and Gynaecologists
  • Royal College of Occupational Therapists
  • Royal College of Physicians
  • Royal Pharmaceutical Society
  • Care Providers Alliance
  • Institute of Health Records and Information Management
  • TechUK

 

Supporters
The Association of Directors of Adult Social Services – ADASS do not have the capability to endorse standards, but do support the standard.

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.