In response to the need for greater integration and personalisation in the planning and delivery of care, support and treatment for service users and carers, we have developed a new ‘my wellbeing plan’ document that is underpinned by a refreshed approach to care and support planning. This approach integrates the requirements of the Care Programme Approach and the Care Act and delivers these in a truly person focused way that maximises participation of people in planning their care and support. The person’s goals are at the centre of the plan and we identify their strengths and personal / family / community resources to produce a personalised approach to enabling recovery, staying safe and preventing and managing crisis. For those people in eligible social need the plan further integrates personal budgets / direct payments to achieve social outcomes.
What We Did
In response to the need for greater integration and personalisation in the planning and delivery of care, support and treatment for service users and carers, we have developed a new ‘my wellbeing plan’ document that is underpinned by a refreshed approach to care and support planning.
This approach integrates the requirements of the Care Programme Approach and the Care Act and delivers these in a truly person focused way that maximises participation of people in planning their care and support.
The person’s goals are at the centre of the plan and we identify their strengths and personal / family / community resources to produce a personalised approach to enabling recovery, staying safe and preventing and managing crisis.
For those people in eligible social need the plan further integrates personal budgets / direct payments to achieve social outcomes.
The approach and documentation / electronic documentation enable a person’s outcomes to be measured through the health and wellbeing wheel. This is focussed around key areas of a person’s life such as finance, relationships, physical wellbeing etc.
Using the wellbeing wheel helps the person to set goals and evaluate their progress. As an organisation we can review the outcomes that are achieved across groups of people to understand where we are having the most impact, or areas of unmet need, allowing us to continually improve practice and service provision at both a person and a strategic level.
For staff the document provides a practice focused tool, leading positive practice and maintaining a focus on the person in the context of their life, whilst minimising bureaucracy and making the best use of the technology available.
It also allows anyone working with a person to support the person from their frame of reference that is meaningful.
Wider Active Support
We work with Hertfordshire County Council to deliver the requirements of the Care Act and ensure that policy and practice is aligned across different service users groups. This would include areas such as self-funding, pre-payment cards and advocacy.
We have also become the first Mental Health Trust to work with and adopt the Think Local, Act Personal “Making It Real” framework, using the ‘I’ Statements to refocus practice and evaluate our progress towards better personalised care and support.
We have established a Making it Real Board to set priorities and drive forward personalisation. This board is made up from partners from local statutory, voluntary and third sector providers as well as service user and carer representatives.
The ‘My Wellbeing Plan’ was co-produced from start to finish. Originating from the recovery care planning group that initiated the work through to the development of the training materials that underpinned the roll out of the new documentation and approach. Service users, carers, staff and other stakeholders all contributed to the final ‘product’.
The action plan that supports the Making it Real work has many elements that support and enhance the cultural change that we are making towards greater personalised care and support, and the ‘My Wellbeing Plan’ and care and support planning approach are central to this.
This action plan was co-produced through the Making it Real board and subgroups comprised of all the partner agencies, HPFT staff and service users and carers. The action plan has 4 priority areas, each of which is led or co-led by a service user or carer.
The actions set out in the plan include the production of information material for people new to services as the existing material did not connect with people. It was through joint working that we were able to establish this and make positive improvements.
Looking Back/Challenges Faced
Our reflection is that working in genuine co-production is a challenge. The work is often slow as there is a need for everyone to understand each other’s perspectives and the constraints that a statutory provider organisation works within, whilst pushing and challenging those boundaries.
We overcame this through recognising that this would be an extended piece of work, committing to this and using the concepts and tools of quality improvement – e.g. working incrementally towards a stretching goal, PDSA cycles etc.
We also underestimated the effort, cost and lead times required to make the necessary changes to the electronic patient record system. For any similar changes in the future we would ensure that (as far as possible) colleagues from IM&T and any other relevant support services were involved right at the start working collaboratively with them from concept through to delivery.
The ‘My Wellbeing Plan’ has been established as the standard / only care and support planning document within the organisation for Adults.
We launched the documentation with associated training that helped staff to understand both the new documentation and the required changes to care and support planning practice that would make it a success.
Our Making it Real action plan continues to evaluate the progress towards the ‘I’ Statements and personalising and sets realistic yet challenging improvement actions that build on the documentation and initial training.
Evaluation (Peer or Academic)
An evaluation has not been conducted.
A baseline of quality in care and support plans was carried out prior to the launch, focused on the person’s goals being evidenced in the care plan and their involvement. An associated audit of care and support planning for people with eligible social care needs was also carried out.
We have scheduled a re-audit of the quality of care and support planning based on a combination of these two audits and this is due to be conducted in August 2017, 6 months after the full roll out of the ‘My Wellbeing Plan’.
Feedback from staff:
“The Wellbeing Plan looks clearer, is a lot more user friendly, and people are more easily able to complete it.”
“It has generally been found to be patient centred.”
“Today I tested the new Wellbeing Plan. It is true life saver! It is concise, recovery focused, user centric and promotes participation throughout! I like that it has merged ‘my health and wellbeing wheel’ – it gives the service user an opportunity to reflect / self rate. The new form definitely cuts administration time and all the other paper work!”
Service User – examples of usage
Service user was a 26 year old female who was inpatient under MHA S3. She had been very reluctant to accept treatment to support her recovery and had been unable to complete previous care plans set on MH specific goals as she was too low in mood to accept improvement in her life.
The My Wellbeing Plan was completed with her whilst an inpatient. The change enabled a shift of focus from trying to identify symptom/medical symptom goals to thinking about how she would like life itself to be and what her life goals had been prior to becoming unwell.
She identified that she had always wanted to travel to south east Asia and backpacking. Identifying this overall goal enabled her to identify other smaller goals (i.e. lose weight and get fitter so I would be able to do this/try going on a shorter holiday to see how I would manage this).
Thinking about her steps to get there shifted her thinking in terms of MH recovery, recognising that she would need to be well in order to achieve this goal. This enabled her to see value in the proposed treatment for her MH in that it would enable her to achieve a dream rather than just to please family/professionals. She is now accepting treatment in the form of talking therapy and eager to move to proposed therapeutic placement.
A service user known to community services but with no recourse to public funds and awaiting decision on their asylum application had experienced trauma related ill-MH and depression.
They were unable to see past their immigration status and the effect of this on their ability to move forward into work, having been previously employed in a professional role in their country of origin.
The Care Co-ordinator completed the My Wellbeing Plan during the pilot phase and used the tool and approach to support the service user to identify that the loss of their role in relation to employment was having huge impact on their mental health.
This enabled the service user to see that finding a purposeful role was their main goal to recovery. They were supported by a Support Time and Recovery Worker to access voluntary opportunities and found voluntary employment in service supporting refugees with the outcome that the service user’s MH improved and they were discharged from services.
We have been talking about our plan and approach openly and transparently with people on an informal basis. We have showcased the approach at a national TLAP sharing good practice conference focused on mental health, the Bradford Positive Practice Integration event and we will be sharing the approach at the Positive Practice Collaborative event we are hosting on 19th May.
We have also shared this with the Chief Social Worker for Adults and key individuals in NHS England working on the adult mental health programme.
We are fully committed to sharing our practice with anyone who has an interest in what we have been doing and are in the process of writing up the work to aide this sharing through practice journals etc.
Is there any other information you would like to add?
Although the approach is in place for adults, we are seeking to implement this for Young People making the transition to adulthood. We believe this will help with the cultural transition to adulthood and adult services and promote increased self-determination and self-management.