School of Medicine
Partnership Working – The Role of
the Person Centred Care Plan
Tony Kelly
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School of Medicine
Ten things the literature suggest
enable a ‘good’ service:
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Commissioning (a dementia specific service)
Integration, coordination and care management (joined up care)
Person and relationship centred care (services designed around the client and carer
rather than the commissioner and embrace the person’s unique biography).
Continuity of care (Allocation of the same care worker(s) to the client in order to build a
trusting relationship).
Support for carers (Early home care may allow the carer to acclimate to the range of
demands placed upon them and can be extremely cost effective).
Care planning (the communication of important information)
Training (One of the attributes regarded as being of most value in supporting someone
with dementia)
Support for staff
Flexible and responsive services (Staff are afforded the necessary time and flexibility)
Organisational factors (culture)
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Characteristics of good care (‘Not just
a number’ CQC, 2013
• Providers and commissioners manage identified issues together
• Relatives and carers are routinely involved in decisions about care
• Care plans are kept up to date, reviewed and adjusted in response to
changing needs and preferences
• There is continuity of care workers
• Staff have a good understanding of dementia and are not asked to
undertake tasks unless they have the necessary knowledge and skills.
• There are regular staff and team meetings, and regular information and
updates for staff
• Managers carry out systematic quality checking. They capture
feedback from staff and use it to improve services, survey results are
acted on and inform improvements
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Partnership working / Integrated care –
is about working together?
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“We need to move beyond arguing for integration to making it happen, whilst exploring
the barriers” (NHS Future Forum)
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“Numerous reports and commissions have highlighted the lack of dignity and compassion
afforded to many (often elderly) frail patients in need of multiple services, and a lack of
co-ordination of care is typically a feature of such analyses” (www.nuffieldtrust.org.uk)
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“The lack of joined-up care is the biggest frustration for patients, service users and
carers. Conversely, achieving integrated care would be the biggest contribution the
health and care services could make to improving quality and safety”
(www.nationalvoices.org.uk)
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The needs of service users have not always been central to the planning of services.
Person-centred planning is now at the heart of the Government’s strategy for people who
use health and social care services (Department of Health, 2005 and 2006)
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Feedback from previous conferences:
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7/1/2016
“Live care plan” (Pregnant red book) ask for advice (cf. Tom Dening’s analogy
to a passport to support)
Communication: Passing on information / effective handover
Communication – timing of visit
Provide more information (the full care plan) on admission and discharge for
everyone to follow the same one, written by the person.
Shared assessments and records / Homecare providers sharing information
Homecare can assist with discharge transition, ensuring settled, transport, meds
and information
Better communication / Sharing of information and knowing what is available
IT systems
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PersonCentred Care
Partnership
Care
Working
Planning
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We all talk about ‘person-centred care’ but
what does it mean?
• “The term person-centred care has become all-pervasive on
the UK dementia care scene. It has been suggested that it has
become synonymous with good quality care. It seems that any
new approach in dementia care has to claim to be pc (personcentred)…………..although what lies behind the rhetoric in
terms of practice may be questionable” (Dawn Brooker)
• The World Health Organization’s (1978: 1) definition of health,
provides a good starting point as it includes a whole-person or
holistic approach to care: ‘a state of complete physical,
mental and social well-being and not merely the absence
of disease or infirmity’.
School of Medicine
We all talk about ‘person-centred care’
but what does it mean(2)?
• Assisting people to maintain their individuality is
important in person-centred care (Ericson et al, 2001)
• This involves an awareness of the individual’s life
before dementia, so as to be able to understand the
individual in his or her own biographical context
(Stokes, 1997)
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What does a good person-centred care
plan look like?
• What does a good person-centred care plan look
like? Think about this during the syndicate work
7/1/2016
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The Care Plan
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Accountability for our practice is increasingly evident in the public reports that result
when things go wrong
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NICE Guidance: “Good communication between care providers and people with
dementia and their families and carers is essential…..” (nice.org.uk)
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The Care Quality Commission’s ‘Essential Standards of Quality and Safety’
Outcome 4: The assessment, planning and delivery of care, treatment and support is
centred on the individual and considers all aspects of their individual circumstances
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The National Dementia Strategy promotes person-centred care planning
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‘Enriched Care Planning is Communication’ (Brooker, Edwards and May, 2009)
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Care plans are used as communication tools (National Care Forum)
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Care plans might, however, tend to focus on ‘secondary purposes’
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How might a good person-centred care
plan help with partnership working?
• Providing a link between services (especially ‘out of hours’)
• Life story work, or biographical approaches, promote person centred
care which strengthens relationships between stakeholders.
• Provides a real sense of team working and shared goals
• “If person-centred care is going to work then it is not just about
individual change but a whole culture change” (Sheard, 2004)
• A fundamental change in the culture that governs services is a
prerequisite to the successful delivery of person-centred planning –
part of the focus of today!
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Barriers to partnership working
• Research on national initiatives designed to promote
multi-agency working has drawn attention to a number
of factors inhibiting data-sharing in specific fields,
including absence of trust, inter-professional rivalries,
non compatible IT systems and conflicting
organisational objectives, as well as uncertainties
about data-protection legislation (Bellamy, et al)
• However, where there’s a will, there is (probably) a
way!
7/1/2016
Event Name and Venue
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The Vision
• A person-centred ‘passport’ to services
• An accessible ‘biography’ that helps services to
understand their client’s care needs
• A mechanism to share important information between
services
• A ‘cloud’ based resource that can be used to facilitate
person-centred care
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A way forward?
• There is currently no legal requirement to base services on
person-centred care planning – so it is up to us
• If we want to move forward to make incremental improvements,
we should be willing to cooperate at local level
• A shared vision helps!
• Understanding the barriers to progress helps!
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Would you like to help?
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Share your knowledge of good practice
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Highlight areas of poor practice needing improvement
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Identify the barriers to good practice
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Identify the barriers to good partnership working
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Help to design a way forward
7/1/2016
Homecare Conference for Service managers
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School of Medicine
References
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Bellamy, C. 6, P and Raab, C. (2006), Joined-up Public Services: Data-sharing and
Privacy in Multi-Agency Working, Economic and Social Research Council , Swindon:
RES-000-23-0158.
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Brooker, D. (2003), What is person-centred care in dementia? Reviews in Clinical
Gerontology / Volume 13 / Issue 03 / August 2003, pp 215-222 Cambridge University
Press
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Brooker, Edawrds and May (2009), Enriched Care Planning for People with Dementia:
A Good Practice Guide to Delivering Person-Centred Care
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Ericson, I., Hellstrom, I., Lundh, U. and Nolan, M. (2001) ‘What constitutes good care
for people with dementia?’, British Journal of Nursing, Vol. 10, No. 11, pp. 710–14
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Sheard, D. (2004) ‘Person-centred care: the emperor’s new clothes?’, Journal of
Dementia Care, March/April, Vol. 12, Issue 2, pp. 22–4
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Stokes, G. (1997) ‘Reacting to a real threat’, Journal of Dementia Care, January/
February, Vol. 5, Issue 1, pp. 14–15