What is personalised care?

Providing personalised care means giving people the choice and control over their health and wellbeing and the way that their care is planned and delivered to ensure that what matters to people as individuals is at the forefront of their care based on their individual strengths and needs. It empowers people to use information to make decisions based on the choice of what is right for them.

What are the benefits of personalised care?

– It improves people’s health and wellbeing, joins up care in local communities, reduces pressure on NHS services and helps the health and care system to be more efficient.

– It helps people with multiple physical and mental health conditions make decisions about managing their health, so they can live the life they want to live, based on what matters to them, as well as the evidence-based, good quality information from the health and care professionals who support them.

– It recognises that, for many people, their needs arise from circumstances beyond the purely medical, and will support them to connect to the care and support options available in their communities.

What are the Personalised Care Roles?

The three roles of Social Prescribing Link Worker, Care Co-ordinator and Health & Wellbeing Coach reduce and support the workload of the GPs and other clinical staff by supporting people to take more control of their health and wellbeing.

Social Prescribing Link Workers

Social prescribing is a way to connect people with community-based services, groups and activities that meet practical, social and emotional needs that affect their health and wellbeing. Physical and mental health and wellbeing is influenced by a range of factors, including their housing, finances, personal relationships and existing health conditions, not all of the factors that affect this can be resolved through conventional health services.

Social prescribing link workers will work with people to offer a person-centred approach to help them to identify issues that affect their health and wellbeing and to co-produce a personalised care and support plan. They will help to connect people to non-medical community-based groups, activities and services that will help to meet their practical, social and emotional needs and work with voluntary, community and social enterprises (VCSE), organisations and local authorities to support population needs. Social prescribing link workers will work closely with other personalised care roles, as well as the wider GP Practice and Primary Care Network teams.

Care Co-ordinators

Care Co-ordinators work closely with people to build trusted relationships and to listen to and understand what matters to them. They help people to co-ordinate and navigate their care across the whole health and care system and they support people to become more active in their own health and care. The health and care system can be complex and difficult to manage, especially for people with multiple care or complex needs. The care co-ordinator can help people to make the right connections, with the right teams, at the right time.

Care co-coordinators will take a personalised and holistic approach, looking at the person rather than the conditions that they have. They are skilled in personalised conversations, assessing people’s needs and facilitating joint working to ensure that there is an effective flow of information. Care co-ordinators will work closely with other personalised care roles, as well as the wider GP Practice and Primary Care Network teams.

Health & Wellbeing Coaches

Health and wellbeing coaches work with people with physical and/or mental health conditions and those with long-term conditions. They focus on improving health related outcomes where lifestyle modification and self-management have a significant impact on outcomes and prognosis. Health and wellbeing coaches use coaching skills, models of behaviour change and positive psychology to guide people on how to meet their personal health and wellbeing goals. They support people to identify their challenges, what their goals are and how they can be motivated and committed to making changes to their lifestyle to improve their health.

Health and wellbeing coaches will use a personalised care approach when working with individuals. They may also support groups of people through group coaching and structured self-management education. Health and wellbeing coaches will work closely with other personalised care roles, as well as the wider GP Practice and Primary Care Network teams.