  

Persono/ neo/th P/on Pi/ot

Leornino lromework- Phose 1
8/ueprint
1o support the proctico/ use ond imp/ementotion of
the Persono/ neo/th P/on for Peop/e with Lono 1erm
conditions, their corers ond key workers

  
16 April 2009 Version 0.7

Contents

5ection 1
 LxecuLlve Summarv
 Þro[ecL Cvervlew
 kev Þrlnclples
 MeLhodoloav
 1he Learnlna and CulLural AllanmenL lramework
5ection 2
 1o 8e SnapshoL: Þerson wlLh Lona 1erm CondlLlon
 1o 8e SnapshoL: Carer
 1o 8e SnapshoL: kev Worker

5ection l
 kev llndlnas and Caps Cvervlew
 kev llndlnas and Caps:
 Þerson wlLh Lona 1erm CondlLlon
 Carer
 kev Worker
5ection 4

 ÞPÞ ConslderaLlons for Maralnallsed Croups
 8ecommendaLlons
 Learnlna lramework ÞracLlcal use and 8eneflLs


  

2
Lxecut|ve 5ummary

£ost of £no/ond
Persono/ neo/th P/on
Pi/ots
1he LasL of Lnaland SLraLealc PealLh AuLhorlLv launched a Þersonal PealLh Þlan (ÞPÞ)
plloL for people wlLh lona-Lerm condlLlons across 16 prlmarv, communlLv and secondarv
care slLes ln March 2009. 1he purpose of Lhe Lhree monLh plloL proaramme was Lo
provlde a learnlna around for Lhe roll-ouL of ÞPÞs for Lwo lona Lerm condlLlons bv March
2010 and a furLher Lhree bv SepLember 2010 across Lhe LasL of Lnaland. ln llne wlLh Lhe
ÞersonallsaLlon and Self Care aaendas, ÞPÞs are a vehlcle of empowermenL for people
wlLh lona-Lerm condlLlons Lo Lake areaLer ownershlp and conLrol over Lhelr care needs ln
equal parLnershlp wlLh Lhelr kev workers and carers. lf embedded successfullv, Lhe ÞPÞ
represenLs a mlnd-shlfL and culLural chanae Lo exlsLlna wavs of operaLlna and Lhe
LradlLlonal cllnlclan/paLlenL relaLlonshlp.
Project 4ims,
4ctivities ond
ue/iverob/es
Capaemlnl has been enaaaed bv Lhe SPA ln a Lwo-phased approach aL Lhe bealnnlna and
end of Lhe plloL proaramme Lo:
1. uevelop a Learnlna lramework for Lhe supporL of Lhe roll-ouL of Þersonal PealLh Þlans
conslderlna Lhe behavlours, skllls and knowledae and culLural lmpllcaLlons of Lhls
chanae for people wlLh L1Cs, Lhelr carers and kev workers
2. underLake an AssessmenL of Lhe LoL ÞlloL Þroaramme
1he ob[ecLlve of Þhase 1 ln March/Aprll 2009 was Lo underLake an lnlLlal basellne
assessmenL of Lhe plloLs and Lo develop a hlah level 8lueprlnL Learnlna lramework Lo be
valldaLed and aareed aL Lhe end of Lhe plloL proaramme as parL of Þhase 2 acLlvlLles when
a compleLe evaluaLlon of Lhe plloLs can be underLaken. uurlna Þhase 1 Lhe Leam enaaaed
wlLh 33 plloL sLakeholders lncludlna people wlLh L1Cs, Lhelr carers, kev workers and plloL
coordlnaLors Lhrouah a comblnaLlon of quesLlonnalres, focussed one-Lo-one sesslons
(wlLh kev workers and plloL coordlnaLors onlv) and a workshop Lo aaLher daLa for Lhe
Þhase 1 dellverables. 1he purpose of Lhls documenL ls Lo presenL Lhe Þhase 1 8lueprlnL
Learnlna lramework, kev flndlnas and recommendaLlons. AlLhouah closelv lnLerllnked,
Lhe ÞPÞ 8asellne AssessmenL dellverable ls presenLed ln a separaLe documenL.
key lindinos
1he alm of Lhe daLa aaLherlna acLlvlLles was Lo develop a snapshoL of whaL 'aood looks
llke' once ÞPÞs are successfullv embedded, deLermlne Lhe currenL slLuaLlon and underLake
a hlah level aap analvsls. ln summarv, Lhe flndlnas show Lhere ls a fundamenLal lack of
undersLandlna of ÞPÞs amonasL people wlLh L1Cs, Lhelr carers and manv kev workers.
1here were varled lnLerpreLaLlons and percepLlons of whv ÞPÞs have been lnLroduced and
where ownershlp of Lhe ÞPÞ lles. 1o a larae exLenL Lhe lack of undersLandlna can be
aLLrlbuLed Lo Lhe ÞPÞ Lool lLself ln Lerms of lLs lenaLh and sLaLlc/snapshoL-ln-Llme look and
feel. 1hls lack of undersLandlna had an assoclaLed lmpacL on enaaaemenL and moLlvaLlon
Lo use Lhe ÞPÞ. Manv parLlclpanLs ldenLlfled aap areas ln behavlours and skllls of people
wlLh L1Cs, Lhelr carers and some kev workers Lo successfullv embed Lhe ÞPÞ as a new wav
of worklna. ln parLlcular, communlcaLlon, relaLlonshlp bulldlna and coachlna skllls &
behavlour aaps were hlahllahLed for kev workers. Caps ln Lhe oraanlsaLlonal allanmenL of
ÞPÞs were also ldenLlfled, such as Lhe need Lo llnk ÞPÞs Lo performance measures and
exlsLlna [ob descrlpLlons of kev workers.
kecommendotions
ond Next 5teps
llve recommended 'bulldlna blocks' for Lhe successful roll-ouL of ÞPÞs have been
ldenLlfled:
 8evlslon of Lhe ÞPÞ 1ool
 uevelopmenL of a CommunlcaLlons Þlan
 uevelopmenL of a SLakeholder LnaaaemenL SLraLeav
 CreaLlon of a CapablllLv SupporL Þlan
 Workforce and SLraLealc AllanmenL
1he flndlnas and recommendaLlons from Lhe 8lueprlnL Learnlna lramework wlll be
valldaLed and developed as parL of Þhase 2 pro[ecL acLlvlLles.
  

3
Þro[ect Cverv|ew
1he Persono/
neo/th P/on
1he Þersonal PealLh Þlan ls a documenL LhaL ls owned bv people wlLh L1Cs. 1he ÞPÞ
brlnas LoaeLher lnformaLlon abouL Lhe person wlLh L1Cs lnLo a slnale, overarchlna
personal care plan. 1he documenL ls Lhe resulL of care plannlna consulLaLlons wlLh Lhe
person and Lhelr kev worker, wlLh an emphasls on aoal seLLlna, equal parLnershlp,
neaoLlaLlon and shared declslon maklna beLween Lhe person wlLh an L1C and Lhelr kev
worker. 1he purpose of Lhe documenL ls Lo advocaLe Lhe personallsaLlon aaenda,
placlna a sLrona emphasls on Lhe person's lndlvldual needs and cholces abouL Lhelr
care, Lherebv enabllna enhanced self manaaemenL of Lhelr care. (uP 2009) 1he currenL
verslon of Lhe ÞPÞ ls 10 A4 paaes ln lenaLh and comprlses Lhe followlna 3 secLlons:
 AbouL Me
 Mv Þreferences
 lmporLanL lnformaLlon
 Pow l Am now
 Mv PealLh AcLlon Þlan
£ost of £no/ond
PnP Pi/ot
Prooromme
Slnce SepLember 2008 Lhe LasL of Lnaland (LoL) SPA has been hosLlna consulLaLlon
exerclses durlna Lhe bulld up Lo, and preparaLlon for, Þersonal PealLh Þlan plloLs. 1wo
larae mulLl-sLakeholder consulLaLlon evenLs Look place ln SepLember and CcLober 2008
and over a hundred sLakeholders were consulLed wlLh on a drafL ÞPÞ Lool ln november
2008. Cn lebruarv 12Lh 2009, Lhe offlclal launch of Lhe ÞPÞ plloLs Look place brlnalna
LoaeLher kev sLakeholders enaaaed aL Lhe onseL of Lhe ÞPÞ plloLs across Lhe 16 aareed
plloL slLes. 1he plloLs are belna held over a Lhree monLh perlod and Lhe alm ls Lo use Lhe
proaramme Lo develop and revlse Lhe ÞPÞ Lool as parL of Lhe learnlna process for Lhe
wlder LoL roll-ouL of ÞPÞs. SlLes are aeoaraphlcallv dlspersed across Lhe LoL ln a varleLv
of locaLlons - prlmarv, communlLv, secondarv care and a prlson (PMÞ). 1here was an
lnlLlal Lwo week delav due Lo pracLlcal and loalsLlcal lssues assoclaLed wlLh Lhe klck-off
of Lhe ÞPÞ plloLs, and so Lhev beaan on March 16Lh 2009. 1he plloL ls belna run ln
preparaLlon for Lhe naLlonal roll-ouL of ÞPÞs bv uecember 2010.
Leornino
lromework Project
Phose 1

