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Leadership for Personalised Care – update from our national roundtables

The Coalition for Collaborative Care (C4CC) and the Leadership Academy ran three virtual roundtable events on 14th March aimed at building support and consensus for an approach to leadership for personalised care, co-production and community building.

Colleagues from the Personalised Care Group at NHS England joined the session together with representatives from Public Health England, Community Catalysts, Altogether Better, Macmillan, British Heart Foundation and a range of community-facing organisations, front-line leaders and citizen representatives also joined to engaged in lively debate and discussion.

At the heart of the roundtable was the question: What mindset, skills and behaviours do NHS leaders need to ensure that personalised care becomes part of the DNA of the NHS?   And following on from that, what does that mean for the Leadership Academy and other organisations providing leadership development at support work at the level of neighbourhood, place and health system?

There was a great deal of consensus from the participants – getting personalised care to be widespread requires transformational change.  We therefore need leaders who have tenacity, courage and a willingness to take on the pain of such bit change by working towards the greater good, across boundaries and are not just concerned with their own organisation.  To get leaders to do that we need to ensure they are engaging with personalised care at a level of values and identity to ensure they have a personal connection with the vision.  Leaders need to develop local, shared purpose and ensure that power is shared with people and communities.  Leaders need a mindset of collaboration, not competition and to be able to think creatively and beyond NHS organisations for solutions.  They need to inspire others and create the space for conversations about what matters at every level.    There was a lot of talk about complex system leadership, the ability to adapt and flex, as well as the need for knowledge about how large scale change really happens – through connected networks, saying ‘yes to the mess’, to work with ‘emergence’ and that ‘those who do the work do the change’.

The outputs from the roundtables will feed into a set of recommendations for the Leadership Academy, and will shape the Personalised Care Group’s leadership development strategy moving into 2019-20.

If you would like to contribute to this work and share your views, please complete this short survey.

To find out more, please get in touch with Catherine Wilton at

RCGP work to update person-centred care resources

The Royal College of General Practitioners (RCGP) is currently working to update its resources on person-centred care around personal health budgets, the new Universal Personalised Care Plan and Comprehensive Model.

For several years, the RCGP has been working with NHS England and key stakeholders to support GPs and primary care teams to deliver person-centred care. In that time, it has developed animations, toolkits, guides, FAQs, training videos and a network of person-centred care champions – just to name a few!

Over the next couple of months, the RCGP will be uploading updated definitions and standards, patient pathway exemplars for cancer, mental health, learning disabilities and diabetes as well as short case studies on how to make quick easy changes to implement person-centred care in practices.

In the meantime, a selection of current RCGP resources can be found below, please feel free to forward and share with your networks. The RCGP is also happy to collaborate on blogs and news articles to support and raise awareness of personalised care.


  • Animation on personalised care for people with long-term conditions
  • Training videos on social prescribing and link workers
  • Animation on Collaborative Care and Support Planning Video

Toolkit with guidance on: social prescribing, health literacy, shared decision making, health coaching, personal health budgets, the consultation, evidence

Guidance on Collaborative Care and Support Planning and on commissioning principles for collaborative care and support planning.

The RCGP PCC Network of Champions online and in-person network brings together GPs, primary care colleagues and people with lived experience who share an enthusiasm for person-centred approaches to health and well-being. The network aims to promote person-centred care approaches in members’ own localities, feed into national pieces of work, represent the RCGP regionally and nationally for PCC among other activities.

For a full list of resources and for more information on the RCGP Person-Centred Care Programme visit our website or contact

Meet Ken….

What’s the best way to support someone who’s too well to stay in hospital, but not quite well enough to go home?

This is a question that Shared Lives Plus has been working on for the past three years.  Together with members, healthcare professionals and hospital trusts, Shared Lives Plus has been developing a way of supporting people who need intermediate care.

They’ve created a short film about Ken who’s in precisely this boat.

Shared Lives intermediate care can provide a stepping stone between hospital and home and offers a natural-feeling home environment for people to recover from illness and regain independence.  Through intermediate care, people are also supported to manage their long-term health condition and lead a healthier lifestyle.  It’s particularly beneficial for people with mental ill health and people recovering from life changing health issues and those who need time to make longer-term arrangements.

Find out more about Shared Lives Plus here.

Invitation to tender: Reading Well co-production

The Reading Agency is looking for a co-production partner to facilitate the development of Reading Well for children and family mental health, which will launch in public libraries in February 2020.

The scheme aims to support the mental health and wellbeing of children aged 4-11 and their families and carers.

They are keen to adopt an approach that embeds co-production throughout and puts children and families at the heart of design and development.

Find out more about this opportunity on the Reading Well website.

Ensuring a comprehensive approach to community

Following the publication of the Universal Personalised Care model, C4CC partners Professor David Morris of the Centre for Citizenship and Communities at the University of Central Lancashire, and Dr Brian Fisher of the New NHS Alliance wrote to C4CC partners to invite discussions with other partners in a call to action to support the ambition in relation to community based approaches, and to develop further dialogue with James Sanderson and the Personalised Care Group about how this can be taken forward by C4CC partners.

