WORKING TOGETHERFOR PERSONALISED,COMMUNITY-BASEDCARE AND SUPPORTA Partnership Agreement

2014-17

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It has been developed withTLAP partners and peopleinterested in what’s next forpersonalisation.2 It builds onthe Personalisation ActionPlan,3 provides the platform forTLAP’s national workprogramme and will inform thework of all partners. It sets thenational context for thecontinued transformation ofhealth, care and support atlocal level. The agreement ispublished alongside a first setof commitments from each ofour partners describing howthey will support its delivery.

Personalisation remains central to the Government’svision for health and wellbeing,special educational needs anddisability (SEND).

The Care Act4 and Caringfor our future White Paperconfirm personalisation instatute and policy and placethe promotion of individualwellbeing at the centre ofthe care and support system.

The drive for “person-centred, coordinated care”through the Sharedcommitment to integratedcare and support,5 therollout of personal healthbudgets6 and thestrengthened focus onpersonal care and supportplanning extendpersonalisation to the NHS.

The SEND reforms enshrined inthe Children and FamiliesAct 2014, will extend choiceand the possibility of person-centred provision of services forchildren, young people, theirfamilies and carers, includingthe option of personal budgetsand the introduction of a singleEducation, Health and CarePlans for 0-25 year olds.7, 8

This Agreement confirms thecommitment of key nationalpartners across the sector –government, commissioners,providers, people using services,their carers and families – towork together as equalpartners in supporting thedrive towards personalised careand support. This will need:

The leadership of people and communities as well as organisations.

A broader view across health and other sectors,including equally theexperiences of people whofund their own care.

A relentless focus onensuring the benefits ofpersonalisation are felt byall, including those with themost complex needs.

A serious, cross-sectorcommitment to co-production9

with people, carers andfamily members so that theirpriorities are at the heart ofthis shared endeavour.

While it is clear that someprogress has been made (seeTLAP’s first phase review10),the next phase of personalisinghealth, social care, housing,education and beyond willrequire deeper and widerchanges to achieve the profoundcultural transformation needed.At a time of severe and sustainedpressure on public finances, therecan be no complacency.

About this agreement

This partnership agreement for Think Local Act Personal (TLAP)is centred on the experiences of people with health, care andsupport needs, families and carers. It draws upon learningfrom more than six years of implementing personalisation andsets a framework for action for the next phase.1

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PERSONALISATION IS A

WAY TO INDEPENDENCE

Because we know that ourhealth and care system andwider public services, need towork differently to reflect thechallenging economicenvironment, changingexpectations and the enduringgoals of independent living.Personalisation should mean aholistic approach that promotesindependence by acknowledgingpeople’s skills, gifts and talentsas well as their needs.

PERSONALISATION IS

A WAY TO WELLBEING

In the broadest sense,including enhancing people’sopportunities to contribute,with support that promotesemotional and mental well-being as well as physical health.Personalisation should mean asystem that brings togetherhealth, care, housing and supportaround people’s whole life needs,from birth to end of life.

PERSONALISATION IS

A WAY TO ENHANCED

CITIZENSHIP

So that people can make andmaintain connections, buildtheir social capital and be part

of supportive communities thatpull together to empower andenable those most in need.Personalisation should mean asystem that focuses on communityresilience, enhancing everyone’sright to equal citizenship.

The vision

Personalisation is fundamentally about better lives, not services. It is rooted in the power of co-production withpeople, carers and families to deliver better outcomes for all.It is not simply about changing systems and processes orindividualising funding, but includes all the changes needed toensure people have greater independence and enhancedwellbeing within stronger, more resilient communities.

DIAGRAM 1: WHAT TLAP MEANS BY PERSONALISATION

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3 WORKING TOGETHER FOR PERSONALISED, COMMUNITY-BASED CARE AND SUPPORT

Delivering this vision requiresjoined up plans for buildingcommunity capacity andpreventing need, enablingchoice and control, tailoringsupport and coordinating care.

BUILDING COMMUNITY

CAPACITY – EARLY HELP

AND PREVENTION

Early identification of need andearly help to prevent needsfrom escalating are at the heartof personalisation. This includestargeted services aimed atkeeping people outside of thesystem, reducing or delayingthe need for more intensivesupport, and universal serviceswhich build the capacity andresilience within individualsand communities.

This can reduce the need forservices and help people of allages to remain safely in their

homes and communities, with the support they need toself-manage. Some progresshas been made, but thereremains much to do. Peopleare too often assessed in termsof their deficits rather thantheir strengths. This must beturned on its head. As needsincrease and pressure onbudgets continues, it will be vital to harness all theresources available locally.