Capaemlnl were commlssloned Lo underLake a 2-phase plece of work worklna closelv
wlLh Lhe plloL slLes, aL Lhe sLarL and end of Lhe plloL process. ln March-Aprll 2009, as
parL of Þhase 1 Lhe ob[ecLlves were Lwo-fold:
1. uevelop a hlah-level, 8lueprlnL Learnlna lramework for Lhe supporL of Lhe roll-ouL of
Þersonal PealLh Þlans conslderlna Lhe behavlour, skllls and knowledae and culLural
lmpllcaLlons of Lhls chanae on people wlLh L1Cs, Lhelr carers and kev workers
2. underLake a 8asellne AssessmenL aL Lhe sLarL of Lhe plloL process
1he purpose of Þhase 2 ls Lo valldaLe and aaree Lhe blueprlnL Learnlna lramework and
Lo conducL an assessmenL of plloLs aL Lhe end of Lhe plloL process uslna Lhe basellne
daLa as a benchmark. lL ls envlsaaed LhaL durlna Þhase 2 valldaLlon, areaLer enaaaemenL
wlLh a hlaher numbers of sLakeholders wlll Lake place Lo LesL and aaree Lhe hlah-level
deslan before lL ls used Lo supporL Lhe roll-ouL of Þersonal PealLh Þlans ln Lhe LasL of
Lnaland. 1he purpose of Lhls documenL ls Lo presenL Lhe blueprlnL Learnlna lramework
and deLall Lhe assoclaLed flndlnas and recommendaLlons.

ÞnÞ ko||-Cut 5upport Þ|an- Last of Lng|and, 5nA


n|gh Leve| Des|gn Va||dat|on 8u||d ko|| Cut
Þhase 1¬ March 2009
Þ||ot 5tart
Þhase 2¬ Iune 2009
Þ||ot Lnd 8y December 2010

  

4
key Þr|nc|p|es
7
common
core
Princip/es
of 5e/f
core

Þersonal PealLh Þlans are belna lmplemenLed as parL of Lhe Self Care aaenda Lo enable people
wlLh lona-Lerm condlLlons Lo Lake areaLer conLrol and manaaemenL of Lhelr care. 1he Seven
Common Core Þrlnclples of Self Care as ouLllned ln Lhe ueparLmenL for PealLh auldance ln 'Skllls
for Care' (2009) have been used as Lhe cenLral auldlna prlnclple ln enabllna Lhe success of ÞPÞs.
1. Lnsure lndlvlduals are able Lo make lnformed cholces Lo manaae Lhelr self care needs
2. CommunlcaLe effecLlvelv Lo enable lndlvlduals Lo assess Lhelr needs, and develop and aaln confldence
Lo self care
3. SupporL and enable lndlvlduals Lo access approprlaLe lnformaLlon Lo manaae Lhelr self care needs
4. SupporL and enable lndlvlduals Lo develop skllls ln self care
3. SupporL and enable lndlvlduals Lo use Lechnoloav Lo supporL self care
6. Advlse lndlvlduals how Lo access supporL neLworks and parLlclpaLe ln Lhe plannlna, developmenL and
evaluaLlon of servlces
7. SupporL and enable rlsk manaaemenL and rlsk Laklna Lo maxlmlse lndependence and cholce.
lcebero
cu/turo/
Metophor
1he Þersonal PealLh Þlan ls a vehlcle Lo empower people wlLh lona Lerm condlLlons Lo enaaae ln
equal parLnershlp wlLh Lhelr kev workers. lor some, Lhls represenLs a mlnd-shlfL chanae, an
lnLrlnslcallv new wav of operaLlna LhaL mav be ouL of Lhelr LradlLlonal comforL zone. Such
culLural chanaes are ofLen deplcLed bv an lcebera meLaphor:

Porodiom Porodiom
1he visib/e siono/s oive you o c/ue obout the "token-for-
oronted"-ness thot /ies underneoth.
Assumpt|ons and
be||efs that dr|ve
behav|our
What you see
What ||es beneath
cu/ture
V|s|b|e Day-to-Day
8ehav|ours
"1he vost mojority of on
ice-bero is not visib/e.
1o understond cu/turo/
imp/icotions of chonoe we
need to consider whot /ies
beneoth the visib/e
monifestotions of cu/ture"

lcebero
cu/turo/
Metophor
1he Learnlna and CulLural AllanmenL lramework for Þersonal PealLh Þlans has been
developed Lo represenL Lhe learnlna and developmenL, as well as Lhe culLural aspecLs of
chanae requlred Lo ensure Lhe success of Þersonal PealLh Þlans wlLh Lhe 7 Common Core
Þrlnclples aL Lhe cenLre.

8ehav|ours
Crgan|sat|ona|
A||gnment
5k|||s & know|edge M|ndset
8ehav|ours
Crgan|sat|ona|
A||gnment
5k|||s & know|edge M|ndset
7
Common Core
Þr|nc|p|es of
5e|f Care
1be obsetvoble wov
people oct ooJ
tespooJ to tbe lnl
novloo tbe obllltv
ooJ lofotmotloo to
moke tbe lnl wotk
well
£osotloo tbe lnl ls
compotlble wltb
cotteot svstems ooJ
ptocesses
1be bobltool wov of
tblokloo ooJ
petcelvloo tbe lnl

  

3
Methodo|ogy
ln LoLal, Lhe Leam enaaaed wlLh 33 lndlvlduals across Lhe kev sLakeholders aroups as parL of
daLa aaLherlna for Lhe Þhase 1 hlah level deslan of Lhe Learnlna lramework.
Ouestionnoires
 CuesLlonnalres focusslna on Lhe lnlLlal percepLlons of Lhe ÞPÞ and Lhe
skllls/knowledae, behavlour and aLLlLudes requlred Lo make ÞPÞs work well were
dlsLrlbuLed Lo 16 ÞlloL slLes across Lhe LasL of Lnaland
 1hree Lvpes of quesLlonnalres were devlsed and Lallored Lowards kev workers,
people wlLh lona Lerm condlLlons and Lhelr carers
 ln LoLal, 499 quesLlonnalres were dlsLrlbuLed and 23 were reLurned
 A low reLurn raLe was expecLed as manv ÞPÞ ÞlloL slLes had noL veL sLarLed Lhe roll-
ouL of ÞPÞs and due Lo pro[ecL Llmescale consLralnLs
 1he quesLlonnalre had over 43 quesLlons and Lhe alm was Lo recelve a small number
wlLh deLalled quallLaLlve responses and noL a sLaLlsLlcallv valld number
workshop
 A workshop was held wlLh kev workers, people wlLh L1Cs, Lhelr carers and Lhe LasL of
Lnaland plloL coordlnaLors Lo aaln furLher quallLaLlve feedback and enaaae
parLlclpanLs ln dlaloaue on Lhe Þersonal PealLh Þlans
 A LoLal of 14 parLlclpanLs Look parL ln a 'World Cafe' approach, where lndlvlduals
enaaaed ln Lable-Lop dlscusslons ln small aroups on a seL quesLlon and recorded Lhelr
LhouahLs and kev polnLs on wrlLable 'Lable cloLhs'. 1hls approach was chosen Lo
enaender a frlendlv and relaxed aLmosphere, allowlna lndlvlduals Lo openlv share
Lhelr vlews, LhouahLs and feellnas
 1he ouLpuL was a seL of commenLs wrlLLen bv Lhe parLlclpanLs Lhemselves ln
response Lo 6 focussed quesLlons. 1hls helped Lo uncover some of Lhe deep-held
LhouahLs, assumpLlons and aLLlLudes relaLlna Lo ÞPÞs as well as Lhe culLural barrlers
Lo chanae
locussed One- to
One -5essions
 As parL of Lhe daLa collecLlon process, Lhe Leam enaaaed wlLh each of Lhe 16 plloL
slLe coordlnaLors LhrouahouL Lhe pro[ecL llfe-cvcle and aalned a aood undersLandlna
of some of Lhe earlv successes and learnlna from Lhe roll ouL of ÞPÞs. kev polnLs
ralsed were recorded ln a daLa capLurlna Lool
 ln addlLlon, 14 locus Sesslons were held wlLh Lhree kev workers and nlne plloL
coordlnaLors and Lwo Sub[ecL MaLLer LxperLs Lo probe deeper lnLo Lhe challenaes,
enablers and earlv successes
 1he Lwo locus Sesslons held wlLh LasL of Lnaland Sub[ecL MaLLer LxperLs who had
pracLlcal experlence of runnlna behavlour chanae and educaLlon proarammes almed
aL kev workers and paLlenLs as parL of Lhe Self Care aaenda helped Lo scope
addlLlonal secondarv research requlred
5econdory keseorch
 1he followlna documenLs were revlewed and analvsed as parL of Lhe secondarv
research:
 ueparLmenL of PealLh Culdance 'Skllls for Care - Self Care Þrlnclples',
 'ÞromoLlna CpLlmal Self Care' Alf Colllns eL al
 'Co-CreaLlna PealLh' 1he PealLh loundaLlon
 AddlLlonal lnformaLlon on Lhe LxperL ÞaLlenL Þroaramme and ÞromoLlna Self
Care plloL pro[ecL
  