In the letter, Brian and David said: We are pleased that community based approaches have featured in UPC and we also recognise there is much more work to do in this area.   To this end, we have had a range of positive conversations highlighting how developing community approaches will only become a reality if its focus on the individual is balanced with one which includes a comprehensive approach to community-centred and community strengthening ways of working.  This is important for prevention, local empowerment and health creation.

We therefore welcome UPC highlighting that local areas need to have “a whole-system strategy to develop community-based approaches”.  We know that this community level perspective is of fundamental importance to the success of personalised care and the allied policy on social prescribing”.

A number of partners gathered together to have a short discussion at the Partners Day on 14 February, and a further date to meet has been agreed to enable a more detailed discussion. If you are interested in contributing as this discussion develops, please contact Carey

C4CC partnership continues to grow

C4CC welcomes three new partners this month, Power to Change, Disability Rights UK and the National Association of Link Workers.  The C4CC partnership now represents a broad mix of more than 60 organisations all committed to working together to ensuring better personalised care in health services.

Disability Rights UK (DR UK) is an organisation led by people with lived experience across the spectrum of disability and health conditions, including mental health conditions, learning disabilities, dementia and autism.  They are a pan disability membership organisation led by disabled people seeking change. Its membership includes individual disabled people and organisations working on their behalf including disabled people led organisations. Among its membership are over three hundred organisations that give advice directly to disabled people, particularly in respect of benefit issues.

Sue Bott, Deputy Chief Executive, Disability Rights UK said: “We are delighted to be signed up as partners with C4CC.  Together we will promote our shared values of co-production and autonomy for and with people who need support.”

Power to Change is the independent trust that supports community businesses in England.  Community businesses are locally rooted, community-led, trade for community benefit and make life better for local people.  From pubs to libraries; shops to bakeries; swimming pools to solar farms; community businesses are creating great products and services, providing employment and training and transforming lives. Power to Change received its endowment from the National Lottery Community Fund in 2015.

Susie Finlayson, Development Manager at Power to Change, said: “Power to Change is pleased to join the Coalition for Collaborative Care to contribute to driving forward the shift to more personalised care for people with long-term conditions. We are excited to work with the individuals and organisations in the partnership and believe that community businesses can play a part in changing the system to work better for the people who need it.”

The National Association of Link Workers (NALW) is the only national professional network for social prescribing link workers in the UK.  It is an independent grassroot social movement and community of practice for link workers.

Christiana Melam, CEO National Association of Lin Workers, said: “The National Association of Link Workers is delighted to join the Coalition of Collaborative Care.  We look forward to working together with partners to mainstream ‘gold standard’ universal social prescribing in order to realise the positive outcomes it can provide for the person, their families, friends and community as well as the reduction in the inappropriate use of health and social care services.”

What the announcement of new areas of ‘Rights to Have’ for a personal health budget means in practice

On 21 February 2019 the Department of Health and Social Care published the consultation response on extending legal rights for personal health budgets and integrated budgets.

In doing this, Caroline Dinenage, Minister for Care, announced the first new areas which will have a legal right to a personal health budget. These are for people eligible for an NHS wheelchair and people who access after care services under section 117 of the Mental Health Act.

This announcement supports the commitment in the NHS Long Term plan that up to 200,000 people will have access to a personal health budget by 2024. It extends the legal ‘right to have’ beyond NHS Continuing Healthcare (CHC) and Children and Young People’s Continuing Care.

The announcement signals the intent to CCGs who should now be preparing for the legal rights to come into force. Work is now underway to include these rights in legislation and it is anticipated this could be in place as early as Autumn 2019.

Survey for people with experience of a personal health budget

NHS England has commissioned Quality Health to run a survey from 14 March to 14 May 2019 to gather feedback about people’s experiences of personal health budgets and integrated personal budgets.

It is open to all current or previous budget holders and those who support them, including those who responded last year, and, for the first time, will separate out wheelchair budgets from other types of personal health budget.

As a result of the 2018 survey, NHS England has:

  • Started a new project to explore the challenges you face with recruiting and employing personal assistants
  • Launched #myPHBstory as a Twitter hashtag to capture and share people’s stories
  • Executed a series of eight regional workshops across the country to commissioners to help them improve their personal health budgets for NHS Continuing Healthcare – co-produced and co-delivered with people with lived experience of personal health budgets
  • Developed long-term plans to offer better information, advice and support for those entitled to or interested in a personal health budget (p10, action 18)
  • Committed to training more people with lived experience to influence systems and support individuals
  • Are identifying more ways to improve the quality of information available to personal health budget holders and commissioners who support personal health budgets

The findings will again be used to improve the support for budget holders and applicants in England.

Please share the link widely, using the hashtag #NHSPHB or tagging @NHSPHB, to make sure everyone’s views are represented.

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.