This will mean:

Taking a universal approach,where leaders across thesystem see prevention, thepromotion of wellbeing andenhancing citizenship ascore responsibilities.

Focusing on reducing demandand increasing wellbeingthrough early help, includingre-ablement services,11

assistive technology andadaptations and extendeduse of universal services.

Enhancing the role ofhousing services inpromoting wellbeing,providing and maintainingsafe and secureaccommodation for people of all ages to live full and active lives in their communities.

Developing strategies thatrecognise and build on theresourcefulness of people,carers, families andcommunity groups anddevelop their capacity tolead and influence.

Empowering health andwellbeing boards to take the lead on communitydevelopment and to makedecisions based on evidence of what works.

Targeting resources at “pressurepoints” so that people canavoid unnecessary hospitaladmissions and reduce therisk of readmission.

What needs to happen?

The next phase of personalisation requires a change of emphasis to secure progress in those aspects that are less advanced. This means building new pathways forpeople to navigate through the system that are firmly rootedin community rather than leading inevitably to services.

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WORKING TOGETHER FOR PERSONALISED, COMMUNITY-BASED CARE AND SUPPORT 4

Recognising andencouraging the role thatflexible homecare servicescan play in enabling peopleto remain independent inthe community.

Ensuring carers have therecognition and supportthey need to continue intheir caring roles, to meettheir own needs as well asthose they care for.

Thinking beyond services tofocus on what people wantfrom life, prioritisingrelationships and helpingpeople of all ages tomaintain their connections.

Supporting families andcommunity groups to self-help, through peer networksand circles of support.

Ensuring that high quality,community-based support is available for people withthe most complex needs.

ENABLING CHOICE

AND CONTROL

Choice and control meanseveryone having access to theinformation and advice theyneed with a choice of highquality supports in every area. It also means having controlover the resources availablewith the support to planeffectively how they are used.The Care Act builds on manyyears of learning to placepersonal care and supportplanning and personal budgetson a statutory footing for thefirst time, including for carers.Personal health budgets will beavailable by right for peoplewith NHS Continuing HealthCare, with anyone that has along term condition, disabilityor mental health need alsoable to benefit.

Yet there remains much to doto ensure that the numbers ofpeople with personal budgetsand care and support planscomes hand-in-hand withgenuine choice and controland better outcomes. In thenext phase, we must learnfrom what works and ensurethis is common practice whilefocusing relentlessly onimproving people’sexperiences. The ambition has to be getting it right, foreverybody, all of the time, so that the benefits areexperienced equally.

This will mean:

Improving the availability of clear, accessible and ageappropriate information andadvice, so people understandtheir rights and choices.

Ensuring consistency inpolicy and practice, so thatprofessionals value livedexperience equally, whereverthey sit in the system.

Realising the potential ofpersonal care and supportplanning to put people incontrol of how their supportis arranged and managed.

Reducing bureaucracy andrestrictive policies so thatpeople have a betterexperience of accessing andusing personal budgets forhealth and care, withdecision making as close tothe person as possible andcreativity actively encouraged.

Making further progresswith personalisation inmental health, where thebenefits can be greatest.

Exploring and evaluating theuse of personal healthbudgets beyond ContinuingHealth Care and targetingtheir use to those groupsmost likely to benefit.

Extending the reach ofdirect payments so thatmany more people benefit,with a stronger range ofoptions to support their use.

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5 WORKING TOGETHER FOR PERSONALISED, COMMUNITY-BASED CARE AND SUPPORT

Actively involving people,carers and families in thedesign, delivery and reviewof care and supportarrangements and groundingcommissioning decisions ingenuine co-production.

Building the localinfrastructure needed toenable people to commissionservices for themselves andto join together tocommission with others.

Shaping diverse markets ofhigh quality care andsupport within every area tomeet people’s needs andaspirations, includinghousing options, micro andsocial enterprise and user-led organisations.

Making commissioning foroutcomes the norm andputting personalisation atthe heart of jointcommissioning strategies.

TAILORING SUPPORT

Choice and control needs to come hand-in-hand with a broaderapproach to tailoring all the services and supports people need tolive good lives, whether they are state or self-funded, have ahealth or care need. This means starting from the person andwhat is important to and for them, rather than slotting peopleinto one size fits all. Tailored support should be synonymous withhigh quality support – it should respect dignity, recogniseindividuality, promote inclusion, acknowledge contribution, reflectaspiration and ensure safety – in any setting.

This will mean:

Prioritising co-production and getting serious about the co-design of services with people, carers and families, embeddingthis in the way organisations develop.

Recruiting and developing staff for their values and ability toconnect with people.

Creating an enabling environment for staff to work creativelyand know they have the support to do things differently.