6
1he Learn|ng and Cu|tura| A||gnment Iramework
Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
C
a
r
e
r
s K
e
y

W
o
r
k
e
r
s
PeopIe with Long Term Conditions
PersonaI HeaIth PIan
Learning & CuIturaI AIignment Framework
PHP TooI Revision
Behaviours OrganisationaI
AIignment
SkiIIs &
KnowIedge Mindset
7
Common Core
PrincipIes of
SeIf Care


1he Learnlna and CulLural AllanmenL lramework has been developed speclflcallv for Lhe lmplemenLaLlon of
Þersonal PealLh Þlans ln LasL of Lnaland. 1he framework lllusLraLes:
 lour kev learnlna and culLural aspecLs of chanae: 8ehavlours, Skllls and knowledae, CraanlsaLlonal
AllanmenL and MlndseL
 1hree kev sLakeholder aroups lnvolved ln Lhe chanae: Þeople wlLh L1Cs, Lhelr Carers and kev Workers
 llve recommended soluLlons/approaches Lo supporL Lhe successful roll-ouL of ÞPÞs: ÞPÞ 1ool 8evlslon,
CommunlcaLlons Þlan, LnaaaemenL Þlan, 8ulldlna Lhe CapablllLv, Workforce and SLraLealc AllanmenL.
AL Lhe cenLre of Lhls framework ls Lhe 7 Common Core Þrlnclples of Self Care deLalllna Lhe 'Lo-be'/end-sLaLe
behavlours and compeLencles kev workers should demonsLraLe once chanae ls embedded. 1hls framework forms a
common Lhread, repeaLed LhrouahouL Lhe documenL Lo hlahllahL Lhe elemenLs LhaL are belna explored ln areaLer
deLall ln Lhe secLlons LhaL follow.

  

7

1o-8e 5napshot: Þerson w|th a Long 1erm Cond|t|on
What Good Looks L|ke
1he 'snapshoL' of Lhe Learnlna and CulLural AllanmenL lramework below lllusLraLes, aL a
hlah level, Lhe deslred end-sLaLe for a Þerson wlLh a Lona-1erm CondlLlon when Þersonal
PealLh Þlans are successfullv rolled-ouL and embedded. 1he purpose of Lhls ls Lo frame
Lhe end-sLaLe conLexL for a aap analvsls and subsequenL recommendaLlons. 1he
'snapshoL' below has been developed from a comblnaLlon of Lhe 7 Common Core
Þrlnclples of Self Care and daLa aaLhered from Lhe enaaaemenL wlLh LoL plloL proaramme
sLakeholders.
8ehav|ours
 Makes lnformed cholces Lo manaae
care needs Lhrouah Lhe ÞPÞ
 Works ln equal parLnershlp wlLh kev
workers and carers
 uemonsLraLes confldence ln
communlcaLlna Lhelr needs and
preferences
Crgan|sat|ona| A||gnment
 leels supporLed and encouraaed Lo
demonsLraLed self care bv kev
workers
 Pas an undersLandlna of supporL
neLworks and ls able Lo access Lhem
 Pas an undersLandlna of
where Lo flnd relevanL
lnformaLlon ln relaLlon Lo
Lhelr care needs
5k|||s & know|edge
 Pas a aood
undersLandlna of Lhe
ÞPÞ , lLs purpose and Lhe role Lhev
plav
 Shows an awareness of self-care
skllls requlred Lo make ÞPÞs work
 undersLands how Lo access
avallable learnlna and developmenL
supporL
M|ndset
 leels empowered and
moLlvaLed Lo Lake
ownershlp over Lhelr
care
 Þercelves Lhemselves as Lhe kev
declslon maker ln care relaLlna
maLLers
 ls comforLable LhaL 'Lhe docLor
doesn'L alwavs know whaL ls besL'
7
Common Core
Þr|nc|p|es of
5e|f Care

Descr|pt|on of a Þerson w|th Long-1erm Cond|t|on (L1C):
1hls ls a person wlLh lona-Lerm condlLlon(s), llvlna wlLh an lncurable lllness, usuallv
deaeneraLlve, causlna llmlLaLlons Lo phvslcal, menLal and/or soclal well-belna. Lona-Lerm
condlLlons lnclude ulabeLes, CCÞu, AsLhma, ArLhrlLls, Lpllepsv and MenLal PealLh. (uP,
2009).

Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
C
a
r
e
r
s
K
e
y
W
o
r
k
e
r
s
Þersona| nea|th Þ|an
Learn|ng & Cu|tura| A||gnment Iramework
PHP TooI Revision
Behaviours OrganisationaI
AIignment
SkiIIs &
KnowIedge Mindset
7
Common Core
PrincipIes of
SeIf Care
PeopIe with Long Term Conditions
  

8

1o- 8e 5napshot: Carer for peop|e w|th Long 1erm Cond|t|ons
What Good Looks L|ke
1he 'snapshoL' of Lhe Learnlna and CulLural AllanmenL lramework below lllusLraLes, aL a
hlah level, Lhe deslred end-sLaLe for a Carer of a Þerson wlLh a Lona-1erm CondlLlon when
Þersonal PealLh Þlans are successfullv rolled-ouL and embedded. 1he purpose of Lhls ls Lo
frame Lhe end-sLaLe conLexL for a aap analvsls and subsequenL recommendaLlons. 1he
'snapshoL' below has been developed from a comblnaLlon of Lhe 7 Common Core
Þrlnclples of Self Care and daLa aaLhered from Lhe enaaaemenL wlLh LoL plloL proaramme
sLakeholders.
8ehav|ours
 SupporLs Lhe person Lhev care for Lo
make lnformed cholces and manaae
Lhelr care Lhrouah Lhe ÞPÞs
 Works ln equal parLnershlp wlLh kev
workers and Lhe lndlvldual Lhev care for
 SupporL Lhe lndlvldual Lhev care for
 CommunlcaLe Lhelr care
needs and preferences
Crgan|sat|ona| A||gnment
 leels supporLed and enabled bv kev
workers and exLernal oraanlsaLlons
 Pas an undersLandlna of supporL
neLworks and ls able Lo access Lhem
 Pas an undersLandlna of where
Lo flnd relevanL lnformaLlon ln
relaLlon Lo care needs
5k|||s & know|edge
 Pas a aood
undersLandlna of Lhe
ÞPÞ, lLs purpose and Lhe role
Lhev plav
 ls aware of Lhe skllls and knowledae
Lhev need Lo supporL Lhe person Lhev
care for use Lhe ÞPÞ well
 undersLands how Lo access avallable
learnlna and developmenL
M|ndset
 8elleves Lhe ÞPÞ ls a useful
Lool ln empowerlna Lhe
lndlvldual Lhev care for Lake
areaLer conLrol over Lhelr
care
 undersLands Lhe ÞPÞ ls paLlenL-owned
 ls comforLable LhaL 'Lhe docLor doesn'L
alwavs know whaL ls besL'
8ehav|ours
 SupporLs Lhe person Lhev care for Lo
make lnformed cholces and manaae
Lhelr care Lhrouah Lhe ÞPÞs
 Works ln equal parLnershlp wlLh kev
workers and Lhe lndlvldual Lhev care for
 SupporL Lhe lndlvldual Lhev care for
 CommunlcaLe Lhelr care
needs and preferences
Crgan|sat|ona| A||gnment
 leels supporLed and enabled bv kev
workers and exLernal oraanlsaLlons
 Pas an undersLandlna of supporL
neLworks and ls able Lo access Lhem
 Pas an undersLandlna of where
Lo flnd relevanL lnformaLlon ln
relaLlon Lo care needs
5k|||s & know|edge
 Pas a aood
undersLandlna of Lhe
ÞPÞ, lLs purpose and Lhe role
Lhev plav
 ls aware of Lhe skllls and knowledae
Lhev need Lo supporL Lhe person Lhev
care for use Lhe ÞPÞ well
 undersLands how Lo access avallable
learnlna and developmenL
M|ndset
 8elleves Lhe ÞPÞ ls a useful
Lool ln empowerlna Lhe
lndlvldual Lhev care for Lake
areaLer conLrol over Lhelr
care
 undersLands Lhe ÞPÞ ls paLlenL-owned
 ls comforLable LhaL 'Lhe docLor doesn'L
alwavs know whaL ls besL'
7
Common Core
Þr|nc|p|es of
5e|f Care


