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C4CC partners respond to launch of Universal Personalised Care

C4CC partners have begun to respond to the publication of Universal Personalised Care: Implementing the Comprehensive Model.

The NHS Long Term Plan (LTP) says that the time has come to give people the same choice and control over their mental and physical health that they have come to expect in every other part of their life.

Universal Personalised Care sets out the plan for achieving this change. It establishes the comprehensive personalised care model with six evidence-based programmes of work and details how the NHS can support people of all ages, and their carers, to manage their physical and mental health and wellbeing, build community resilience, and make informed decisions and choices when their health changes.

Responses to the plan from C4CC’s partners can be found below. We will add to this page as more come through.

C4CC’s response can be read here, and our co-chair Anna Severwright has also written a blog post sharing her thoughts on how Universal Personalised Care provides the opportunity to move personalised care from the margins to the mainstream.


Age UK

Royal College of Occupational Therapists

National Voices


Think Local Act Personal

Shared Lives Plus

1,000 link workers to be recruited to support social prescribing roll-out

NHS England has this week announced plans to recruitment  1,000 ‘link workers’ to help patients live fitter, healthier lives and combat anxiety, loneliness and depression.

Around half of GP appointments are not directly related to medical conditions and growing evidence shows that referrals to community services such as exercise or art classes  – known as social prescribing – can boost health and wellbeing.

The recruitment of 1,000 link workers is part of NHS England’s plans to expand social prescribing.  Link workers will be able to give people time to talk about what matters to them and support them to find suitable activities that are a better alternative to medication as part of a step change in the provision of ‘personalised care’.

The blueprint for Universal Personalised Care, which will also free up GPs to deal with patients who really need them, is due to approved by the NHS England Board later this week.

The NHS Long Term Plan will see GPs surgeries big and small will work to support each other in around 1,400 Primary Care Networks covering the country, with each network having access to a social prescriber link worker and NHS England agreeing to fund their salaries in full.

By 2023-24, social prescribers will be handling around 900,000 patient appointments a year.

Dr Nikita Kanani, NHS England’s Acting Medical Director of Primary Care, said: “We will be recruiting a substantial number of people to support general practitioners over the next five years, to help ease the workload and pressures that we know general practice is under. But we see the network of social prescribers as a fundamental change to the way primary care operates and vital to the future. Recruiting social prescriber link workers will be a priority target as a part of the Universal Care Plan.”

The expansion of social prescribing is backed by family doctors and comes alongside plans to expand the primary care workforce as outlined in the NHS Long Term Plan.

James Sanderson, NHS England’s Director of Personalised Care, said: “A further 2.5 million people will benefit from personalised  care by 2024. A one-size-fits-all health and care system simply cannot meet the increasing complexity of people’s needs and expectations, so we’re setting out how people who live with multiple long term conditions can expect the same choice and control over their mental and physical health that they have come to expect in every other aspect of their life.”

“Social Prescribing is an important component of the NHS comprehensive model of Personalised Care and there is emerging evidence that it can lead to a range of positive health and wellbeing outcomes for people, such as improved quality of life and emotional wellbeing. The aim is that social prescribing schemes lead to a substantial reduction in the use of NHS services, including GP attendances.”

Dr Richard Vautrey, BMA GP committee chair said: “Every day, GPs see a large number of patients with a broad range of health conditions. But often, those who come to see their GP will have complex underlying reasons for doing so, not always medical and often linked to social and domestic circumstances which affect their physical and mental wellbeing.

“Good access to professionals who can link patients to local services and activities – such as community support groups and classes – can be of great benefit to patients, actively involving them in their own care and improving their longer-term wellbeing. This should also allow GPs to focus their time and expertise on treating people’s more immediate or acute health needs.

“GPs and their teams are under a huge amount of pressure to deliver high quality care to a rising population with increasingly complex needs, and therefore it is vital, now more than ever, that patients are able to see the right healthcare or support professional for them within a reasonable timeframe. The BMA has long-backed social prescribers supporting the general practice team, and this commitment to roll them out across the country is very welcome.”

The NHS Long Term Plan is the first time in the NHS’ 70 year history when there will be a new guarantee that investment in primary, community and mental health care will grow faster than the growing overall NHS budget.

This will fund a £4.5 billion new service model for the 21st century across England, where health bodies come together to provide better, joined up care in partnership with local government.