Firmly consolidating the best person-centred practices whichenable people to design support that is right for them andshape it day-to-day, across the full spectrum of care.

Broadening and strengthening the use of Individual ServiceFunds (ISFs)12 as a means of personalising care and support inevery setting.

Taking a more collaborative approach, recognising what allservices have to offer and working to harness and combine allthe resources available to improve quality.

Ensuring that personalised and community-based approacheswork for everyone, reducing reliance on service models thatconstrain independence.

Avoiding narrow definitions of health, care and support thatlead to silo thinking by taking a whole life, community wideview of what good care looks like.

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WORKING TOGETHER FOR PERSONALISED, COMMUNITY-BASED CARE AND SUPPORT 6

COORDINATING CARE

Integration13 andpersonalisation are two sides ofthe same coin. Each requiresthe other. A personalised careand support system will not besuccessful if it remains separateto the NHS, deals with people’sneeds in silos and maintains acliff edge between health andcare. Integration that addressesthe fragmentation betweenhealth and care withoutrecognising the role people canplay in managing their ownneeds and encouraging self-determination will also fallshort. By bringing our healthand care systems closertogether we must ensure thatwith integration, comespersonalisation. So that peoplecan expect the same focus ontheir independence, the sameregard for their dignity andwishes and the sameopportunities to make choicesand take control, whetherthey have a long term healthcondition or a social care need, a mental health problemor a learning disability.

This will mean:

Focusing on integration at the individual level, wrapping health, care and other support around what people need to live good lives.

Seizing opportunities to embed personalisation, co-productionand community-based support in the wholesale reconfiguration of local services.

Adopting networked models of care that break downprofessional and structural barriers to joint working.

Building multi-disciplinary approaches that combine professionaland clinical expertise to support people to meet their outcomes.

Aligning mechanisms that support person-centred care across organisational boundaries, including personal care andsupport planning, self-management, shared decision makingand personal budgets.

Addressing the barriers to integrating personal budgets acrosshealth, care and other funding, in one place around the person.

Recognising and promoting the potential for service providersto support people across health and care boundaries in waysthat maximise the potential for efficient and effective delivery.

Benchmarking and measuring progress in terms of people’sexperience of person-centred coordinated care and requiringcommissioners to act on the results.8

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The Partnership spans centraland local government, theNHS, the voluntary, communityand independent providersectors and people with careand support needs, carers andfamily members, through theNational Co-productionAdvisory Group.14 TLAP is:

A catalyst for change:focusing the work ofpartners on a shared visionfor personalisation andsecuring specificcommitments, renewed

annually, for how they willsupport its delivery.

An enabling framework:through the production ofpractical tools and resourcesand support for their use.

A knowledge exchange:creating opportunitiesnationally and regionally forleaders to share learningabout what works and usingpartner’s extended networksto reach out and engageorganisations locally.

A model of co-production inpractice: setting an examplein the way people with careand support needs, carersand family members areengaged in leading andshaping the work programme.

A different approach toimprovement: which inchallenging times, recognisesthe benefits and necessity ofshared endeavour and valueseveryone’s contribution tomaking change happen.

Supporting change to happen

Think Local Act Personal (TLAP) is a national strategic partnershipof more than 40 organisations committed to supporting thecontinued implementation of personalisation and communitybased health, care and support, as described in this agreement.

DIAGRAM 2: TLAP IN ACTION

Improved healthand wellbeing

Greaterindependence

OUTCOMES

Enhancedcitizenship

- BuildingCommunityCapacity

- Ensuring choiceand control

- Tailoring support

- CoordinatingCare

LOCAL PRACTICE

TLAP Action

- Work programme

- Shaping andinfluencing policy

- Actions of partneragencies

Other nationallevel improvementactivity

NATIONAL ACTION

CO-PRODUCTION

SU

STA

INA

BLE H

EA

LTH

A

ND

CA

RE S

YSTE

M

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WORKING TOGETHER FOR PERSONALISED, COMMUNITY-BASED CARE AND SUPPORT 8

TLAP aims to support thisagreement in three main ways:

SHAPING POLICY

Working to shape andinfluence national policyrelating to personalisation andcommunity-based support across the publicservice reform agenda.

DELIVERING A WORK

PROGRAMME

Through a number of workstreams focused on supportingthe drive to deliverpersonalisation andcommunity-based support.

CALLING ON ACTION

FROM PARTNERS

To make commitments, shapethe work programme andcontribute their time andenergy to its delivery.

Building on this approach inthe next phase, TLAP will:

Redouble efforts to securesign-up and engagementwith the Making it Real15

markers, providing supportfor agencies to self-assessand understand their progress.

Coordinate the delivery ofthe Personalisation ActionPlan, developed with keystakeholders to addressimplementation issues.