Descr|pt|on of a Carer:
1hls ls a person who looks afLer someone who ls unable Lo manaae Lhelr condlLlon on
Lhelr own, wlLhouL belna pald Lo do so. Manv people do noL see Lhemselves as carers, buL
slmplv as someone who ls helplna ouL of a frlend or relaLlve, who mav be elderlv, lll or
dlsabled. Carers carrv ouL Lasks whlch mav lnclude personal care, such as baLhlna,
dresslna and cooklna, phvslcal help wlLh movlna around, or carrvlna ouL errands, such as
shopplna or plcklna up prescrlpLlons. (nPS Cholces WebslLe, 2009)
Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
PeopIe with Long Term Conditions
Þersona| nea|th Þ|an
Learn|ng & Cu|tura| A||gnment Iramework
PHP TooI Revision
Behaviours OrganisationaI
AIignment
SkiIIs &
KnowIedge Mindset
7
Common Core
PrincipIes of
SeIf Care
K
e
y
W
o
r
k
e
r
s
C
a
r
e
r
s
  

9

1o-8e 5napshot: key Worker
What Good Looks L|ke
1he 'snapshoL' of Lhe Learnlna and CulLural AllanmenL lramework below lllusLraLes, aL a
hlah level, Lhe deslred end-sLaLe for a kev Worker when Þersonal PealLh Þlans are
successfullv rolled-ouL and embedded. 1he purpose of Lhls ls Lo frame Lhe end-sLaLe
conLexL for a aap analvsls and subsequenL recommendaLlons. 1he 'snapshoL' below has
been developed from a comblnaLlon of Lhe 7 Common Core Þrlnclples of Self Care and
daLa aaLhered from Lhe enaaaemenL wlLh LoL plloL proaramme sLakeholders.
8ehav|ours
 Lncouraaes lndlvlduals Lo Lake
areaLer conLrol of Lhelr care
plannlna
 uemonsLraLes effecLlve llsLenlna
and relaLlonshlp bulldlna
 SupporLs and enables lndlvlduals Lo
develop self-care skllls
Crgan|sat|ona| A||gnment
 ls lncenLlvlsed and rewarded Lo
successfullv roll ouL ÞPÞs
 leels Lhere ls adequaLe supporL and
Llme Lo make ÞPÞs work well
 undersLands how Lhe ÞPÞ flLs lnLo
exlsLlna pracLlces and sLraLealc alms
5k|||s & know|edge
 Pas a aood
undersLandlna of Lhe
ÞPÞ, lLs purpose and Lhe role
Lhev plav
 uemonsLraLes sLrona coachlna skllls
 uemonsLraLes sLrona
communlcaLlon skllls
M|ndset
 undersLands Lhe
poLenLlal beneflLs of
Lhe ÞPÞ
 AcLlvelv supporLs and encouraaes
Lhe use of ÞPÞs
 Þercelves Lhe ÞPÞ as an
empowermenL Lool and ls confldenL
Lo adapL Lhelr approach ln
lnLeracLlna wlLh paLlenLs
7
Common Core
Þr|nc|p|es of
5e|f Care


Descr|pt|on of a key Worker:
1hls ls a care professlonal (lncludlna an lndlvldual from Lhe lndependenL or Lhlrd secLor)
who supporLs people wlLh L1Cs ln assesslna and oraanlslna Lhelr care. 1hev wlll have
knowledae of Lhe person's parLlcular lona-Lerm condlLlon and Lhelr lndlvldual needs, as
well as access Lo furLher knowledae and skllls Lo supporL Lhe manaaemenL of Lhelr care
(LoL worklna deflnlLlon).
Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
C
a
r
e
r
s
PeopIe with Long Term Conditions
Þersona| nea|th Þ|an
Learn|ng &Cu|tura| A||gnment Iramework
PHP TooI Revision
Behaviours OrganisationaI
AIignment
SkiIIs &
KnowIedge Mindset
7
Common Core
PrincipIes of
SeIf Care
K
e
y

W
o
r
k
e
r
s
  

10

key I|nd|ngs and Gaps - Cverv|ew
8ehoviour
 5e|f Care 8ehav|ours - Lhere ls a sLrona percepLlon LhaL manv people wlLh L1Cs
are comforLable wlLh belna dependenL and have llLLle deslre Lo chanae Lhelr
behavlours and demonsLraLe areaLer ownershlp over Lhelr care. Manv kev
workers feel Lhev are onlv parLlallv able Lo demonsLraLe Lhe behavlours relaLlna
Lo Lhe 7 Common Core Þrlnclples of Self Care.
 key Workers as Levers for 8ehav|our Change- llsLenlna and relaLlonshlp bulldlna
were broadlv ldenLlfled as poLenLlal aap areas for kev workers Lo develop as was
'supporLlna lndlvlduals Lo develop skllls Lo manaae Lhelr care'. 8v developlna
Lhese behavlours, kev workers could be seen as a lever ln enabllna behavlour
chanae ln oLhers.
 Þos|t|ve Þerce|ved Impact of ÞnÞs - once parLlclpanLs aalned an undersLandlna
of Lhe ÞPÞ, Lhe vasL ma[orlLv felL lL would poslLlvelv lnfluence behavlours and
relaLlonshlps beLween kev workers and people wlLh L1Cs.
5ki//s ond
know/edoe

 know|edge and Understand|ng of ÞnÞs - Lhere was a clear lack of knowledae and
undersLandlna of Lhe ÞPÞ and lLs purpose across all aroups. Manv lnlLlallv
percelved lL as a dupllcaLlon of exlsLlna medlcal records. 1hls lack of
undersLandlna has a dlrecL lmpacL on peoples' moLlvaLlon Lo use Lhe ÞPÞ. Manv
of Lhose surveved feel Lhev would beneflL from furLher lnformaLlon abouL Lhe
ÞPÞ.
 Þercept|ons of 5k|||s and know|edge kequ|red - all kev workers lnLervlewed
elLher 'dlsaareed' or 'sLronalv dlsaareed' LhaL people wlLh L1Cs and carers have
Lhe skllls and knowledae Lo make ÞPÞs work well. Powever, Lhe ma[orlLv of kev
workers felL Lhev Lhemselves had Lhe skllls and knowledae Lo make ÞPÞs work
well. 1hls mav suaaesL a lack of undersLandlna of Lhe skllls requlred and could be
a poLenLlal blocker Lo rolllna ouL developmenL proarammes for kev workers.
 Commun|cat|on and Coach|ng 5k|||s -workshop parLlclpanLs felL LhaL, Lhere was a
sLrona llkellhood LhaL manv kev workers lack Lhe communlcaLlon, lnLerpersonal
and coachlna skllls requlred Lo enable Lhe success of ÞPÞs.
 Lngag|ng w|th Þeop|e w|th L1Cs and Carers -manv suaaesLed non-convenLlonal
and lnformal Lralnlna Lechnlques should be used such as suraerv 'coffee-
mornlnas' Lo up-sklll people wlLh L1Cs and Lhelr carers. lnformaLlon leafleLs were
also vlewed as a popular meLhod of recelvlna lnformaLlon and developlna skllls.
lollowlna analvsls of all Lhe daLa aaLhered, lL ls clear LhaL kev workers are Lhe
mosL powerful lever ln enabllna chanae ln oLhers. 1he developmenL of a coachlna
approach when deallna wlLh people wlLh L1Cs and Lhelr carers ls Lherefore a
crlLlcal success facLor Lo enabllna Lhe success of ÞPÞs.

Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
Þersona| nea|th Þ|an
Learn|ng &Cu|tura| A||gnment Iramework
PHP TooI Revision
Behaviours OrganisationaI
AIignment
SkiIIs &
KnowIedge Mindset
7
Common Core
PrincipIes of
SeIf Care
K
e
y

W
o
r
k
e
r
s
C
a
r
e
r
s
PeopIe with Long Term Conditions
  

11
Commun|cat|on Þ|an
Lngagement Þ|an
8u||d|ng the Capab|||ty
Workforce &5trateg|c A||gnment
Þersona| nea|th Þ|an
Learn|ng &Cu|tura| A||gnment Iramework
ÞnÞ 1oo| kev|s|on
8ehav|ours Crgan|sat|ona|
A||gnment
5k|||s &
know|edge M|ndset
7 Core
Common
Þr|nc|p|es of
5e|f Care
k
e
y
W
o
r
k
e
r
s
C
a
r
e
r
s
Þeop|e w|th Long 1ermCond|t|ons



Oroonisotiono/
4/ionment
 1he ÞnÞ 1oo|/Document - Lhere ls a recoanlLlon LhaL boLh Lhe conLenL and look
and feel of Lhe ÞPÞ needs flexlblllLv Lo meeL varvlna sLakeholder requlremenLs.
CurrenLlv lLs lenaLh, sLaLlc feel and chosen secLlons lead manv Lo lnfer lL ls a
snapshoL ln Llme medlcal record documenL and needs Lo be a proacLlve plan. 1hls
has an assoclaLed lmpacL on Lhe moLlvaLlon Lo compleLe and own Lhls documenL.
 1|me Þressures and Workforce Cons|derat|ons - Llme and workforce pressures
have been quoLed as one of Lhe blaaesL challenaes Lo ensurlna Lhe success of
ÞPÞs. Cenerallv, 'Llme pressures' refer Lo a number of assoclaLed lssues such as
Lhe lenaLh of consulLaLlon Llme wlLh kev workers, dallv workload pressures for kev
workers, and Lhe percelved exLra burden Lhe ÞPÞ mav place on some carers.
Manv have suaaesLed addlLlonal resource, perhaps non-cllnlcal, mav be requlred
Lo help lndlvlduals and Lhelr carers compleLe ÞPÞs and LhaL Lhere wlll need Lo be
a chanae Lo currenL [ob descrlpLlons of kev workers.
 keward and Incent|ves - |n order Lo aaln kev worker commlLmenL, lL has been
suaaesLed ÞPÞs should be allaned wlLh exlsLlna performance LaraeLs ln Lhe form
of lndlvldual ob[ecLlves as well as wlder performance LaraeLs such as CÞ CCl
LaraeLs.
 Lxterna| A||gnment -Lhere ls a lack of clarlLv and communlcaLlon around how Lhe
ÞPÞs allan Lo exLernal oraanlsaLlons such as carer neLworks and Lhe
Lhlrd/lndependenL secLors ln aeneral.
Mindset
 Þat|ent Lngagement - has been ldenLlfled as Lhe kev blocker and enabler Lo
chanae. Manv of Lhose lnLervlewed and surveved, lncludlna people wlLh L1Cs
belleve LhaL ÞPÞs can onlv work lf lL ls 'paLlenL-led' as well as 'paLlenL-owned'.
Powever, Lhere was a percepLlon LhaL manv people wlLh L1Cs feel comforLable
wlLh belna dependenL on kev workers and do noL wanL Lo demonsLraLe self care.
 Mot|vat|on - a lack of moLlvaLlon Lo compleLe Lhe ÞPÞ bv boLh kev workers and
people wlLh L1Cs has been ldenLlfled as a sLrona emeralna Lheme. 1hls ls parLlv
due Lo a lack of undersLandlna of Lhe purpose of ÞPÞs, Lhe currenL formaL and
parLlv due Lo a comblnaLlon of oLher facLors such as lack of lncenLlves and Llme
pressures.
 5h|ft |n 8a|ance of Þower - manv see Lhe ÞPÞ as represenLlna a shlfL ln power
relaLlons beLween kev workers and people wlLh L1Cs and a chanae Lo exlsLlna
wavs of operaLlna. 1hls percepLlon mav become a barrler Lo chanae for boLh kev
workers and lndlvlduals.
 Þos|t|ve Þercept|ons of ÞnÞs - when conslderlna Lhe percepLlons of Lhe ÞPÞ, lL ls
lmporLanL Lo acknowledae LhaL once Lhe lndlvlduals aalned an undersLandlna of
Lhe ÞPÞ and lLs purpose, manv, especlallv carers, were whollv supporLlve of lL and
felL lL would have poslLlve lmpacLs on relaLlonshlps, communlcaLlon and Lhe
empowermenL of people wlLh lona Lerm condlLlons. 1hls suaaesLs LhaL wlLh Lhe
rlahL level of supporL and developmenL, as lona as people had a aood
undersLandlna of ÞPÞs, all parLles would be wllllna Lo make lL work.
Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
Þersona| nea|th Þ|an
Learn|ng &Cu|tura| A||gnment Iramework
PHP TooI Revision
Behaviours OrganisationaI
AIignment
SkiIIs &
KnowIedge Mindset
7
Common Core
PrincipIes of
SeIf Care
K
e
y

W
o
r
k
e
r
s
C
a
r
e
r
s
PeopIe with Long Term Conditions
  

12

key I|nd|ngs and Gaps: Þeop|e w|th Long 1erm Cond|t|ons


8ehoviour
 Cnce Lhe concepL of Lhe ÞPÞ was explalned Lo parLlclpanLs ln workshops, Lhev
expressed poslLlvlLv abouL Lhe lmpacL lL could have on relaLlonshlps wlLh Lhelr kev
workers bv encouraalna debaLe, honesLv and beLLer communlcaLlon
 Lven ln plloL slLes where lnLroduclna ÞPÞs Lo lndlvlduals was lnlLlallv a sLruaale and
Llme-consumlna, Lhe process lLself has "brouahL up new Lalklna polnLs and
enabled lndlvlduals Lo Lhlnk Lhrouah Lhelr preferences"
 Manv felL LhaL aL presenL, lndlvlduals were noL acLlvelv demonsLraLlna Lhe
behavlours relaLlna Lo self care and Lhls was due Lo Lhe percepLlon LhaL ºLhe
docLors know besL" and quesLlonlna and debaLe was noL encouraaed or necessarv
 kev workers held a sLrona percepLlon LhaL manv people wlLh L1Cs feel comforLable
wlLh belna dependenL and do noL wanL ownershlp over Lhelr care
5ki//s ond
know/edoe
 All of Lhe kev workers lnLervlewed elLher 'sLronalv dlsaareed' or 'dlsaareed' wlLh
Lhe sLaLemenL LhaL lndlvlduals wlLh L1Cs have Lhe skllls and knowledae Lo make
ÞPÞs work
 Manv of Lhe workshop parLlclpanLs felL LhaL Lhe ma[orlLv of people wlLh L1Cs
would noL be able Lo compleLe Lhe ÞPÞ as lL assumed a cerLaln level of llLeracv and
menLal well-belna.
 lndlvlduals wlLh L1Cs felL Lhev would beneflL from more lnformaLlon and Lralnlna
on Lhe ÞPÞ and ln aeneral preferred lnformal meLhods of learnlna such as coffee
mornlnas and lnLeracLlve sesslons as well as lnformaLlon bookleLs
Oroonisotiono/
4/ionment
 1here was a sLrona percepLlon bv mosL of Lhose lnLervlewed LhaL more
lnformaLlon abouL Lhe ÞPÞ, whaL lL ls and whv lL has been lnLroduced needs Lo be
undersLood bv lndlvlduals wlLh lona Lerm condlLlons
 Manv of Lhe lndlvlduals wlLh L1Cs felL LhaL Lhere was noL enouah Llme ln
consulLaLlon meeLlnas wlLh kev workers Lo be able Lo fullv arasp Lhe ÞPÞ
 Some lndlvlduals suaaesLed Lhe ÞPÞ documenL should be made more user-frlendlv
bv Lurnlna lL lnLo a bookleL or a folder where oLher medlcal record lnformaLlon can
be sLored.
 1here was a suaaesLlon Lo Lake ouL Lhe medlcal secLlons of Lhe form ln order Lo
make lL appear less cllnlcal and focus on Lhe plannlna and preferences aspecLs
 1here was a concern expressed bv some LhaL ÞPÞs would be dlsreaarded ln a
secondarv care seLLlna and ºwould noL work well ln hosplLals - where Lhev have
Lhelr own rules"
Mindset
 ÞaLlenL enaaaemenL was ldenLlfled bv Lhe ma[orlLv of Lhose lnLervlewed as belna a
kev challenae. Manv felL lndlvlduals wlLh L1Cs wlll be dlslnLeresLed ln ÞPÞs and
feel comforLable belna dependenL on Lhelr kev workers for Lhelr care
 Lquallv, Lhe mosL lmporLanL enabler ldenLlfled bv parLlclpanLs was maklna Lhe ÞPÞ
'paLlenL-led'
 1here was a percepLlon LhaL Lhose lnLeresLed ln ÞPÞs are Lhe Lvpe of paLlenLs who
would beneflL mosL as Lhev are alreadv aood aL manaalna Lhelr own care
 lf successful, lndlvlduals wlLh L1Cs and Lhelr carers could see how Lhe ÞPÞs could
provlde Lhem wlLh a volce and Lhe confldence Lo challenae kev workers and
lnfluence cholce
 CurrenLlv, Lhe lnlLlal percepLlon of lndlvlduals ls LhaL Lhe ÞPÞ ls an nPS owned Lool
and LhaL Lhe 'kev workers' wlll have Lhe areaLesL lnfluence over Lhe ÞPÞ and anv
declslon-maklna assoclaLed wlLh lL
Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
C
a
r
e
r
s
K
e
y
W
o
r
k
e
r
s
Þersona| nea|th Þ|an
Learn|ng & Cu|tura| A||gnment Iramework
PHP TooI Revision
Behaviours OrganisationaI
AIignment
SkiIIs &
KnowIedge Mindset
7
Common Core
PrincipIes of
SeIf Care
PeopIe with Long Term Conditions
  