Professor Helen Stokes-Lampard, chair of the Royal College of General Practitioners, said: “Often the underlying reason a patient visits their GP is not medical, yet it can have a considerable impact on their health and wellbeing. Ensuring that GPs and our teams have good, easy access to people who can link patients with classes or groups in the community and other non-NHS services, that could potentially be of far more benefit than any medicine, is something the College has long called-for, so the focus on this is incredibly welcome.”

The NHS Long Term Plan has a commitment to have 1,000 link workers in Primary Care Networks by April 2021, rising further by 2023-24, and within five years over 2.5 million more people will benefit from social prescribing, a personal health budget, and new support for managing their own health in partnership with patients’ groups and the voluntary sector.

GPs and local agencies work with patients who have multiple long term health conditions to make decisions about managing their health and care, by asking what matters to that individual, rather than just what’s wrong with them. Together, they create a personalised care and support plan that recognises the patient’s personal, social and financial circumstances can also impact their health, so connects them to care and support options in their communities alongside appropriate NHS care.

They will connect patients to community groups and agencies for practical and emotional support for a wide range of people, including those:

  • with one or more long-term condition
  • who need support to help with alcohol and smoking issues
  • who need support with their mental health
  • who are lonely or isolated
  • who have complex social needs which affect their wellbeing.

Dr Marie-Anne Essam, a GP in South Oxhey, an area of significant deprivation in South West Hertfordshire, is the social prescribing ambassador for the Herts and West Essex STP.

She said: “In the 30 years I have spent as a GP, social prescribing represents the most effective, wide reaching and life changing of all initiatives to date. Sometimes I have no idea what underlies a person’s repeated presentation to the surgery.

“Sometimes I catch a glimpse of one or two social determinants of health – like seeing the tip of an iceberg. The link worker spends time and expertise which I lack, to explore with the patients the rest of the iceberg, bit by bit.

“People are enabled to use the clinical services more productively, and make personal advances which are both transformative and sustainable.”

Meanwhile, the NHS Leeds Social Prescribing scheme aims to help 5,000 people a year proactively manage their health and wellbeing and address wider issues that impact on their health such as housing issues and reducing social isolation.

GPs refer those who would benefit from more time to talk about the source of the issue and link them with wider community groups such as walking or singing or mental health support charities; people can also self-refer.

In the Leeds scheme, patients have an in-depth consultation with a well-being co-ordinator who can spend time listening to the person’s needs and goals and help put a plan together.

Commissioned by NHS Leeds Clinical Commissioning Group, the £1.5million programme also frees up GP appointments so doctors can spend more time with people with complex conditions.


Why it matters to me that personalised care features in the NHS Long Term Plan

Anna Severwright

C4CC’s co-chair Anna Severwright, blogs about the NHS Long Term Plan and why the incusion of personalised care matters to her.

As someone living with multiple long term conditions, there’s a lot in the newly published NHS Long Term Plan that is important to me but nothing quite as much as this statement in chapter 1: “People will get more control over their health and more personalised care when they need it”.

I am very grateful for all the great clinical care that I receive from the NHS. But I find I am seen by multiple different professionals, focussed on either a specific condition or a particular part of my body. Many of them don’t see me as a ‘whole person’ or take the time to understand how my conditions affect my life.

I recently had an appointment with one of my consultants who I have seen for a few years. He treats one of my conditions, but he doesn’t know about my role with the Coalition for Collaborative Care (C4CC) or anything about my life. This is because I am never asked about anything other than my clinical symptoms. (He also referred to me as Emma not Anna in his last letter…)

The reality for me is that my consultant can’t fully treat my condition without knowing how my condition limits me, my priorities for treatment and about my life. Living with a long term condition is not just about clinical indicators and blood test results – but also about getting my quality of life to be the best it can be.

The Long Term Plan states the need to shift from ‘what’s the matter with someone’ to ‘what matters to someone’. C4CC has championed better conversations between people and professionals since we formed and it’s great the plan says it will support and train staff to have these conversations in a more person-centred way.

The plan also talks about ‘creating genuine partnerships’ between patients and staff. If healthcare professionals acknowledge that people and their carers are experts in their own lives and conditions, then a joint plan, using both the patient’s and professional’s respective knowledge can be agreed. I know that if I co-create a plan – one that actually works with my life – I’m much more likely to follow it and for it to positively impact my health.

‘A shared responsibility for health’ is also referenced in the plan and this will only be achieved with a shift from ‘doing to’ to ‘doing with’. The reality is that every day I manage my long term conditions and it’s hard work. It is welcome that the plan says it will ‘ramp up support for people to manage their own health’ but this support needs to be individually tailored to people.

