Personalised Care, Social Prescribing, Assessment and Improvement

Delivering Universal Personalised Care to 2.5 million people by 2024 is a key aspect of the NHS Long Term Plan published in 2019.

• Supporting people to make informed decisions and choose to do what matters to them for their health and well-being, is becoming business as usual.
• Measuring patient and carer experiences, of services and in the community, is more important than ever before.

Social prescribing and community-based support

GPs, nurses and other primary care professionals can refer people to a range of local, non-clinical services (a 'community referral').

Social prescribing is used where people can live better by improving social and environmental aspects of their lives. For example, social prescriptions might encourage people to live better by being active in their local community by volunteering, befriending or doing activities provided by community organisations.  

Social prescribing has been found to benefit people affected by dementia and services.

• Example of Dementia Companions in Shropshire 
• Example of Primary Care Navigators in Gateshead
  • NHS England: Improving dementia care through care navigation and social prescribing. It was noted that there was a lot of variation in outcomes for people with dementia nationally. In Gateshead, the Primary Care Navigator role in a GP practice connected people with dementia and carers to services and activities to help with well-being. This led to measurable benefits in a short period including reduced hospital admissions and improved patient experience.
• A survey in 2018 by the Royal College of GPs (General Practitioners) found that 59% of GPs believe social prescribing not only helped patients, but also reduced their workload by an average of 28%, and called for its use more widely.

Care Planning and shared decision-making

'Care planning is a priority for NHS England and plays a vital role in improving the quality of mental health and dementia services.' (NHS England: Dementia - good care planning (2017)).

Yet, according to the GP Patient Survey (NHS England, 2018)

• only 40% of adults report that they have had a conversation with a healthcare professional in their GP practice to discuss what is important to them
• only 7% of adults have been given (or offered) a written copy of their care plan.

Everyone diagnosed with dementia should have an individual care plan, with, wherever possible, greater integration with support plans in other areas such as social services. 

• a care plan should
  • be written- in clear, simple and precise language that is accessible for the person with dementia, or be in an appropriate alternative format.
  • understand what matters to the person with dementia.
    • It should include goals or actions to enable the person with dementia to live well, to maintain their health and well-being, including  through pursuing interests, hobbies and social functioning, and supporting them to self-manage their dementia.  
  • explain care: including contingency plans for the future, and arrangements for review
  • be developed by staff together with the person with dementia and carers
    • the staff should be trained in care planning, including encouraging the person with dementia to express themselves.
    • the process should start with asking what is important to the person with dementia, their concerns and priorities, now and for the future. 

Dementia Assessment and Improvement Framework

The framework supports leaders in NHS provider organisations, such as consultants, charge nurses, and allied health professionals, to provide ‘outstanding’ care for people with dementia in acute, community and mental health settings.

The framework is evidence based, integrating best practice, national policy and the voices of people with dementia and carers.  

NHS Improvement recommends that the framework forms part of an organisation’s quality improvement programme across all services, adapted by organisations for local use.

The framework has eight standards against which services self-assess and identify where improvements are needed and have improved desired outcomes. These include:

• diagnosis
• person-centred care
• patient and carer information and support
• involvement and co-design
• workforce education and training.