13

key I|nd|ngs and Gaps: Carer




8ehoviour

 1he ma[orlLv of carers felL Lhelr would be no chanae when asked wheLher
Lhere wlll be a chanae Lo communlcaLlon and relaLlonshlps beLween
Lhemselves, Lhe person Lhev care for and Lhelr kev worker
 1hls flndlna mav be lndlcaLlve of a lack of undersLandlna of Lhe ÞPÞ and lLs
ob[ecLlves and suaaesLs LhaL Lhe behavlour chanae lmpllcaLlons are noL veL
undersLood
 ln a workshop seLLlna and havlna had Lhe opporLunlLv Lo aaln a beLLer
undersLandlna of ÞPÞs, manv carers could see how lL could poslLlvelv affecL
relaLlonshlps beLween Lhe kev worker and Lhe person Lhev care for bv
lmprovlna Lhe kev workers' knowledae of Lhe paLlenL
5ki//s ond
know/edoe
 When asked lf Lhev belleve carers have Lhe skllls and knowledae Lo make ÞPÞs
work well, Lhe vasL ma[orlLv of kev workers surveved answered 'dlsaaree' and
'sLronalv dlsaaree'
 ln conLrasL, all carers surveved 'aareed' or 'sLronalv aareed' wlLh Lhe sLaLemenL
LhaL Lhev had Lhe skllls and knowledae Lo ensure Lhe success of ÞPÞs
 All of Lhe carers surveved also belleved Lhev know how Lo flnd Lhe relevanL
lnformaLlon Lo make ÞPÞs work well
 1he above flndlnas mav be lndlcaLlve of a lack of undersLandlna of Lhe Lvpes of
skllls requlred and a more aeneral lack of undersLandlna of Þersonal PealLh
Þlans
 1he ma[orlLv of carers enaaaed wlLh vla quesLlonnalres and Lhe workshop felL
Lhev would beneflL from more lnformaLlon abouL Lhe ÞPÞ

Oroonisotiono/
4/ionment
 Some parLlclpanLs flaaaed Lhe lssue LhaL compleLlna a ÞPÞ mav become an
exLra burden for a carer
 1here ls a suaaesLlon LhaL addlLlonal resource opLlons should be explored Lo
help carers and people wlLh L1Cs compleLe ÞPÞs
 1he ma[orlLv of carers preferred lnformaLlon bookleLs as a means of recelvlna
lnformaLlon and developlna skllls
 Manv parLlclpanLs ralsed a concern abouL how aware carer oraanlsaLlons are of
ÞPÞs and whaL Lhelr role was ln maklna ÞPÞs successful
Mindset
 Manv lndlvlduals wlLh L1Cs felL LhaL whlle Lhe ÞPÞ could be used as a vehlcle
for lmprovlna communlcaLlon and relaLlonshlps wlLh kev workers, lL would noL
have Lhe same beneflL for carers, who Lhev felL, alreadv had a sLrona bond wlLh
Lhe lndlvldual Lhev cared for. 1hls mav be reflecLlve of onlv some carer/paLlenL
relaLlonshlps.
 As wlLh all oLher sLakeholder aroups enaaaed wlLh, manv carers were unsure of
Lhe purpose of ÞPÞs and assumed lL ls a medlcal record owned bv Lhe nPS.
 Manv belleved LhaL Lhe ºnPS and care professlonals" wlll have Lhe mosL
lnfluence over ÞPÞs and LhaL ºnurslna sLaff wlll be Lhe declslon makers"
 All of Lhe carers surveved and Lhose LhaL Look parL ln Lhe workshop expressed
a poslLlve aLLlLude Lowards ÞPÞs and saw lL as a welcome measure Lo supporL
Lhose Lhev cared for

Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
PeopIe with Long Term Conditions
Þersona| nea|th Þ|an
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7
Common Core
PrincipIes of
SeIf Care
K
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W
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14
key I|nd|ngs and Gaps: key Worker





8ehoviour



 kev workers feel LhaL on Lhe whole Lhev are onlv 'parLlallv' able Lo
demonsLraLe Lhe behavlours underplnnlna Lhe 7 Common Core Þrlnclples
when lnLeracLlna wlLh paLlenLs. Manv sLaLe Lhls ls due Lo Llme consLralnLs.
 When asked Lo assess Lhe behavlour of Lhelr kev workers, Lhe percepLlons of
lndlvlduals wlLh L1Cs and Lhelr carers are sllahLlv beLLer. 1he ma[orlLv of Lhose
surveved belleve kev workers demonsLraLe Lhe behavlours underplnnlna Lhe 7
Common Core Þrlnclples 'ofLen' or on a frequenL basls
 Carers and lndlvlduals wlLh L1Cs ldenLlfled Lhree aap areas ln Lhe behavlours of
kev workers:
 SupporL lndlvlduals Lo develop skllls Lo manaae Lhelr care
 Lnable lndlvlduals Lo use Lechnoloav Lo supporL self care
 SupporL lndlvlduals Lo plan and evaluaLe servlces Lhev recelve
 LlsLenlna and relaLlonshlp bulldlna were broadlv ldenLlfled bv parLlclpanLs as
behavlours cenLral Lo Lhe success of ÞPÞs. 1here ls a percepLlon LhaL some kev
workers lack Lhese behavlours. A quoLe from an lndlvldual wlLh an L1C
lllusLraLes Lhls polnL - ºa loL of docLors are noL human, Lhev are machlnes -
Lhev don'L Lalk Lo vou as a person".
5ki//s ond
know/edoe
 When asked lf Lhev belleve Lhev have Lhe skllls and knowledae Lo ensure Lhe
success of ÞPÞs, Lhe ma[orlLv of kev workers belleved Lhev dld, and lndlcaLed
Lhe onlv beneflclal Lralnlna would be cllnlcal Lralnlna on L1Cs
 1hese flndlnas are mlrrored bv Lhe lnlLlal percepLlons of lndlvlduals wlLh L1Cs
and Lhelr carers who demonsLraLe a hlah level of confldence ln Lhe skllls and
knowledae of Lhelr kev workers ln enabllna Lhe success of ÞPÞs
 1he flndlnas from Lhe workshop however demonsLraLe LhaL lndlvlduals do noL
have a aood undersLandlna of Lhe skllls and knowledae requlred Lhemselves
for Lhe success for ÞPÞs and ln Lhe flrsL lnsLance refer Lo cllnlcal skllls onlv
 When probed abouL lnLerpersonal and communlcaLlon skllls, Lhere ls a
percepLlon LhaL some kev workers have aaps ln Lhese areas and Lhls neaaLlvelv
lmpacLs on Lhe kev worker/paLlenL relaLlonshlp and muLual LrusL
Oroonisotiono/
4/ionment
 1here ls a sLrona percepLlon bv all Lhose lnLervlewed LhaL ÞPÞs wlll add Lo Lhe
workload of kev workers who percelve lL ºas veL anoLher form" Lo compleLe.
º1lme consLralnLs" were quoLed on numerous occaslons as Lhe blaaesL
challenae Lo maklna ÞPÞs work well.
 Manv felL Lhe ÞPÞ documenL was Loo lona and dlfflculL for manv people wlLh
L1Cs Lo compleLe and LhaL kev workers would need Lo provlde supporL
 1here was a sLrona percepLlon LhaL Lhe ÞPÞ ln lLs currenL form ls a sLaLlc,
snapshoL ln Llme documenL and lL would be dlfflculL Lo updaLe reaularlv
 ln order Lo aaln CÞs and oLher kev workers' commlLmenL, manv felL Lhe
compleLlon of ÞPÞs should be llnked Lo CCl LaraeLs
 Manv ÞPÞ plloL coordlnaLors and kev workers suaaesLed addlLlonal resources
were requlred Lo help roll-ouL ÞPÞs successfullv and some suaaesLed uLlllslna
PealLhcare SupporL Workers Lo dellver Lhe ÞPÞ
Mindset
 Manv kev workers lnlLlallv percelve Lhe ÞPÞ Lo be a medlcal record raLher Lhan
a care plan and as such, see lL as a poor dupllcaLlon of exlsLlna records e.a. CÞA
 MosL kev workers, when quesLloned, undersLand Lhe ÞPÞ Lo be a paLlenL-
owned documenL veL sLlll Lhlnk Lhev wlll need Lo help Lhe paLlenLs compleLe lL
ln pracLlce
 Some kev workers feel LhaL Lhe ÞPÞs represenL a shlfL ln Lhe balance of power
beLween Lhe cllnlclan and paLlenL and fear lL mav cause paLlenLs Lo develop
unreallsLlc expecLaLlons
Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
C
a
r
e
r
s
PeopIe with Long Term Conditions
Þersona| nea|th Þ|an
Learn|ng &Cu|tura| A||gnment Iramework
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Behaviours OrganisationaI
AIignment
SkiIIs &
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Common Core
PrincipIes of
SeIf Care
K
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W
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ÞnÞ Cons|derat|ons for Marg|na||sed Groups



