Personalised Care

Personalised care represents a new relationship between people, professionals and the system. It happens when we make the most of the expertise, capacity and potential of people, families and communities.

See February’s Personalised Care Bulletin here.


What's happening

Opportunities and Offers

An Introduction to personal health budgets eLearning

The introduction to personal health budgets eLearning module has been updated. This online training is intended to support all staff who are involved in the delivery of personal health budgets (PHBs). The module covers a variety of topics including: the legal right to have a PHB, budget management options, and what a PHB can and cannot be spent on. It also offers guidance on the steps involved in implementing and maintaining a PHB, and the key features that ensure people experience the best outcomes possible.

Health Coaching Programme 2023

The (FREE) two- day course is for staff who have the opportunity to support people to make behaviour changes that will encourage improved health and well-being.

It will provide a range of tools and techniques that will help structure conversations to help individuals to set and work towards goals that are important to them, whether this is about lifestyle changes that will promote better health and well-being or being better able to manage long term conditions. Please find below further information on this training opportunity.

(via TPC Health)

The Health Coaching Train the Trainer programmes are designed for organisations that want to develop an internal training resource for a cost effective roll-out of health coaching training and become independent in educating their workforce.

Participants will need to be available for all 6 sessions in full.

The first training dates of this 6 day course (6th and 7th of Dec) are approaching fast.

Please send all completed Expression of Interest Forms to healthierlsc.personalised[email protected] by 5.00pm on Friday 11th November.

View the below flyer for more information.

Improvement Fundamentals Course

Free online course, enrolling now.

An Introduction to Spreading Improvement Gains, the fourth mini-course of the Improvement Fundamentals programme is enrolling now. 

The course covers the important topic of how to spread your quality improvements beyond your immediate workplace.  

You don’t have to have completed any of the previous courses to participate – you just need to have an idea of a project to work on. 

Enrol here, if you are already registered on the NHS England platform. If you are not yet registered, register here then enrol.  Should you experience any issues enrolling or have any questions, please e-mail [email protected] 

The Leadership for Personalised Care programme

The Leadership for Personalised Care programme is suite of cutting-edge learning and development programmes aimed at leaders at all levels in health, social care and beyond, to help them champion personalised care, community development and co-production and lead system transformation from the ground up. Leadership for personalised care requires a paradigm shift from seeing public services as simply ‘providing’ a solution to focusing on what matters to people and families, in the context of their whole lives and communities. It is a person- and community-centred complex adaptive approach to leadership. It involves specific actions around individual care – ensuring approaches like care and support planning, social prescribing and proactive support for self-management are in place, but also creating the conditions for these things to happen, an in the most effective and asset-based way.

Find out more on their website. 

Introduction to Leadership for Personalised Care Course

New free online course: NHSE have created an ’Introduction to Leadership for Personalised Care’ course, that takes their high-quality content and makes it easily accessible via the FutureLearn platform. 

This 3-week online course is free, easy to access and open to anyone who wants to find out more about leading a person-centred approach, offering you the same high-quality content as their other programmes. 

Learning online means you can be self-directed and take advantage of the flexible, accessible, and bite-sized content, providing you with a foundation in leadership for personalised care practice. It will help you take the first step in being a leader in this field and develop the skills and confidence to go further. 

Enrolment is now open.

PAM (Patient Activation Measure ) Workshop

Over 46,000 PCI training courses have now been completed by clinicians. The free training delivered through the PCI helps to develop the professional skills and behaviours required to deliver shared decision making, personalised care and support planning and health coaching, as fundamental ways of working across health and care staff.

This progress takes the PCI closer to the Universal Personalised Care Action 5 that at least 75,000 clinicians will be trained by 2023/24.

Take part in training today by visiting the Personalised Care Institute website.

Personalised Care Institute (PCI) training

Patient Activation sessions are back up and running across 

The Patient Activation webinar will enable participants to gain further insight into Patient Activation and the different ways in which the PAM tool can be used.

Please find the be;pw details of PAM (Patient Activation Measure) and how this can benefit you in your current role. Please also find below a PAM Application Form, should you wish to attend any of our free PAM sessions being delivered, via teams from Sep – Dec 2023.

Details of the PAM Workshop sessions (all same content)  are stated on both of the attached docs.

Please fill out an application form, highlighting the dates you wish to attend and send to [email protected]

further information


Social prescribing link workers, health and wellbeing coaches, and care coordinators (non-medical roles) are all included in the Additional Roles Reimbursement Scheme, with a specific aim of supporting people based on what matters to them, and helping address their holistic needs through advice, guidance, and connection to wider support services, including social, practical and financial support.

These roles can help identify and address unmet social needs and health inequalities through targeted work with specific groups identified through proactive approaches.

Social Prescribing Link Worker

Social prescribing link workers connect people with local community activities and services that can help.

Find out more about the role on the NHS Health Careers website.

If you have any questions please email [email protected]

A new survey for social prescribers, link workers, social prescribing programme managers, or leads with a caseload is now open. The research is being conducted by Citizen’s Advice (CA), a national Information, Advice and Guidance (IAG) service, and National Association of Link Workers (NALW) to explore the role social prescribing link workers play in CA’s rising referral rates, and the impact this has on local IAG services.

