Personalised Care in Practice

The policy of introducing Personalised Care plans is a part of the Maternity Transformation policy for England, Patience Pounds, Doctoral Researcher, Associate Midwifery Professor and Consultant Midwife in Suffolk, explains and discusses the development of the policy and how it is being implemented locally. 

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Personalised Care in Practice: Comments on the introduction of Personalised Care and Support Plans (PCSPs) in maternity services

A note on language  

This article uses the terms ‘woman’ or ‘mother’ throughout. These should be taken to include people who do not identify as women but are pregnant or have given birth. Similarly, where the term ‘parents’ is used, this should be taken to include anyone who has main responsibility for caring for a baby.    

 

In March 2021, NHS England published guidance on the implementation of Better Births’ National Maternity review first recommendation, personalised care, in the form of their Personalised Care and Support Planning Guidance document. More recently, in March 2023, the ‘Three-year delivery plan for maternity and neonatal services’ was published . This policy document highlights the need for maternity and neonatal services to be safer, more personalised and more equitable. What is clear from reading this later document is the interrelatedness of Better Births’ recommendations. The plan for implementing personalised care is interwoven with the need for progress in improving choices, continuity of carer, unbiased information and safer care.     

Drawing on my clinical experience, midwifery expertise and PhD research evaluating Better Births across East Suffolk and North Essex NHS Foundation Trust (ESNEFT), in this article I will comment on the introduction of Personalised Care and Support Plans (PCSPs) in maternity services and discuss some of the work I have been involved in to progress the Personalised Care agenda within my Trust.   

So, what exactly is Personalised Care in maternity services?    

Personalised care is a fundamental theme of Better Births . The goal to deliver personalised care is a whole system approach and not exclusive to maternity services. The NHS Long Term Plan  sets out an ambitious target for the implementation of the comprehensive model for personalised care across the health and care system. 

In maternity services, ‘Personalised care’ is woman-centred: care that is personal to the individual woman, her baby, and her family, based around their needs and their decisions, where they have genuine choice, informed by unbiased information (Cumberlege, 2016).  

Central to this is the development of personalised care plans for women, which the ‘Personalised Care and Support Planning Guidance’ document seeks to provide in the form of PCSPs whereby : 

people [have] proactive, personalised conversations which focus on what matters to them…and [pay] attention to their clinical needs as well as their wider health and wellbeing  

Women’s health and maternity services are high on the national safety in healthcare agenda which drives maternity services to focus on consistently putting actions in place which ensure that women and their families are listened to at every stage of their health and wellbeing journey (Winfield & Booker 2021).  Some of these actions is the introduction of PCSP in maternity services.  

PCSPs must meet five criteria as set out in the NHS’s Universal Personalised Care Model  

1. People are central in developing and agreeing their PCSP, including deciding who is involved in the process. 
2. People have proactive personalised conversations that focus on what matters to them, paying attention to their needs and wider health and wellbeing. 
3. People agree the health and wellbeing outcomes they want to achieve in partnerships with the relevant professionals. 
4. Each person has a sharable PCSP that records what matters to them, their outcomes and how they will be achieved.  
5. People are able to formally and informally review their PCSP. 

Indeed, it is evident that PCSP values women/birthing people as active participants and experts in the planning and management of their own health and well-being. Moreover, personalised care is highlighted as being particularly beneficial to people from lower socio-economic groups and presented as a positive step towards tackling health inequalities by the implementation of PCSPs.  

In addition, the Montgomery ruling draws our attention to informed consent and encourage us to respect and seek a better understanding of women’s choice, the way their care is planned and received based on ‘what matters’ to them and their individual risk factors and needs. Although critics of shared decision-making argue that women should not have to participate in shared decisions as the decision is theirs alone; PCSPs encourage personalised care by supporting the process of shared decision making – a key component of  the NHS’s Universal Personalised Care Model. Shared decision- making in maternity care is a collaborative process through which a midwife and/or obstetrician shares their knowledge and understanding to support the woman in their decision- making. This ensures that individuals are supported to make decisions that are right for them.  