1he £/der/y
 1hls chanae challenaes deep-seaLed aLLlLudes and percepLlons abouL Lhe
paLlenL/docLor relaLlonshlp - as lllusLraLed bv a quoLe from a workshop
parLlclpanL ºln Lhe old davs Lhe docLors wenL Lo unlverslLv and vou llsLened Lo
Lhem as Lhev know besL"
 1here mav be dlfflculLv wlLh compleLlna a lenaLhv form due Lo a lack of manual
dexLerlLv, vlsual lmpalrmenL or Lhe menLal dexLerlLv Lo compleLe a form uslna
unfamlllar lanauaae
 1he elderlv people wlLh L1C's we enaaaed wlLh sLaLed a preference for a
paper-based ÞPÞ documenL
Prisoners
 lndlvlduals wlLh L1Cs ln a prlson seLLlna are unllkelv Lo have carers and Lherebv
have a heavler rellance on Lhelr kev workers Lo help Lhem compleLe Lhe ÞPÞ.
1hls mav have workforce lmpllcaLlons.
 1he plloL-coordlnaLors and kev workers worklna ln a prlson seLLlna have
commenLed LhaL Lhe sLandards of llLeracv are aenerallv lower for prlsoners.
1hls makes Lhe ÞPÞ form lnaccesslble Lo Lhem and ralses conslderaLlons for
developlna a new approach Lo Lhe ÞPÞ for some prlsoners.
 lL ls llkelv Lo be even more of a challenae and mlnd-shlfL chanae for some
prlsoners Lo pracLlce self care behavlours and feel empowered.
Peop/e from poor
socio-economic
bockorounds
 Lower llLeracv raLes and Lhe ablllLv Lo undersLand Lhe Lerms referred Lo ln Lhe
ÞPÞ mav be a challenae for some people wlLh L1Cs who are from poorer soclo-
economlc backarounds
 uemonsLraLlna Lhe confldence Lo use Lhe ÞPÞ Lo express Lhelr preferences and
challenae kev workers ls llkelv Lo be a areaLer challenae for some people wlLh
L1Cs from poorer soclo-economlc backarounds
 1here are llkelv Lo be lanauaae challenaes for Lhose wlLh Lnallsh as a second
lanauaae. 1he use of a LranslaLor should be consldered as parL of Lhe ÞPÞ
conversaLlons as well as dlfferenL lanauaae verslons of Lhe ÞPÞ.
Peop/e with
mento/ heo/th
prob/ems
 Some people wlLh menLal healLh problems mav noL be able or wllllna Lo plan
for Lhe fuLure due Lo lmpalred coanlLlve ablllLv. As explalned bv one kev worker
some people wlLh menLal healLh lssues "are bevond Lhe sLaae of plannlna for
Lhe fuLure, as Lhev no lonaer have Lhe ablllLv Lo make consclous cholces or
declslons". 1he currenL ÞPÞ Lool and approach should be reconsldered for
some lndlvlduals ln Lhls aroup.



Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
C
a
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e
r
s
K
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y
W
o
r
k
e
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s
Þersona| nea|th Þ|an
Learn|ng & Cu|tura| A||gnment Iramework
PHP TooI Revision
Behaviours OrganisationaI
AIignment
SkiIIs &
KnowIedge Mindset
7
Common Core
PrincipIes of
SeIf Care
PeopIe with Long Term Conditions
  
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16
kecommendat|ons
1he flndlnas from Lhe daLa aaLhered as parL of Þhase 1 lndlcaLe Lhere are flve kev aap areas Lo
address when rolllna ouL ÞPÞs across Lhe LasL of Lnaland. 1he flve kev areas are deLalled below
and can be Lurned lnLo preparaLorv bulldlna blocks of acLlvlLv Lo supporL Lhe ÞPÞ roll-ouL process.

 Whv?
Llnk beLween flndlnas and
recommended bulldlna
blocks
Pow?
SuaaesLed approaches and soluLlons
ÞnÞ 1oo|
kev|s|on
1he ÞPÞ 1ool/uocumenL lLself was
percelved bv manv as an lnlLlal
blocker for a varleLv of reasons
lncludlna lLs lenaLh, sLaLlc look and
feel and percelved lnaccesslblllLv
Lo some maralnallsed aroups. As a
prlorlLv, a Lhorouah revlew of Lhe
ÞPÞ Lool ls recommended. 1hls
allans well wlLh Lhe kev ob[ecLlve
of Lhe ÞPÞ plloLs.
 8evlse Lhe conLenL of ÞPÞ Lool bv conslderlna reduclna
Lhe lenaLh and replaclna exlsLlna secLlons wlLh newlv
suaaesLed secLlons such as a dlarv
 8evlse Lhe 'look and feel' of Lhe ÞPÞ Lool conslderlna a
less sLaLlc/snapshoL ln Llme feel perhaps Lhrouah Lhe use
of a bookleL, blnder and/or elecLronlc formaL
 Conslder lmpllcaLlons for maralnallsed aroups when
revlslna Lhe conLenL
 Conslder seamenLlna dlfferenL Lvpes of lona Lerm
condlLlons lnLo a ÞPÞ capablllLv specLrum wlLh reaard Lo
coanlLlve, phvslcal and lanauaae ablllLv. CreaLe a plan Lo
lncrease Lhe proporLlon of self care for each aroup, as
approprlaLe from a cllnlcal & safeLv perspecLlve, and
conslder lLeraLlna Lhe ÞPÞ Lool and approach accordlnalv.
Commun|cat|on
Þ|an
1he flndlnas lndlcaLe a lack of
undersLandlna of Lhe fundamenLal
concepL of Lhe ÞPÞ, lLs purpose
and beneflLs amonasL manv arass-
rooLs sLakeholders. 1he
developmenL of lncluslve and
accesslble communlcaLlons prlor
Lo Lhe lnLroducLlon of ÞPÞs ls kev
Lo Lhe chanae manaaemenL
process.
 ueflne clear and conslsLenL communlcaLlon messaaes ln
relaLlon Lo Lhe baslcs of Lhe ÞPÞ such as: whaL ls Lhe ÞPÞ?
Who owns Lhe ÞPÞ? Whv should l have a ÞPÞ? LLc.
 Conslder developlna a ÞPÞ-dedlcaLed lnLerneL slLe
accesslble Lo kev workers and compuLer-llLeraLe people
wlLh L1Cs and Lhelr carers
 Conslder developlna onllne bloas, lACs and Wlklpedla
lnLerneL secLlons Lo deflne Lhe ÞPÞ, lLs purpose and
aovernance
 uevlse non-elecLronlc communlcaLlon channel, such as
lnformaLlon leafleLs Lo reach aroups who do noL readllv
use Lhe lnLerneL Lo ensure communlcaLlons are accesslble
Lngagement
Þ|an
Manv parLlclpanLs expressed an
lnlLlal dlsenaaaemenL and lack of
moLlvaLlon Lo use ÞPÞs. AlLhouah
Lhls mav be due Lo a lack of
undersLandlna of ÞPÞs and Lhelr
percepLlons of Lhe Lool lLself,
sLakeholder enaaaemenL and buv-
ln ls fundamenLal Lo successfullv
embed ÞPÞs. ConslderaLlon
should be alven Lo developlna an
LnaaaemenL sLraLeav
 Conslder adopLlna a vlral MarkeLlna Approach - sLarLlna
wlLh low kev communlcaLlons and araduallv lncreaslna Lhe
lnLenslLv of messaaes Lo sLakeholders Lo drum up lnLeresL
and enaaaemenL
 SelecL Chanae Champlons l.e. Lhose who have poslLlve
experlences of ÞPÞs ln order Lo advocaLe Lhe ÞPÞ Lo
oLhers
 CreaLe Local Chanae AcLlon 1eams Lo supporL and embed
local roll-ouL of ÞPÞs
 Conslder Lhe use of vldeocasLs and ÞodcasLs as powerful
communlcaLlon/enaaaemenL Lools. lor example, a person
wlLh an L1C explalnlna Lhelr own words Lhelr lnlLlal
reservaLlons Lowards Lhe ÞPÞ and how, ln Lhe end lL has
beneflLed Lhem.
 Pold lnLeracLlve Workshops Lo allow people Lo explore
Lhe concepL of Lhe ÞPÞ
Communication PIan
Engagement PIan
BuiIding the CapabiIity
Workforce & Strategic AIignment
C
a
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r
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e
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k
e
r
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PeopIe with Long Term Conditions
PersonaI HeaIth PIan
Learning & CuIturaI AIignment Framework
PHP TooI Revision
Behaviours OrganisationaI
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SkiIIs &
KnowIedge Mindset
7
Common Core
PrincipIes of
SeIf Care
  

