Standard 5: Care is based on the assessed unique needs

5.1 Implement Personalised Care and Support Planning (PCSP)

• Objectives of Personalised Care and Support Planning (PCSP) agreed by practice team and recorded
• Objectives need to cover:
  Medical plans, such as Emergency Health and Advance Care Planning
  Demedicalised (non-health) Wellbeing plans, such as mapping care and support networks to enable care preferences

• Consider different needs for both:
  • Medical plans, such as Emergency Health and Care Planning
  • Demedicalised plans, such as mapping care and support networks to enable care preferences
• Consider evidencing peer discussion to agree objectives of PCSP
  • Peer discussion / reflective reading on what makes effective PCSP.
  • Consider another practice, hospital or hospice system or invite external peer review
  • Consider use of PPI feedback to improve outcomes
• Recognise the relevant legal framework in relation to o Valid consent
  • Capacity Assessments and Best Interest decisions
  • Advance Decision Making and Lasting Power of Attorney

• Use a holistic PCSP template to identify and record the key medical and 'demedicalised' information for PCSP
• Holistic PCSP template used relevant to age, diagnosis, cultural and psychosocial needs
• Offer sensitive conversations on items in minimum dataset and record on PCSP template
• Use of PCSP recorded for people on Practice Register
• The practice team have constructed a process map of PCSP
• Offer copy and/or access (if available) of PCSP to patient

• NHS England Personalised Care and Support Planning Handbook - Core Information
• Considering using common assessment tools to identify and assess needs. For example, SNAP tool - Support Needs Approach for Parents
• National Voices' Guide to Care and Support Planning 
• RCGP Collaborative Care and Support Planning Toolkit 

• Sample letters designed by one practice can be used in the process:
  • Letter to patient – my life plan (invite)
  • Letter to patient – my life plan (new)
  • Letter to patient – my life plan (review invite)
  • Letter to patient – my life plan (updated)
    Managed MDT
  • My life plan – first consultation 
  • Treatment escalation plan

The recorded plan, including EOLC dataset, once started is completed and regularly reviewed and updated, in a timely manner and includes:

• Medical plans including assessment of pain, other physical symptoms and emergency health and care planning.
• Demedicalised plans, such as mapping care and support networks to enable care preferences.
• Assessing and reviewing mental capacity.
• Benefits guidance, e.g. DS1500.
• Sensitive involvement and communication with patients, families and carers.
• DNACPR documentation, where appropriate.
• Holistic needs, including: practical, communication & disability, psychological, social, spiritual and cultural needs.
• Date and place of death recorded within 2 weeks of death.

• Evidence continuous improvement of assessing, documenting and reviewing mental capacity.
• Evidence documentation of relevant and sensitive communication with patients, families and carers.
• Consider recommendations for DNACPR discussions to be part of the PCSP journey and ideally not to be done in isolation.
• Consider using common assessment tools to identify and assess needs.For example, SNAP tool - Support Needs Approach for Parents
• Consider how to ensure patients' pain and/or other physical symptoms will be effectively controlled.
• Consider how to ensure decision-making is shared with the patient and those important to them.
• Consider how to meet the communication and information needs of patients' with disabilities and sensory loss, in line with NHS England's Accessible Information Standard 

• Goals of care are recorded and commenced early.
• How care is aligned to those goals recorded.
• Information on self-management and enhanced care models available to patients and their carers.

• Evidence that conversations about goals of care commence early to optimise opportunities to align care to those goals.
• Consider how the practice evaluates sensitive and compassionate communication.
• Consider how patients have an opportunity through early identification to benefit from self-management and enhanced care models.
• Evidence family and carers are involved in planning patient-centred care
• When patients lack capacity, ensure an understanding of how to make best interest decisions and involving LPAs and Court of Protection deputies, as appropriate.
• Reflect how the practice minimises non-beneficial or burdensome care in partnership with the patient and those important to them.
• A toolkit on PCSP for patients not necessarily at EOLC