Suffolk & North East Essex Integrated Care System

Giving people more control & personalised care

Why this is important for people in Suffolk and North East Essex

Choice and control over our own health and care are essential if everyone in Suffolk and North East Essex is to live well. Personalised care means people have choice and control over the way their care is planned and delivered, based on ‘what matters’ to them and their individual strengths, needs and preferences. In health and social care, personalisation focuses on placing the individual at the centre of their care and gives people a voice.

As an Integrated Care System our vision is to

Co-produce and deliver person centred, personalised care for all our population that respects choice, addresses inequalities and increases independence and wellbeing.

Our mission is to deliver a fundamental shift in how we work alongside people and communities, recognising that the importance of ‘what matters to someone’ is not just ‘what’s the matter with someone’.

To enable personalised care, we want to achieve the following benefits:

  • People are involved in decisions and planning their care.
  • People have access to care that is integrated – joined up and focused around them and their carer’s needs.
  • People can access support that is flexible to meet their needs and circumstances.
  • People have access to local resources that reflect their community’s needs and challenges.
  • People know how to live as well as possible with their health conditions and where to obtain help if their needs change.

Our approach will focus on:

  • Engaging people, integrating care and reducing avoidable service use
  • Supporting people to build knowledge, skills and confidence and to live well with their health conditions and
  • Supporting people to stay well and building community resilience, enabling people to make informed decisions and choices when their health changes
Giving people access
What do we know about people’s local experiences?
  • We should encourage personal responsibility in self-care and maintaining own health, and promote healthier lifestyles, screening and health checks.
  • Technology is useful in supporting people; professionals could promote apps to help with self-care, but older people lack of awareness about assistive technology.
  • We should improve awareness of personal budgets and facilitate personalised support.
  • The person must be put first. Professionals should treat people with respect and dignity, be caring, value their opinions, believe the patient, and give people enough time. Health professionals must acknowledge that the patient or their carer are often the expert in their condition and involve them in care planning.

For further information go to Healthwatch Essex and Healthwatch Suffolk

Personalised Care Staff Newsletter

Our ICS wide Personalised Care Strategy

Has been developed for the next three-year timeframe (2022-2025) bringing together all the guidance, best practice, local ambitions, targets and planning requirements into a strategy direction of travel document setting out how the ICS will deliver its Personalised Care vision, mission, outcomes and key deliverables.

The strategy sets out how the ICS will deliver the nationally endorsed Universal Personalised Care Comprehensive Model locally for our communities through our Alliance partnerships and workforce in Ipswich and East Suffolk (IES), West Suffolk (WS) and North East Essex (NEE) building on progress to date, delivering continuous improvement and learning from best practice.

There are six delivery workstreams set out in the strategy which are: shared decision making; care and support planning; patient choice; social prescribing; self management and personal health budgets

Delivery of these workstreams will be supported by a range of enablers including co-production, communications, workforce development, commissioning, digital and evaluation.

The full ICS Personalised Care Strategy can be accessed here.

What’s the current picture?
  • Research has indicated that personal budgets impact positively on well-being, increasing choice and control, reducing cost implications and improving outcomes. Studies have shown that direct payments increase satisfaction with services and are the purest form of personalisation. The Care Act places personal budgets on a statutory footing as part of the care and support plan.
  • Percentage of people aged 65 and over using social care that receive self-directed support and those receiving direct payments
  • From tracking over 9,000 people with long-term conditions across a health and care system, evidence has shown that people who are more confident and able to manage their health conditions (that is, people with higher levels of activation) have 18% fewer GP contacts and 38% fewer emergency admissions than people with the least confidence.
  • A literature review of over 1,000 research studies found peer support can help people feel more knowledgeable, confident and happy, and less isolated and alone.

The graphic below demonstrates the benefits and difference personalised care has made in line with the 6 Strategy delivery workstream areas:

How will the personalisation of care make a difference to you?

1. Shared Decision Making: People have expert support to make the care decisions that are right for them

  • People will be supported to be as involved as they would wish, in the decisions about which courses of action are best for them to take (or not take) to treat changes in their health.
  • People will be supported to understand their diagnosis. What the different options are and the risks, benefits, and consequences of each action.
  • Staff will use tools and evidence that demonstrate to people the effectiveness of specific options and treatments. This helps people to make informed decisions about their care and should include use of digital technologies, such as the NHS approved Mum and Baby App, which supports families by providing up to date evidence-based information, enabling them to make informed choices about their care throughout their antenatal and postnatal journey.
  • People are supported to talk about ‘what matters to me’ to meet the outcomes most important to them and with a mutual agreement made about the next steps.

1.2 People can encourage these conversations with ‘Ask 3 Questions”

1.3 How will the system support the people

  • Health and care staff will be trained to help patients make informed choices and decisions. Since individuals’ values and preferences differ, ensuring choice and sharing control can meaningfully improve care outcomes.
  • Staff will gauge a person’s level of knowledge, skills, and confidence. Understanding and engaging peoples’ confidence to be involved in healthcare decisions will increase the success of a mutual outcome.
  • People who need extra support to make and communicate their choices will have support to make decisions, such as through social prescribing link workers. Approaches based on what is important to the person can help ensure those who need extra support to make decisions have their voices fully heard.

Last Updated on May 17, 2022

2. Personalised Care and Support Planning

  • Personalised care and support planning is a key component being rolled out for people receiving health and social care services to help improve successful support.
  • Conversations are be facilitated between staff and patients (or those who know them well) to better understand their health and wellbeing in the context of their whole life.
  • A person’s skills, strengths and experiences are being recognised to understand what is most important to them- helping address areas that are not working and actions to resolve these.