17
8u||d|ng the
Capab|||ty
1here was a percelved lack of
skllls, knowledae and behavlours
Lo successfullv embed ÞPÞs across
all sLakeholder aroups. ÞarLlcular
conslderaLlon should be alven Lo
kev workers as levers Lo enable
behavlour chanae ln oLhers.
lnnovaLlve and lnformal learnlna
and developmenL soluLlons should
be explored for people wlLh L1Cs
and Lhelr carers.
 Scope kev sklll and behavlour focus areas Lo address such
as, Coachlna, CommunlcaLlon and 8elaLlonshlp 8ulldlna
for kev Workers
 uevelop blended learnlna soluLlons wlLh a comblnaLlon of
LradlLlonal Lralnlna and more lnformal developmenL
Lechnlques such as 'suraerv coffee- mornlnas' Lo ensure
learnlna soluLlons are lncluslve and accesslble Lo all ÞPÞ
sLakeholders
 Conslder Lhe use of '1echnoloav Lnabled Learnlna',
especlallv for kev workers based ln dlsparaLe locaLlons
and who cannoL free up Lhe Llme Lo aLLend a Lralnlna dav.
L-learnlna Lools and vldeo/podcasLs mav be useful modes
of dellverv Lo explore.
 uevlse and lmplemenL a '1raln Lhe 1ralner Þroaramme for
ÞC1s' ln preparaLlon for rolllna ouL ÞPÞs uslna proven
lnLeracLlve meLhods of dellverv wlLh kev workers such as
acLlon learnlna seLs.
 Comblne and allan capablllLv bulldlna for ÞPÞs wlLh
exlsLlna lnlLlaLlves where posslble, such as Lhe LxperL
ÞaLlenL Þroaramme and Lhe ÞromoLlna Self Care ÞlloL
Þro[ecL
Workforce and
5trateg|c
A||gnment
1lme pressures, workforce
consLralnLs and a lack of clarlLv of
how ÞPÞs flL lnLo exlsLlna
processes and performance
measures were quoLed bv manv as
percelved blockers Lo chanae. An
ldenLlflcaLlon and revlew of
workforce, procedure and process
Louch-polnLs should be
underLaken Lo achleve allanmenL.
 uevlse auldance on how Lhe roll-ouL of ÞPÞs should form
parL of performance revlew ob[ecLlves for kev workers Lo
ensure Lhev know whaL ls expecLed of Lhem
 Conslder Lhe revlslon of speclflc [ob descrlpLlons Lo
formallse ÞPÞs as an expecLed wav of worklna
 8evlew and allan Lhe roll-ouL of ÞPÞs wlLh exlsLlna
performance measures and LaraeLs such as CCl for CÞs
ensurlna focus ls LaraeLed aL embeddlna ÞPÞs and
reallslna beneflLs raLher Lhan on Lhe numbers rolled-ouL
 Conslder launchlna lnnovaLlve SPA/ÞC1-wlde ÞPÞ
recoanlLlon and reward schemes for kev workers, people
wlLh L1Cs and carers Lo relnforce behavlour chanae.
 Lnsure kev worker recrulLmenL and lnducLlon
proarammes are revlsed Lo allan wlL Lhe skllls,
compeLencles and behavlours requlred Lo successfullv
embed ÞPÞs

ÞarL of Þhase 2 pro[ecL acLlvlLles wlll be Lo valldaLe Lhe above hlah-level recommendaLlons wlLh a
wlder and represenLaLlonal sLakeholder aroup. 1he flve bulldlna blocks ouLllned above can be used
Lo frame and focus Þhase 2 acLlvlLles wlLh each block represenLlna a pro[ecL work-sLream almed aL
deflnlna and bulldlna a LoolklL readv Lo supporL Lhe roll-ouL of ÞPÞs. uependlna on Lhe scope of
Lhe Lool-klL, Lhe 8ulld sLaae mav exLended pasL Þhase 2. 1hls ls lllusLraLed bv Lhe Llmescale
dlaaram below.
ÞnÞ ko||-Cut 5upport Þ|an- Last of Lng|and, 5nA

n|gh Leve| Des|gn Va||dat|on 8u||d ko|| Cut
Þhase 1¬ March 2009
Þ||ot 5tart
Þhase 2¬ Iune 2009
Þ||ot Lnd 8y December 2010

  

18
Learn|ng Iramework Þract|ca| Use and 8enef|ts
lor
commissioners
 1o lnform servlce speclflcaLlons Lo ensure meanlnaful adopLlon and roll ouL of
ÞPÞs. lor lnsLance, speclflcaLlons Lo supporL people wlLh L1Cs and Lhelr carers
abouL Lhe premlse and use of ÞPÞs.
 1o undersLand Lhe culLure chanae requlred for exlsLlna commlssloned servlces
and Lhe commlsslonlna of new servlces Lo supporL ÞPÞ lmplemenLaLlon.
 1o develop local models Lo exLracL mlcro commlsslonlna needs Lo lnform
macro commlsslonlna. lor example, Lralnlna and educaLlonal
proarammes/courses requlred Lo up-sklll exlsLlna workforce Leams, or
commlsslon e-learnlna soluLlons/Lralnlna Lo lncrease awareness and supporL
for ÞPÞs.
lor providers
 1o underpln Lhe developmenL of a seL of avallable Lools and resources Lo
supporL meanlnaful lmplemenLaLlon of Lhe ÞPÞs, lncludlna preparaLorv
resources and auldance Lo ensure users, carers and kev workers are lnformed
of Lhe chanaes expecLed as a resulL of ÞPÞ roll ouL.
 1o lnform plans for ConLlnulna Þrofesslonal uevelopmenL aL a 1rusL level, Lo
subsequenLlv lnform CounLv Workforce Croups' workforce plans.
 1o use Lhe Þerformance uevelopmenL 8evlew Þrocess Lo capLure kev workers
developmenL needs and ob[ecLlves Lo ensure Lhe skllls, knowledae and
behavlour requlred Lo lmplemenL ÞPÞs are belna addressed durlna Lhe course
of Lhe vear.
 1o map local needs Lo Lhe lmplemenLaLlon of ÞPÞs Lo Lhe realonal porLfollo of
resources and Lools Lo ensure LhaL acLlvlLles are flexed Lo meeL local needs. ln
parLlcular, Lhe besL use of exlsLlna local workforce Leams Lo supporL ÞPÞ roll
ouL.
 1o enable Lhe developmenL of local champlons Lo supporL sklll and knowledae
acqulslLlon as well as Lo challenae exlsLlna behavlours. ln parLlcular, Lralnlna
and educaLlonal needs requlred Lo ensure LhaL users and Lhelr carers, as well
as kev workers fullv undersLand Lhe premlse and value of ÞPÞs Lo efflclenLlv
and effecLlvelv offer ÞPÞs Lo people wlLh L1Cs.
lor county
workforce 6roups
 1o lnform Lhe deslan, dellverv and access Lo ConLlnulna Þrofesslonal
uevelopmenL.
 1o lnform access Lo educaLlon commlsslonlna. lor example, e-learnlna or local
coffee mornlnas, or speclflc ÞPÞ supporL neLworks for users and Lhelr carers Lo
supporL ÞPÞ lmplemenLaLlon aL a arass rouLes local level.
 1o lnform workforce plannlna, ln parLlcular, kev communlcaLlon and
enaaaemenL acLlons requlred aL a local level Lo supporL ÞPÞ lmplemenLaLlon.
1hls mav lnclude a kev focus on closer parLnershlp worklna beLween local
healLh care, soclal care, Lhlrd and volunLarv secLor oraanlsaLlons, lncludlna
carers supporL neLworks, Lo ensure LhaL skllls and knowledae requlremenLs, as
well as behavlours and culLural capablllLles are ln place Lo supporL ÞPÞs aL a
local level.

  

19
1hank you

Capgem|n| wou|d ||ke to thank the Last of Lng|and 5nA for the
opportun|ty to deve|op a 8|uepr|nt Learn|ng Iramework to
support the |mp|ementat|on of ÞnÞs. Capgem|n| wou|d a|so ||ke
to thank a|| peop|e w|th L1Cs, the|r carers, key workers, p||ot co-
ord|nators and other hea|th and soc|a| care profess|ona|s who
have supported th|s engagement. Capgem|n| |ook forward to
work|ng w|th the Last of Lng|and to further support the ro|| out of
ÞnÞs.