Enhanced Services Primary Care Networks

Summary of draft PCN specification: Personalised care

A summary of the proposed service specification to be included in the new Network contract DES

This element of the proposed Network service specifications falls under the NHS Long Term Plan to ‘make personalised care business as usual across the health and care system as one of the five major, practical changes to the NHS service model’.

NHS England says personalised care means ‘people have choice and control over the way their care is planned and delivered, based on “what matters” to them and their individual diverse strengths, needs and preferences’ and that ‘this happens within a system that supports people to stay well for longer and makes the most of the expertise, capacity and potential of people, families and communities in delivering better health and wellbeing outcomes and experiences’.

The specification is based on a ‘Comprehensive Model for Personalised Care’ that is underpinned by ‘six evidence-based and inter-linked components, each of which is defined by a standard, replicable delivery model’.

The components are listed as:

1. Shared decision making

2. Personalised care and support planning

3. Enabling choice, including legal rights to choose

4. Social prescribing and community-based support

5. Supported self-management

6. Personal health budgets (PHBs) and integrated personal budgets.

The idea is that the specification will be phased in over four years.

Service requirements

In the first year, 2020/21, practices in PCNs would need to:

1. Identify a clinical lead responsible across the PCN for delivery of the service

2. Ensure 5–10 per 1,000 patients receive a Personalised Care and Support Plan (PCSP). In 2020/21 these patients must include:

  • All people thought to be in last 12 months of life
  • Individuals eligible in the Anticipatory Care and Enhanced Health in Care Homes cohorts

Other patients might include:

  • People with multiple long-term conditions and/or at high risk of hospital admission
  • People with a diagnosis of Cancer

3. Promote personal health budgets to those patients with a legal right to a PHB and any other cohorts identified as eligible within the CCG’s local offer.

4. Deliver shared decision making using available decision support tools, prioritising patients with musculoskeletal conditions such as back pain, hip pain, knee pain and shoulder pain. These conversations will be led by trained physiotherapists

5. Provide relevant training, shared learning and quality improvement for staff in PCNs, foremost:

  • Team members undertaking personalised care and support planning conversations
  • Clinical pharmacists hosting Structured Medicine Reviews
  • PCN MSK practitioners
  • Social prescribing link workers

6. Ensure at least 4 per 1,000 patients are referred for social prescribing.

7. Measure shared decision making using the Patient Activation Measure in

  • People living with newly diagnosed Type 2 diabetes
  • People referred to social prescribing link workers

Proposed metrics to assess PCN’s delivery of the service:

1. The number of personalised care and support plans delivered (including measure of delivery rate for required cohorts)

2 The number of shared decision making conversations completed (including measure of delivery rate for required cohorts)

3. The quality of shared decision making conversations

4. The quality of shared decision making conversations

5. The number of social prescribing referrals made

6. The number of patient activation measurement assessments undertaken (including measure of delivery rate for required cohorts)

7. The number of Personal Health Budgets

In 2021/22, PCNs will be expected to build on the requirements including increasing the number of personalised care plans in place to 10-15 per 1,000 patients, expanding the shared decision making provision to patients with MSK problems and people with AF at risk of stroke and providing supported self-management to certain cohorts.

The expectation for social prescribing referrals will go up to at least 8 per 1,000 patients.

Thereafter further expansion of shared decision making, PHB promotion, training and supported self management is still to be confirmed, but by 2023/24 the requirement for personalised care plans would go up to 20-25 per 1,000 patients and the required number of social prescribing referrals to 16-22 per 1,000 patients.

For full details of the proposed service specifications you can download the full document here.

Guide URL:
https://pulse-intelligence.co.uk/guide/summary-of-draft-pcn-specification-personalised-care/
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