Personalised Care and Support Planning

Instead of starting with a focus on cancer and its treatment, personalised care plans start with the person and their priorities. The approach aims to ask ‘what matters to you?’ – rather than ‘what’s the matter with you?’.

The process involves the person in a rounded discussion of their personal situation, assets, needs, values, and priorities, including not just biological and physical but also psychological and social domains. It does not only focus on a person’s challenges and health issues but also recognises their strengths and capabilities.
Personalised Care and Support Planning helps set individualised goals that reflect the person’s own preferences and aspirations, and identifies the actions, interventions, and continuing support required to achieve these.

How do we do Personalised Care and Support Planning?

The first step in the PSCP process is an initial holistic and comprehensive assessment about the person’s health and wellbeing needs. A Holistic Needs Assessment (HNA) is often used to support patients to think about their concerns. The assessment should always involve a conversation about needs and concerns, which may be physical, emotional, practical, financial, or spiritual. Personalised care and support planning requires a skilled conversational approach, one that meets the individual where there are at, acknowledging individuals’ varying confidence engaging in healthcare environments/conversations and differing needs.

Following this assessment, the clinician can work with the person to develop a Personalised Care and Support Plan. There is no set template for what a personalised care and support plan should look like, but it should:

• capture and record conversations, decisions and agreed outcomes or goals in a way that makes sense to the person
• be proportionate, flexible and coordinated and adaptable to a person’s health condition, situation and care and support needs
• include a description of the person, what matters to them and all the necessary elements that would make the plan achievable and effective

To find out more about how personalised care and support planning allows you offer the best support for people living with cancer, please visit our workforce and education page on personalised care

Why does Personalised Care and Support Planning matter?

People with cancer often use a range of services and support. Tailored plans like these are the cornerstone of coordinated care.

A Personalised Care and Support Plan helps to:

• keep a record of conversations, decisions and agreed outcomes
• understand a patient’s care and support needs, their life and family situation
• ensure people’s physical, practical, emotional, and social needs are identified and addressed at the earliest opportunity
• know what is required to make the plan achievable and effective

Why do we measure how many HNAs and PSCPs are offered to patients?

Data on the number of HNAs and PSCPs is collected as part of the Cancer Outcomes and Service Dataset (COSD).

This data is important:

• to understand what is happening, and where improvements are needed, as well as to influence and make change happen using data
• to illustrate and celebrate what is being achieved and benefits of any interventions or service improvement projects
• to enable inequalities in service provision to be identified and addressed
• to ensure governance/planning requirements are being delivered, and funding is being used effectively as directed

The NDRS have developed a new training resource aimed at CNS teams to help improve data capture and quality. The ‘COSD for Clinical Nurse Specialist Teams has been created as a 9-minute narrated slideshow, and covers the data basics for HNA, PCSP and EoTS. There is also a PowerPoint (.ppt) document to go along with it, which allows the slides to be printed so teams can put them on your wall or share with other colleagues.

To access the training resource go to: Cancer data training materials – NDRS and scroll down to ‘COSD for Clinical Nurse Specialist Teams’.

What is a Treatment and Care Summary?

The Treatment and Care Summary is a short patient-facing document completed by the healthcare team which states information about the diagnosis, side effects of treatment, signs and symptoms of recurrence and who to contact with any concerns.

What is included in a Treatment and Care Summary?

• The Treatment and Care Summary informs patients about some of the possible late effects of their treatment and possible long-term psychological and emotional problems, such as depression and anxiety, which can occur after treatment
• The Treatment and Care Summary includes details that are relevant to further management and care, for example, any maintenance treatment or ongoing surveillance
• Plans for ongoing secondary care follow-up and recommended GP actions are included

How should a Treatment and Care Summary be used?

A Treatment and Care Summary should be used alongside a Holistic Needs Assessment (HNA) and Care and Personalised Care and Support Plan. While the HNA Care and Support Plan will look at the holistic needs, the Treatment and Care Summary will also summarise the treatment given and indicate any ongoing clinical needs.

To support continuity of care, the Treatment and Care Summary should follow from the Personalised Care and Support Plan.

It is then shared with the patient and their primary care team to inform them of any actions required. The GP can then update the records and use the document as a basis for conducting the Cancer Care Review, again supporting coordination and continuity of care.

Why do we measure how many Treatment and Care Summaries are offered to patients?

Data on the number of Treatment and Care Summaries (labelled EOTS) is collected as part of the Cancer Outcomes and Service Dataset (COSD).

This data is important:

• to understand what is happening, and where improvements are needed, as well as to influence and make change happen using data
• to illustrate and celebrate what is being achieved and benefits of any interventions or service improvement projects
• to enable inequalities in service provision to be identified and addressed
• to ensure governance/planning requirements are being delivered, and funding is being used effectively as directed

The NDRS have developed a new training resource aimed at CNS teams to help improve data capture and quality. The ‘COSD for Clinical Nurse Specialist Teams has been created as a 9-minute narrated slideshow, and covers the data basics for HNA, PCSP and EoTS. There is also a PowerPoint (ppt) document to go along with it, which allows the slides to be printed so teams can put them on your wall or share with other colleagues.

To access the training resource go to: Cancer data training materials – NDRS and scroll down to ‘COSD for Clinical Nurse Specialist Teams’.

To find out more about how personalised care and support planning allows you offer the best support for people living with cancer, please visit our workforce and education page on personalised care