2.1 What does the plan look like?

Whilst there is no set template for the plan, it will reflect the following:

  1. A reflection of conversations, decision and agreed outcomes, presented in a way that clearly make sense to the person
  2. Relevant, coordinated, and adaptable to a person’s health conditions, situation and needs.
  3. Include what is important to the person and the necessary elements required to make the plan achievable and effective.

Last Updated on May 17, 2022

3. Enabling choice, including legal rights to choice

  • Enable choice of provider and services that are able to better meet individuals’ needs, including the legal rights to choice in respect of first outpatients appointments and finding alternative suitable providers if required.
  • This will mean that:
    • People are aware of their choices, including their legal rights.
    • GPs and referrers are aware of and want to support people in exercising the choices available to them.
    • People and GPs/referrers have relevant, good quality information to help people make choices about their care, treatment and support

Last Updated on May 17, 2022

4. Social prescribing and community-based support

  • Social prescribing link workers in Primary Care Networks will work with people to develop tailored plans and connect them with local groups and support services. Social prescribing can result in improved quality of life and wellbeing; and reduce demand on statutory health and care services.
  • People will be better informed about local groups and communities. Accurate and updated information enables people to access support independently, not solely when ‘prescribed’.
  • Community-based groups, and primary care resources such as pharmacists, will advise and motivate people to self-care. Communities play an important part in proactive self-care.

Last Updated on May 17, 2022

5. People have the advice and support they need to self-manage their health and wellbeing

  • Social prescribing link workers in Primary Care Networks will work with people to develop tailored plans and connect them with local groups and support services. Social prescribing can result in improved quality of life and wellbeing; and reduce demand on statutory health and care services.
  • People will be better informed about local groups and communities. Accurate and updated information enables people to access support independently, not solely when ‘prescribed’.
  • Community-based groups, and primary care resources such as pharmacists, will advise and motivate people to self-care. Communities play an important part in proactive self-care.

Last Updated on May 17, 2022

6. Personal Health budgets: People with long term conditions and disabilities have more choice and control over how the funds for their health and wellbeing are spent

  • Collaborative care planning and agreement between the individual/representative and the CCG about how the funding for their health and wellbeing need will be met, is a different approach to spending money which transfers choice and control to the person being cared for.
  • Encouraging the uptake of personal budgets and direct payments in social care, and the uptake of integrated personal budgets. Personalised care and support planning is key to this approach. Everyone in health and care has a role in encouraging people to take control over their care in this way.
  • Using public health management approaches to identify groups wherever uptake of personal budgets is low. Targeting specific groups and communities can be an effective way to improve uptake of personal budgets.

Last Updated on May 17, 2022

Case Study: Connect for Health (Ipswich and East Suffolk)

  • Back in 2018 the Ipswich and East Suffolk CCG brought together statutory services, the voluntary and community sector, and patient representatives to understand how a social prescribing programme could work to benefit patients. The Connect for Health programme was the answer to this, initially launching in 2019. It aimed to connect people with their communities, linking them with services to improve their health and wellbeing.

    Community connectors are able to spend extended time periods to work with individuals to create a personalised plan of support, based on what is important to them, their skills, strengths and areas of need. This may include those who feel isolated being connected to befriending groups and individuals with housing issues being connected to housing officers and citizens advice.

    A case study from the Ipswich and East Suffolk Connect for Health social prescribing service is set out below:

    Personalised care

Last Updated on May 17, 2022

Case Study: Health Coaching (West Suffolk)

Between 2019-2021 the Health Coaching team at West Suffolk Hospital have provided training for over 340 staff from 25 different organisations. The Health Coaching training course provides community practitioners, link workers, activators etc. with new mind-sets, communication skills and behaviour change techniques that transform the practitioner – patient relationship and enable patients to become more active participants in their own self-care. This training has led to more confident staff teams, a reduced amount of service needed and most importantly better outcomes for people.

A case study from the West Suffolk Health Coach programme is set out below:

Amy a respiratory physiotherapist was working with a Steve, 68-year-old gentleman who suffered with chronic breathlessness. Steve had previously been previously referred for exercise on prescription by his GP but had never actively participated. Subsequently Steve’s condition had not improved, leaving him feeling angry and frustrated.

Amy utilised her health coach training to create an open discussion around what was most important in his life, his main barriers and what he felt capable of achieving moving forwards. Through health coaching, Steve was able to better accept his diagnosis and how he could manage it. Feeling generally happier and more motivated he was able to create a self-identified action plan with Amy. What’s more, Steve’s motivation to self-manage eventually meant he no longer required consultant care.

Last Updated on May 17, 2022

Case Study: Green Prescribing (North East Essex)

Through a collaborative partnership with system partners, North East Essex has been able to develop and deliver different green nature prescriptions. Green social prescribing, which is the introduction of nature and nature-based activity, has been shown to improve mental health and reduce health inequality.

Projects include Clacton-on-Sea’s community garden, which formally opened in October 2021 and sits alongside Kennedy Way Medical Centre. It is formed of raised beds, grassy areas with benches, allotments, refreshment facilities and wildlife areas, providing a beautiful space for people sit and connect with nature. Activities at the community garden range from having space to connect and meet new people, growing vegetables, to building a shed. Not only does spending time outdoors impact mental health and wellbeing, but the Kennedy Way Community Garden helps reduce social isolation and build new skills.

One such example is Gary, who in August 2021 suffered a stroke. Gary was supported to join the Men’s Shed within the Community Garden, who enabled Gary to build a frame for a new tool shed. Not only did this help Gary’s physical rehabilitation, but it gave him a sense of purpose, helping to reduce his isolation and cope with his depression.

Last Updated on May 17, 2022

Last Updated on May 17, 2022

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