Focus the work programmeon “stuck” issues to findpractical approaches todelivering personalisation inthe current financial context.

Broaden the scope ofprogramme activity toinclude issues relevant tochildren and young people.

Continue to track progressand outcomes from personalbudgets and personal healthbudgets through annualnational surveys.

Further build the evidencebase for community capacitybuilding and share ourlearning with health andwellbeing boards.

Support regional activity,encouraging alignmentbetween personalisation andother important agendas.

Develop practical tools and resources to assist local leaders to deliver newduties in the Care Act.

More detail on specificactivities planned will be setout in the work programme,developed annually.

The TLAP Partnership is opento any national organisationnot represented through oneof the umbrella bodies alreadyinvolved, that is willing andable to make a specificcommitment of support.

The TLAP programme isagreed with the Partnershipand managed through thenational Programme Board.

The Partnership is co-chairedby two members of theNational Co-productionAdvisory Group. TLAP is grantfunded by the Department ofHealth, with a number ofspecific commissions fromother agencies. Day-to-daywork is delivered by a smallteam reporting to theProgramme Board.

PARTNER COMMITMENTS

This agreement is between organisations that form theTLAP partnership. To demonstrate their commitment torealising the goals outlined in this agreement, eachorganisation has made a specific pledge of support.

These commitments are published on the TLAP websitewww.thinklocalactpersonal.org.uk

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9 WORKING TOGETHER FOR PERSONALISED, COMMUNITY-BASED CARE AND SUPPORT

1 Putting People First: a shared vision and commitment to transforming adult social care was published by the Department of Health in 2007 and was accompanied by a three year transformation grant for Englishcouncils. Think Local Act Personal: A sector-wide commitment to moving forward with personalisation and community-based support was published in January 2011 and was accompanied by a three yearprogramme grant funded by the Department of Health and delivered in partnership with the organisations who signed the original agremeement.

2 TLAP ran a six month online blog and social media campaign to help write this agreement. See Personalisation: What’s Next? www.thinklocalactpersonal.org.uk/Browse/WhatsNext

3 The Personalisation Action Plan was published by TLAP in March 2014www.thinklocalactpersonal.org.uk/_library/PersonalisationActionPlanFINAL.pdf

4 The Care Act received Royal Assent on 14 May 2014 and comes into force in October 2014http://services.parliament.uk/bills/2013-14/care.html

5 HM Government (2013) Shared Commitment to Integrated Care and Support, Department of Healthwww.gov.uk/government/publications/integrated-care

6 Personal Health Budgets www.personalhealthbudgets.england.nhs.uk/About/faqs

7 The Children and Families Bill received Royal Assent on 13 March 2014. The SEND provisions of the Actcome into force in September 2014 www.legislation.gov.uk/ukpga/2014/6/contents/enacted

8 Personal Budgets for adopters are also currently being tested with a number of councils to extend choiceand control to adoptive parents.

9 Co-production means when you as an individual are involved as an equal partner in designing the supportand services you receive. It recognises that people who use social care services (and their families) haveknowledge and experience that can be used to help make services better, not only for themselves but forother people who need social care.

10 TLAP First Phase Review 2011-14 www.thinklocalactpersonal.org.uk

11 Re-ablement means a way of helping you remain independent, by giving you the opportunity to re-learn or regain some of the skills for daily living that may have been lost as a result of illness, accident or disability.

12 Individual service funds are personal budgets that a care provider manages on your behalf.

13 Integration means joined up, coordinated health and social care that is planned and organised around the needs and preferences of the individual, their carer and family.

14 The National Co-production Advisory Group are people, carers and family members who have livedexperience of using care and support. They advise TLAP on all its work.

15 Making it Real: marking progress towards personalised, community based support was published in 2011www.thinklocalactpersonal.org.uk/browse/mir and the Narrative for person-centred, coordinated care waspublished in 2013 www.england.nhs.uk/wpcontent/uploads/2013/05/nv-narrative-cc.pdf

Endnotes

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THINK LOCAL ACT PERSONAL

PARTNERSHIP ORGANISATIONS

TOWARDS EXCELLENCEIN ADULT SOCIAL CAREPROGRAMME

WINTERBOURNE VIEWJOINT IMPROVEMENTPROGRAMME

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Think Local Act Personal (TLAP) is a nationalstrategic partnership of more than 40

organisations committed to supporting thecontinued implementation of personalisation

and community based health, care and support, as described in this agreement.

This document sets a framework for the nextphase of personalisation, what needs to happen

in order to achieve it and how a nationalpartnership of people and organisations are

working together to support this to happen.

www.thinklocalactpersonal.org.uk

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