Man being supported by health and care professional to create a personalised care plan.

Personalised Care and Support Plan Standard

Sharing care plans with people, carers and healthcare professionals

More people than ever are living with long-term conditions in the UK, which includes both physical and mental health problems. As a result, there has been a national drive towards providing people with long-term, personalised care plans.

Personalised care planning standards will help to enable people to manage their own care, with the support of a wide range of services including GPs, hospitals, occupational therapy and social care. This new standard will help citizens and health and care professionals get the right information when they need it, in order to personalise care, and improve the experience for the patient, their carer and their families.


ISN status achieved: 
Dec 2021

The Personalised Care and Support Plan (PCSP) Standard has now achieved ISN status following rigorous quality assurance by the NHS Data Alliance Partnership Board. 

NHS Digital has published the approved ISN along with supporting documentation. The ISN sets out details of the standard, its implementation date, whether it is mandated or voluntary, the legal or contractual basis upon which data is being requested and details of key contacts.

Latest version: V2.0

V2.0 was published to support adults who live with severe and enduring mental health conditions in the community. Co-produced with health and social care professionals, as well as people who use services, the standard is designed to help people stay well and live the best lives they can at home or in supported accommodation. Implementation of the standard is following a phased approach, identifying early adopters and publishing the results of trials to embed learning ahead of the planned full compliance date of 31st January 2024.

 

Summary version of the standard

The table below shows a summary view of the standard. A full view of the information model can be found here.

Table key:
M – Mandatory information must always be included
R – Should be included where the information is available

NameConformanceDescription
Person demographicsMThe person’s details and contact information. Includes Name, address, contact details, NHS number & other identifiers, ethnicity, religion & marital status
GP practiceMDetails of the person’s GP practice.
About meRThe information a person wants to share with professionals providing care.
Professional contactsRThe details of the person’s professional contacts involved in their care, including their role organisation and contact details
Personal contactsRThe details of the individual’s personal contacts including name, relationship and contact details.
FormulationRDetails of the person’s formulation where it exists. A formulation is a joint effort between the person and the professional to summarise difficulties, to explain why they may be happening and to make sense of them. It may include past difficulties and experiences if these are relevant to the present. It acknowledges strengths and resources. It also helps the professional work out what needs to be done in order for the person to feel better and recover.
Care and support planRThe personalised care and support plan agreed during conversation between the person and health and care professional. It includes their strengths, needs, goals and actions and activities to achieve those goals along with progress and outcomes.
– StrengthsRAny strengths and assets the person has relating to their goals and hopes about their health and well-being.
– Needs, concerns or problemsRDetails of the person’s hollistic needs, concerns or problems
–Goals and hopesRThe overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing.
—Actions and activitiesRActions or activities the person or others plan to take to achieve the person’s goals and the resources required to do this. It includes the person’s confidence to do it, status and strategies for potential problems, can have stage goals, and includes date last updated and review date.
-Other detailsRDetails of who the plan was agreed with, when, review date, and funding source
Contingency plansRThese describe what needs to be done and who to contact, should an individual’s health or other circumstances worsen. The contingency plan will include trigger factors, early warning signs, anticipatory medicines, coping strategies and advanced statements. Each plan should also include when it was last updated and when it needs to be next reviewed.
Additional support plansRThis is the content of any additional plans which the person and/or care professional consider should be shared with others providing care and support. They may be structured in different ways, e.g. tables, diagrams, images. It could include specialist or medical care plans; for example a wound care plan or a paediatric asthma treatment plan.

Provenance data

Provenance data for this standard will be shown in a separate information model in the next iteration of the standard following its 3-year maintenance release. Provenance data describes who made the record entry or carried out the activity, where and when. The latest provenance model is available on our website

 

The benefits of using the standard

Erica, a mental health campaigner has lived experience of severe mental illness. Erica talks to PRSB about the need for information sharing between her care providers and why a digital personal care plan is essential for her mental health and wellbeing to prevent any relapses.

Further resources

Personalised Care and Support Plan Standard V2.0

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V2.0 – Json file

Supporting documents

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  • General implementation guidance
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  • Provenance data model

PCSP implementation toolkit

This toolkit has been developed to support the adoption and implementation of this information standard. The materials and resources will support you with your local implementation of the standard.
View the toolkit

Previous version:

V 1.1: Digital Care and Support Plan (2018)

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Community Mental Health final report