The increase in personal heath budgets will allow more people with higher support needs to have greater control over what care they receive, from who and how. This choice and flexibility is so important to allow people the flexibility to live the life they want.

Last year C4CC and Think Local Act Personal (TLAP) published Making it Real a framework which was co-produced with people with lived experience. It includes a series of statements that describe what good personalised care and support looks like from the perspective of individuals and organisations. The first ‘I’ statement begins with “I can live the life I want…” and for me that sums up why personalised care matters.

A key factor in people being able to live the life they want is community. We all need to feel connected to others in some way and loneliness has a massive detrimental effect on a person’s health and wellbeing. The expansion of social prescribing is a welcome shift, from seeing medication as the answer, to thinking more holistically about someone’s life and what else might improve their health. For social prescribing to be successful we need to continue working with communities and the voluntary, community and social enterprise (VCSE) sector to ensure strong communities and that there are welcoming places for people to form connections and feel a part of.

For these approaches to make positive improvements to people’s lives and health however, services need to be co-produced with the local community, workforce, patients and carers. Otherwise they won’t be what people need or want and will be less effective, wasting both time and money.

Inevitably there are challenges in delivering the roll-out of personalised care. The workforce needs training and staff need to feel confident in working more collaboratively with patients. There are many already doing it, but for a lot it’s a new way of working and a culture shift. Also working closely and in partnership with social care and the VCSE sector is vital to this being successful, and health must not try to ‘go it alone’.

The numbers in the Long Term Plan – 2.5 million people benefiting from personalised care in the next five years with this doubling to 5 million in the next decade – are undoubtedly ambitious. In my role as co-chair of C4CC I will be not only be working with partners to harness the collective power of our partnership to help make this a reality but will also be ensuring that as we scale up we focus on quality of personalised care as well as numbers.

This is the largest commitment to personalised care in the NHS that we have ever seen and a great move forward towards the ultimate goal of personalised care becoming ‘business as usual’.


NHS Long Term Plan signals expansion of personalised care

NHS England has today (7 January 2019) launched its Long Term Plan which includes a commitment to rolling out personalised care to five million people over the next ten years.

The plans will ensure that many more people have choice and control over their mental and physical health.

This includes the expansion of personal health budgets with 200,000 people set to benefit from one in the next five years. Around 750,000 people with a long term health condition will also receive a written personalised care and support plan to manage their condition.

Social prescribing also features significantly in the Plan and 1,000 link workers will be recruited for GP practices this year and up to 900,000 people will benefit from social prescribing and community-based interventions by 2024.

Personalised care has been made a priority in the Long Term Plan following a decade of evidence based research working with patient and community groups. Evidence shows that personalised care improves people’s health and wellbeing, joins up care in local communities, reduces pressure on stretched NHS services and helps the health and care system to be more efficient.

Anna Severwright, co-chair of C4CC commenting on the Plan, said: “It is very encouraging to see personalised care feature strongly in the Long Term Plan. As someone with multiple long-term health conditions I know the huge difference it can make when care is personalised and when you are genuinely listened to and recognised as an expert in your own condition – and your own life.

“We now have a fantastic opportunity to make personalised care a reality for many more and ensure that people get the same choice and control in their healthcare as they would expect in every other part of their lives.”

Read Anna’s blog post.

Nigel Mathers, co-chair of C4CC added: “The C4CC partnership has championed personalised care for many years and we are pleased to see the NHS Long Term Plan includes a commitment to its expansion.

“Great progress has already been made and growing evidence supports a personalised approach to healthcare but there is much more to be done to realise the ambitions set out in the Long Term Plan. The success of these plans will require support across the sector, and many organisations and groups, including professional bodies, health organisations and the community and voluntary sector have an important role to play in helping to make personalised care ‘business as usual’ for the NHS.

“C4CC and our partners are looking forward to supporting the NHS with these exciting but challenging plans.”

James Sanderson, Director of Personalised Care, NHS England said: “A one-size-fits-all health and care system simply cannot meet the increasing complexity of people’s needs and expectations. Evidence shows that people will have better experiences and improved health and wellbeing if they have the opportunity to actively shape their care and support. As local health and care organisations work together more closely than ever before, we are also seeing that individuals can be the best integrators of their own care.”

The NHS Long Term Plan can be downloaded here.

A blog post from James Sanderson highlighting how the Long Term Plan puts people at the heart of the system can be read here.