Please complete this survey by 14 February 2023 – views on how social prescribing referrals are recorded are critical in helping NHS England to understand the full impact of social prescribing.

Merton CCG and Merton Council set out to test a model of Social Prescribing that would connect medical care with local voluntary and community resources. Healthy Dialogues was asked by Merton Council to do a formative and summative evaluation of the initial results from the Social Prescribing programme as well as produce recommendations for upscaling across Merton in its second year. An update of the Merton social prescribing evaluation report was completed in August 2021.

Public Health England has advice and guidance for healthcare practitioners on the health needs of migrant patients, including a summary of findings from a recent evidence review that PHE completed on social prescribing for migrants in the UK. It also provides a series of recommendations for referrers to social prescribing services, link workers, social prescribing monitoring and evaluation, and future research. Doctors of the World have also recently launched a toolkit for link workers to support migrants to access healthcare.

This programme is open to clinical and non-clinical NHS colleagues who are passionate about raising the profile of social prescribing and sharing good practice.

Applications are now closed. If you would like to enquire about the programme, please visit the NASP website.

This guide provides additional information to help PCNs introduce the social prescribing link worker role into their multi-disciplinary teams (MDTs) as part of the expansion of the primary care workforce introduced through the Network Contract Directed Enhanced Service (DES) 2022/23 Additional Roles Reimbursement Scheme. It also provides information to deliver the proactive social prescribing element of the Network Contract DES Personalised Care service specification

Social prescribing services and link workers have the potential to make a big difference to the lives of people with musculoskeletal conditions such as arthritis or back pain. This webinar aims to help you understand musculoskeletal (MSK) conditions, their prevention, their impact, and how to consider this when you meet clients. Watch the recording on Arthritis and Musculoskeletal Alliance (AMRA) website

Health Coach

Health coaching is a patient-centred process that is based upon behaviour change theory and is delivered by health professionals with diverse backgrounds.

Working closely with Osca and the Tavistock Institute and in consultation with health coaching commissioners, providers, champions and experts locally and around the country, three products have emerged from this strategic review that address this need:

  • A Quality Framework to help in the commissioning of high quality health coaching staff development programmes, giving examples of projects from across the country
  • A Quality Framework Summary with the main strategies and approaches from the full framework, but without the examples); and
  • The Area Delivery Template which provides ideas on ways in which a health coaching approach can be developed and sustained across a geographical area.

Care Co-ordinator

Care coordinators provide extra time, capacity, and expertise to support patients in preparing for clinical conversations or in following up discussions with primary care professionals. They focus on the delivery of personalised care to reflect local PCN priorities, health inequalities or at risk groups of patients. They can also support PCNs in the delivery of Enhanced Health in Care Homes. 

Tools to implement supported self-management

The Care Coordinators’ welcome pack is designed for newly appointed care coordinators in primary care networks.

Designed to support the delivery of a care coordinator and provide an introduction in the role. The document will also point the reader in the direction of more detailed information that will be useful to their role.

Appointed care coordinators may also find this document helpful as a reference guide to their role.

further information

Resources & Videos

Going Further this Winter Announcement – importance of care plan reviews in dementia

On 18 October NHSE  wrote to system leaders about going further with winter resilience plans. This letter from Amanda Pritchard announced new measures that will support people with dementia, including reducing avoidable admissions through rapid response teams and identifying and supporting high frequency users through proactive personalised care.

The colder months can worsen symptoms of dementia and increase risk of hospital admissions. Evidence indicates that people with dementia occupy 25% of acute hospital beds, stay in hospital twice as long and were admitted for infections treatable in the community.

Integrated and personalised care are key to preventing unwarranted hospital admissions. All those caring for people with dementia including GP teams, PCNs, Anticipatory Care, Frailty, EHCH, palliative and end of life care (PEoLC), and Community, are encouraged to review care plans to enable appropriate support using appropriate guidance

Frameworks, Reports and Guides

This brief summary guide will support integrated care systems to understand and create the conditions for sustainable implementation of personalised care and support planning in line with the essential delivery of personalised care within systems. It is intended to support those involved in the leadership, design, development and delivery of personalised care and support planning across all sectors. It provides best practice advice, not statutory guidance. However, it can be used to self-assess and self-assure the quality of local systems implementation of personalised care and support planning.

This new framework provides guidance for people employed as a link worker and those employing them. It will help increase the understanding of the role and where link workers can have most impact in supporting and empowering people to improve their health and wellbeing. It also sets professional standards and competencies, gives guidance on supervision, training, and continuous professional development. 

Social Prescribing Link Worker Framework

Health and Wellbeing Coaches Framework

Care Coordinators Framework

Addressing palliative and end of life care needs for people living with heart failure: a revised framework for integrated care systems has been published replacing ‘End of life care in heart failure: a framework for implementation’ (2014). Its purpose is to raise awareness of the supportive, palliative and end of life care needs of people living or dying with progressive heart failure, to help in commissioning services to meet their needs. It covers care for adults and refers to anyone aged 18 or over.

