Cookies on the NHS England website

We’ve put some small files called cookies on your device to make our site work.

We’d also like to use analytics cookies. These send information about how our site is used to a service called Google Analytics. We use this information to improve our site.

Let us know if this is OK. We’ll use a cookie to save your choice. You can read more about our cookies before you choose.

Change my preferences I'm OK with analytics cookies

Personalised care and support planning

Personalised care and support planning is a series of facilitated conversations in which the person, or those who know them well, actively participates to explore the management of their health and well-being within the context of their whole life and family situation.

Personalised care and support planning is key for people receiving health and social care services. It is an essential tool to integrate the person’s experience of all the services they access so they have one joined-up plan that covers their health and wellbeing needs.

The process recognises the person’s skills and strengths, as well as their experiences and the things that matter the most to them. It addresses the things that are not working in the person’s life and identifies outcomes or goals and actions to resolve these.

What are the benefits to personalised care and support planning?

Valuing people as active participants and experts in the planning and management of their own health and well-being ensures that the outcomes and solutions developed have meaning to the person in the context of their whole life, leading to improved chances of successfully supporting them.

Integrating health and social care at the point of assessment and planning means the person will not have to repeatedly share their story time and time again, as they will have one assessment and planning experience that results in a single integrated personalised care and support plan.

Personalised care and support plans

The personalised care and support plan is developed following an initial holistic assessment about the person’s health and well-being needs. The person, or their family, work hand-in-hand with their health and social care professionals to complete this assessment which then leads to producing an agreed personalised care and support plan.

There is no set template for what a personalised care and support plan should look like but it should reflect the following:

• A way of capturing and recording conversations, decisions and agreed outcomes or goals in a way that makes sense to the person.
• Should be proportionate, flexible and coordinated and adaptable to a person’s health condition, situation and care and support needs.
• Should include a description of the person, what matters to them and all the necessary elements that would make the plan achievable and effective.

A personalised care and support plan must meet the 5 criteria below:

1. People are central in developing and agreeing their personalised care and support plan including deciding who is involved in the process.
2. People have proactive, personalised conversations which focus on what matters to them, paying attention to their needs and wider health and wellbeing.
3. People agree the health and wellbeing outcomes they want to achieve, in partnership with the relevant professionals.
4. Each person has a sharable, personalised care and support plan which records what matters to them, their outcomes and how they will be achieved.
5. People are able to formally and informally review their personalised care and support plan.

The key features

Perspective – it is a way of ‘seeing people’ as whole person not as a person through the lens of their condition and is fundamental to good personalised care and support planning.

The changed relationship and different conversation will mean that the person:

• is empowered to take control of their own care and builds knowledge, skills and confidence to participate more meaningfully
• experiences hope and feels confident that the process and the plan will deliver what matters most to them
• is central in developing their personalised care and support plan and will agree who is involved.
• is seen as a whole person within the context of their whole life, valuing their skills, strengths, experience and important relationships
• is valued as an active participant in conversations and decisions about their health and well being.

Process – this is the overall process of personalised care and support planning.

A good personalised care and support planning process will mean that the person:

• has the time and support to develop their plan in a safe and reflective space
• is able to access information and advice that is clear and timely and meets individual information needs and preferences
• feels prepared, knows what to expect and is ready to engage in planning supported by a single, named coordinator
• is listened to and understood in a way that builds trusting and effective relationships with key people
• is able to agree the health and well-being outcomes (and learning outcomes for children and young people with education, health and care plans) they want to achieve, in dialogue with the relevant health, education and social care professionals
• has the chance to formally and informally review their personalised care and support plan.

Plan – this is what a good plan looks like.

There is no national template but a personalised care and support plan is:

• a way of capturing and recording conversations, decisions and agreed outcomes in a way that makes sense to the person.
• proportionate, flexible and coordinated and adaptable to a person’s health condition, situation and care and support needs.
• includes a description of the person, what matters to them and all the necessary elements that would make the plan achievable and effective.

Health Systems Support Framework – digital personalised care and support planning systems and services

In Autumn 2021 the personalised care and support planning and digital personalised care teams undertook a procurement exercise on behalf of the NHS through the Health Systems Support Framework (HSSF).

The HSSF makes it easier and simpler for local NHS organisations to identify and commission suppliers. All bids are assessed both for the quality and relevance of the product and the standing of the supplying organisation.

The personalised care and support planning and digital personalised care teams looked for suppliers who could demonstrate the ability to provide digital solutions that support the workforce and the individual through the entire personalised care and support planning process and that provide interoperability across care settings so individuals do not have to share their story multiple times, and which enable access to up to date information.

Organisations wishing to find out more about the HSSF or to commission a supplier for a digital personalised care and support planning system can register for access to the HSSF workspace.

From here, organisations will also be able to find supporting information to assist with the procurement and contracting process, including a buyers’ guide specifically for the digital personalised care and support planning service line. Information on suppliers can also be found on the Health Systems Support Framework website.