A case study highlighting how Dylan has used a personal wheelchair budget to live independently for the first time in his life can be viewed here.

Reinforcing the human and healing aspects of psychiatry

Dr Jed Boardman and Dr Subodh Dave, co-chairs of the Royal College of Psychiatrists Person-Centred Training and Curriculum Scoping Group, blog about the need for training to reinforce the human and healing aspects of psychiatry.

Andrea Sutcliffe, the incoming head of the Nursing and Midwifery, has suggested that nursing needs to rediscover the humanity inherent in its role. This need for rediscovery is not confined to nursing and other professions will recognise the need. Witness the plethora of recent books by clinicians on their own personal and professional experiences. Rediscovery for health and social professionals means not only recognising that patients are people, but that practitioners are people too.

How might the training of practitioners contribute to this? How might we reinforce the human and healing aspects of practice as we move into an ever-changing future? Future generations of practitioners will need the skills and capacities that enable us to listen to people who seek our help, to understand and support them in the social context of their lives, and to place an increased emphasis on the active roles they can play as citizens and partners in care processes. They will need a knowledge of both biological and social sciences, as well as the ability to adapt to changing social trends and service delivery.

Person-Centred approaches may provide one of the components needed for these challenges and the Royal College of Psychiatrists (RCPsych) has recently published a report on Person-Centred Training for core trainees. They conclude that person-centred approaches should provide the overarching orientation for psychiatric practice and should be central and explicit throughout the curriculum and consonant with the expected values and competencies of future practitioners. Significantly, the RCPsych’s Scoping Group on Person-Centred Training, comprised not only of psychiatrists but others with expertise in psychiatric education, clinical practice, lived experience as well as many combined experiences.

If we are to reinforce the importance of personhood in training, then our curricula should be explicitly person-centred in its language as in its content. Training must equip trainees to use a range of person-focused approaches in their daily clinical practice, such as shared decision-making, self-directed support, co-production, collaborative care and support-planning as well as ethics, human rights, community engagement and social inclusion. But perhaps most importantly the role of service users, carers and patient representatives in planning and delivering training courses and supplementary skills training must be strengthened.

Read the report, Royal College of Psychiatrists. Person-centred care: implications for training in psychiatry. College Report CR215. Royal College of Psychiatrists, 2018


Webinar: Care and Support Planning

C4CC and Year of Care Partnerships will be jointly hosting a webinar on Tuesday 20 November on care and support planning from 1pm to 2pm.

Care and support planning is a process which replaces current planned reviews for people with long-term conditions. It provides the opportunity for a ‘better conversation’ between the person and the care professional focusing on ‘what matters to them’ rather than ‘what’s wrong with them’. It looks at the outcomes people want to achieve and what support they can access to help them build their knowledge, skills and confidence to self-manage their health and wellbeing.

The session will include Lindsay Oliver, National Director for Year of Care Partnerships who will outline the principles and process of care and support planning as well sharing practical tips for implementation .

Participants will also hear from Dr Becky Haines who is a GP in Gateshead on how her practice is delivering care and support planning for people with long-term conditions. Dr Haines will talk about how this works on a practical level at the practice and the impact this is having not only on people’s experience and behaviour, but on the practice as a whole, including staff satisfaction, knowledge and skills and on practice productivity.

The webinar will benefit care professionals who want to implement, sustain, scale-up or improve their approach to care and support planning. People with long-term conditions, and their carers are also encouraged to take part to hear about what they should expect from good care and support planning and how they can prepare to get the most benefit from the process.

Year of Care Partnerships, is one of C4CC’s partners and is an NHS based organisation that is dedicated to driving improvement in long-term condition care using care and support planning to shape services which involve people in their own care, provide a more personalised approach and support self-management.

The team is based in Northumbria Healthcare NHS Foundation Trust and has developed a “gold standard” approach to support organisations who want to embed care and support planning and support for self-management.

Dr Becky Haines is a practising GP in Gateshead, Clinical Lead for Diabetes for Newcastle and Gateshead CCG and is a Royal College of General Practitioners (RCGP) champion for person-centred care.

To register for this session, please email

Making it Real launched

C4CC is delighted to this week launch jointly launch with Think Local Act Personal (TLAP), the new Making it Real framework for how to do personalised care and support

Making it Real is for people working in health, adult social care, housing, and for people who access services.  It is an easy to use, jargon-free set of personalised principles that focus on what matters to people.

It was launched on Thursday 11 October to more than 100 senior leaders from across the health, care and housing sectors at an event which was attended by the Minister for Care, Caroline Dinenage.