The National Academy for Social Prescribing worked with National Association for Voluntary and Community Action (NAVCA) and Spirit of 2012 to develop a new toolkit for social prescribing link worker host organisations, with a particular focus on hosting in the Voluntary, Community and Social Enterprise (VCSE) sector.

The resource aims to help primary care networks (PCNs) and host organisations establish, develop and maintain a sustainable and effective social prescribing scheme in their local area.

The data visualisations for the individual employers and personal assistants report 2023 are now available. The report provides information about direct payment recipients and their personal assistants in England

This toolkit has been designed to help NHS organisations reduce the risk of suicide in their workforce. It will assist organisations to embed suicide prevention strategies in the organisation’s health and wellbeing policies and guide the approach to supporting those at risk of suicide within the workforce.

  • Patient experience for people who are homeless
People facing homelessness face significant health inequalities. They face barriers accessing healthcare and often have poor experience of engaging with healthcare servicesThis report examines research published since the Groundswell 2020 #HealthNow literature review and outlines the findings from its five #HealthNow research reports.
  • New digital inequalities research
Research, commissioned by NHS England, provides an insight into the behaviours of people who do not use digital services in health and social care. It highlights opportunities to improve digital inclusion and narrow healthcare inequalities. See this blog from Bola Akinwale, Deputy Director, National Healthcare Inequalities Improvement Programme. 
  • Culturally appropriate care guides
Skills for Care has published a set of resources to help anyone involved in the care and support of individuals to have a clearer understanding of culturally appropriate care and what that may mean to individuals they support. The ‘Culturally appropriate care guide’ covers a broad range of topics that will help you to learn about and be sensitive to people’s cultural identity or heritage. To support the learning within the guide, Skills for Care has also published a series of resources for use in training and development.

The Coalition for Personalised Care (C4PC) has two new Co-Chairs: Sian Lockwood and Liz Sargeant. Both have extensive experience in the health and social care sector and share a passion for Personalised Care. 

The Coalition for Personalised Care is a partnership of people and organisations who work together to make Personalised Care a reality. 

Find out more about the new co-chairs

The general practice team has expanded significantly to include a wide range of healthcare professionals working together to support patients. These teams are already delivering care for patients across the country, and we know it is important that patients understand what all members of the general practice team do and how they support their care.

A range of resources about the general practice team are available to download from the Campaign Resource CentreThe materials aim to support general practice teams to share information about the different professionals working in their practice and explain how they enable patients to receive the most appropriate care as quickly as possible. These include social prescribing link workers, health and wellbeing coaches and care co-ordinators.

blueprint to help recover urgent and emergency care services has been published, which set out how patients will receive an enhanced NHS 111 offer including increased access to specialist paediatric advice for children and direct access to urgent mental health support. This will see some children referred directly to a same-day appointment with a specialist rather than attending A&E, avoiding hundreds of unnecessary hospital admissions. Delivering this ambition will mean supporting more patient-centred, personalised care, accessed closer to, or at, home – but also more integrated services. 

106,126 people in England received a personal health budget by the end of Quarter 1 2023-24. This is an increase of 17,014 people compared to Quarter 1 2022-23 and means more people of all ages have greater choice and flexibility over how their assessed health and wellbeing needs are met.

The two most recent PCN webinars ‘Implementing proactive personalised care to support primary care pressures’ and ‘How mental health practitioners and social prescribers can help to bridge the gap between primary care and mental health services’ are available to view on FutureNHS (login required). 

#CareAboutMe aims to raise widespread awareness of the About Me standard and the improvements it can make to the quality of care administered in health and care, as well as the positive impact it can have on people’s quality of life and health.

PRBS want to help every person share information about ‘what matters to me’ by using PRSB’s About Me standard. Its goal is to help professionals provide better care and for people to experience lasting benefits to their health and wellbeing.

NHS England has published three case study films which give an insight into how social prescribing and the non-clinical additional roles reimbursement scheme (ARRS) roles can help people to better manage their health and well-being.

These members of the general practice workforce can particularly support people who are experiencing the current ‘cost of living’ issues and NHS winter pressures through pro-actively identifying certain groups of people that need more intensive support.

Find out more about how these roles can help people this winter in the recently published guidance. Supporting High Frequency Users (HFU) through proactive personalised care, delivered by Social Prescribing Link Workers, Health and Wellbeing Coaches and Care Coordinators sets out the principles and recommended approach for offering proactive, personalised care for those at higher risk of hospital admissions due to psychosocial needs, as part of a broader strategy for integrated care boards and primary care networks to tackle winter pressures and reduce unplanned admissions.

NHS England has launched this year’s survey for health and wellbeing coaches and care coordinators.

NHSE ran the surveys last year and the feedback was really valuable and informed the work at a national level. For example, it helped shape the content of NHSE’s resources, share and learns and to increase understanding in the system around the roles and how they are being embedded and supported. 

The surveys are open until 2 December 2022

We have published specifications for adults and children and young people service model for delivering specialist level palliative care (SPLC) services from identification of need through to end of life.