Getting Started: Planning the Change


Get started by planning the change. In this section, we will carefully consider the process and the methodologies largely applied to transformation planning for the PCSP standard with regards to care planning to support mental health. We start by understanding the importance of a structured approach, what successful transformation looks like and also which tools to use when measuring progress and agreeing outcomes. 

Planning the change and transformation process

You can work towards improved personalised care and support planning (PCSP) which better meets people’s needs and enables information sharing by working through the structured approach suggested in the PCSP toolkit (see side bar for link to Toolkits).

For any transformation planning, remember to consider the ‘fundamental questions’  as stated in PRSB’s transformation guidance.

If this change is going to be successful everyone who needs to 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. Understanding your stakeholders and how the project will benefit them will help you develop your own local narrative. Carrying out a stakeholder analysis will also help you identify the people you need to actively engage with and contribute to your project and how to get the best from your leaders and sponsors.

Useful resources (click to view): 


What does successful transformation look like?

Before embarking on a digital transformation and discussing the approach and methods of measuring outcomes, first it is important to understand what successful transformation looks like.

Start with the end in mind

Changes to the approach to personalised care and support planning, and to the ways that plans might be made available digitally, will need to be piloted in different parts of the system. These might be geographies, specific services, Primary Care Networks or others.

Applying the 'convoy' approach to PCSP implementation planning

All major projects need to be able to be divided into elements or streams of work for a successful conclusion. For the adoption of personalised care and support planning in Community Mental Health Services we might envision these elements as part of a “convoy”. The journey will not be complete until all parts of the convoy have arrived, but realities and constraints might mean they move at slightly different speeds and may need to take slightly different routes.

Click the link to read more about the convoy approach and how it can be applied to implementing the PCSP standard.

When determining the approach, ask yourself...

  • Is this version of the convoy one that works in your area?
  • If not, what alternative will you adopt to ensure the programme establishes and maintains momentum?

You may find the below resources helpful when considering these questions (click on each item to view);

Agreeing how to assess progress and outcomes

In the context of systems which are continuously improving it can be said that “better is never finished”. Nonetheless, it is important to track progress towards the goal of a fully effective system of personalised care and support planning (PCSP) which is digitally enabled. 

Click the link to read more about agreeing how to assess progress and outcomes.

Working with system suppliers for digital transformation

Digital transformation usually involves procurement or evaluation of technology suppliers. You may also want to ask your (potential) suppliers the following: 

The system supplier diagnostic table (available on the resources page) can be used as a conversation aid with a single supplier (for example an incumbent supplier as part of continuous improvement) or across multiple conversations (within procurement rules) to contrast different offerings. You might also want to add to the diagnostic table and build your requirements specification through the work you do in the stakeholder analysis, stocktake and simulation.


Examples of digitally supported care planning

What is your work programme and outline timetable to develop a strategy for a system of personalised care and support planning (PCSP) which is digitally supported? 

Click each button below to view two differing examples of digitally supported care planning

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.