In her address to delegates, the Minister, said: “When it comes to wellbeing, it’s vital that our services look at people’s needs as a whole, from social care to health and housing. That’s why we want to put power back into the hands of people accessing services, their carers and families – by personalising care and focussing it around individual needs – so we can help people to live happier and more independent lives.

“The new Making it Real guide is an important and practical resource to help make personalised care a reality.”

Built around six themes, Making it Real describes what good looks like from an individual’s perspective and what organisations should be doing to live up to those expectations. It supports coproduction between people, commissioners and providers.

Making it Real is a voluntary commitment with access to free materials and support. If you sign up to get involved, you decide how to make best use of it.

Making it Real has been co-produced by Think Local Act Personal and C4CC, with input from partners, organisations and individuals, including the National Co-production Advisory Group (NCAG).

C4CC’s co-chair, Anna Severwright describes the difference Making it Real would make to her life in the short film below.

C4CC co-chair, Nigel Mathers adds: “We are delighted that the updated Making it Real now includes a focus on health. I would urge all organisations serious about delivering personalised healthcare to make use of this fantastic resource.”

James Sanderson, Director of Personalised Care at NHS England, says: “The NHS is on a journey to make personalised care business as usual across the health and care system. This will require a different relationship between people and professionals, with a shift in power and decision making that enables people to have a voice and be connected to their communities. Making it Real exemplifies this vision and is a practical tool that will help to achieve it.”

Read more from James about Making it Real in this blog post.

Visit the Making it Real website to download the framework and to sign up and commit to ‘Making it Real’ in your organisation.


WEBINAR: Shared decision making for people with a life-changing illness

C4CC is hosting a webinar with Compassion in Dying on Thursday 27th September on shared decision making when someone has a life-changing illness.

This online, interactive session will bring together personal, professional and clinical insight into shared decision making, focusing on people living with life-changing illness. The session will consider the experiences of different communities and patient groups as well as carers; clinical barriers and enablers; and offer practical tools for implementation.

Presenters include:

  • Lynne Craven, lived experience of MS and co-founder of the Self-Management Partnership
  • Dr Gehan Soosaipillai, oncologist and clinical research fellow at Imperial College
  • Natalie Koussa, Director of Partnerships and Services, Compassion in Dying

The webinar takes place 1pm to 2pm, to book, please register here.

Shared decision making is part of a wider drive to personalise health and social care which aims to stimulate a shift in culture, power and decision-making from a paternalistic model of care to one where clinicians and patients act as equal partners.

It is where patients, carers and clinicians work together, as equals, to decide what tests and treatments are most suitable bearing in mind the patient’s individual circumstances. It brings together the patient and/or carer’s expertise and what is important to them together with the clinician’s knowledge about what is known about the benefits and risks of the available options.

Shared decision making is key component of NHS England’s comprehensive model for personalised care which sets out an all age, whole population approach to personalised care. The model brings together shared decision making; choice and control; personalised care and support planning; social prescribing and community-based support; supported self-management and personal health budgets to provide a single operating model for personalised care across the health and care system.

Compassion in Dying is a registered charity that helps people prepare for end of life. It provides support to help people plan for their treatment and care, in case a time comes when they can’t make decisions. Compassion in Dying specialises in supporting people to make Advance Decisions (‘Living Wills’) and to talk about their goals and priorities when living with a life-changing illness.

You can find out more about Compassion in Dying and its work at

C4CC will be hosting a number of webinars over the coming months focusing on making personalised care a reality for all. If you would like to present a session then please contact

Network launched for employers of disabled people and people with long-term conditions

C4CC partner CHANGE has launched a new network that will bring together a group of employers to encourage positive attitudes towards employing and supporting disabled people and people with long-term conditions.

The network is free for the first year and will operate virtually providing opportunities for support, sharing, learning and information.

Members will be encouraged to commit to employing at least one person with a disability or long-term health condition.

For more information, see this flyer, or get in touch with Philipa Bragman, chief executive of CHANGE at or on 0113 2426 619.


Help needed with survey about safe care for adults with complex health needs

The NIHR Imperial Patient Safety Translational Research Centre is running a survey with the James Lind Alliance to rank priorities for research about safe care for adults with complex health needs.

Patients, carers, members of the public and healthcare professionals are needed to fill out the survey so priority areas can be identified.

C4CC would encourage its partners and members to use their networks to publicise the survey, which closes on 15 October 2018.