My Care and Support Plan

Why are the changes taking place?

Community mental health policy and practice have evolved significantly over time and new legislation such as the Care Act 2014 has been introduced. Coupled with investment and changes to community mental health services, it is time for a fresh approach.

What is My Care and Support Plan?

The new approach is based on the following principles:

• A shift from generic care co-ordination to meaningful intervention-based care planned between the service user and their care team.
• A named key worker for all service users but with a multi-disciplinary team approach. This means the right people from a number of different services — including social care and the voluntary sector — can provide the right care at the right time based on an individual’s need. This can help to address people’s social need as well as clinical need. And reduce potential gaps in service provision.
• High-quality, co-produced, holistic and personalised care and support planning with service users actively co-producing and reviewing their care plan with staff. This includes input from non-NHS partners where appropriate, such as social care, housing, public health and the voluntary, community and social enterprise sector.
• Better support for, and involvement of, carers to provide safer and more effective care. This includes encouraging carers and family members to input into care and support planning.​ Because the role of family and friends in a person’s life is important.
• A more accessible, responsive and flexible system in which approaches are tailored to the health, care and life needs, and circumstances of an individual, their carer(s) and family members.

My Care and Support Plan will involve five stages of care:

• Assessment
• Care planning
• Intervention
• Care review
• Recovery

As part of the care planning, the move away from CPA will embrace the newly introduced Patient Reported Outcome Measures (PROMs).

What are PROMs?

PROMs is an acronym that stands for Patient Reported Outcome Measures.

Outcomes refer to the result of any care or treatment provided. It could be that our support has helped someone lead a more fulfilling life, reduced or stopped any symptoms they may have had, or helped them back into employment or education.

Completing these outcome measures helps us to understand a person’s needs and develop meaningful relationships and interventions based more entirely on their goals.

The outcome measures have been developed based on research evidence and recommended for us to use by NHS England and the Royal College of Psychiatrists. 

To support the move away from the CPA, we’ll be using three PROMs. These are:

• DIALOG: This is a simple set of 11 questions that help plan care around what truly matters to the service user
• Goal Based Outcomes (GBO): These focus on what the service user wants to achieve and get out of their care and support. And measures their progress towards these identified goals.
• Recovering Quality of Life (ReQol-10): This has ten questions about quality of life, and how this is linked to the service user’s recovery.

You can read more about PROMs here.

What do the new plans include?

The new plans will:

• Be personalised. Because we’re all different and one size does not fit all.
• Share key information.
• Be developed by the service user with their health care professional.
• Welcome the views of carers, loved ones and family members.
• Consider physical, mental and social needs.
• State what actions people need to improve their health and wellbeing. This includes actions that the service user agrees to take, things that carers might undertake and the actions services will undertake.
• Include care provided by partner agencies.
• Make sure that people don’t need to repeat information to several different agencies.

The plans will also provide detail on a named key worker.

What is a key worker? And what will happen to my care co-ordinator now?

All service users will have a named key worker they can contact. This will be the most suitable person from the multi-disciplinary team. In a lot of cases, this will be their existing care co-ordinator.

But because we’re adopting a multi-disciplinary team approach, service users and carers will be supported by members of the wider care team, too. This means the right people will be able to provide the right care at the right time based on an individual’s need.

Who will My Care and Support Plan be shared with?

The service user will have control of who their plan is shared with. This will be discussed and agreed.

How will carers be supported?

There will be proactive support for carers. Their thoughts, comments and ideas will be welcomed and supported. Service users will be encouraged to share information with them and to include them in care planning and delivery.