For instance, in a shared decision-making conversation, with a woman who wish to birth out of the recommended guidance, the woman is offered the options available to her along with the risks, benefits and consequences of these options. These are then discussed alongside what matters to her and documented. In most cases, these conversations are not in chronological order as conversations merge with other maternity touchpoints. PCSPs can collate all the conversations concerning her birth preferences throughout the maternity care continuum and is owned by the woman. This means she will not have to repeatedly share her story time and time again, as the tool is reviewed by the midwife and/or obstetrician with the woman at each contact. Moreover, it enables her to share discussions with her support network, think about the discussions in her own environment and gives her the opportunity to agree to documented conversations within the PCSP to aid an informed decision.  

Despite the fact that PCSPs can make care more equitable and more personalised, there is no set national template for what a PCSP should look like but rather is delegated to Trusts to develop their own. This is a serious shortcoming to introducing a tool which is key for people receiving health and social care services. This could explain the inconsistencies in the reported and actual use of PCSPs in maternity services. Therefore, successful implementation and sustaining the use of PCSP in maternity services requires healthcare systems to adapt their structures and processes (i.e., integrating the tool into an electronic patient record which is accessible by both the woman and her health care professionals) to accommodate individualised approaches. Furthermore, organisations are long-overdue investing time, training, tools and information to empower maternity and neonatal staff to deliver personalised care as outlined in the ‘Three-year delivery plan for maternity and neonatal services’.  

To progress the ‘Personalised Care’ ambition across ESNEFT, I led a quality improvement project on ‘Out of Guidance Birth’; with the aim to design a robust referral process across ESNEFT for arranging multi-disciplinary team consultation for women wishing to birth outside of the recommended guidance. This project is in response to the needs and requests of women seeking additional information and support to explore their birth options. Through co-production, we have identified areas of concern. For instance, we know from this project that ‘language’ is very important to our women. Women have told us that they feel using the term ‘Out of Guidance’ suggests their requests are somehow wrong and that the term does not convey the non-judgmental principles we are working towards.  

Although this is the term used in the Trust guidelines and national documents, we believe the voice of our service users is essential. The project is still ongoing and involves close multi-agency working as we know this is essential to ensure good outcomes for mothers and babies. This is particularly important when it involves complex decision-making surrounding care planning for women who wish to birth ‘out of guidance’.  

In addition, I led two Choice and Personalisation events across maternity in Summer 2023. We listened to women and those representing users of our service, to ensure all groups were heard, including those most at risk of experiencing health inequalities. We know from these events that some women have positive birth experience, but also through these events, we must acknowledge that there are times when the care we provide could be improved. Therefore, the work we are doing to improve choice and deliver personalised care is continuously evolving and developing in response to the needs of the population we serve.     

One of the means by which we intend to achieve personalised care in maternity services across ESNEFT is through collaborative work with the Local Maternity and Neonatal System (LMNS), Maternity and Neonatal Voice Partnerships (MNVP), other public sector organisations, and a wide range of private and voluntary sector organisations to implement co-produced PCSP as part of the NHS’s Universal Personalised Care Model.     

In summary, personalised care is safe care (Cumberledge, 2016). It means listening to women, understanding what they want and what they need and putting in place a PCSP.  

Although the recommendations may come across vague and without clear targets or measures of success; there is good evidence that PCSP is associated with safer, more equitable and more personalised maternity care. Introducing the tool into maternity services require careful implementation, with on-going evaluation to monitor progress.  

A call to action 

It is clear that there has been a significant and sustained effort to improve maternity safety and deliver high quality and personalised care across England. The work that has been done to improve maternity care through the introduction of PCSPs in maternity services, provides a foundation for healthcare professionals, researchers, policy makers and providers to build on and improve. My PhD research study will provide an opportunity to better understand the barriers and facilitators of implementing PCSP in maternity services across ESNEFT and can inform best practice in deploying PCSP more widely in other hospital Trusts regionally and potentially nationally.  

What can you do to progress the Personalised Care ambition?    

Get in touch     

I would like to know about some of the work you are doing locally to deliver personalised care and if you would like to know more about my work, please get in touch.    

I would like to express my sincere gratitude to ESNEFT for funding this project and my supervisors: Professor Colin Martin, Dr Samantha Chenery-Morris, Dr Katharine Fowler. Thank you for your invaluable support and guidance throughout my doctoral journey so far. Your expertise, encouragement, and discussions have influenced this article.  

 

Patience Pounds (RM, MBA)  

Doctoral Researcher, 

Associate Midwifery Professor 

University of Suffolk  

[email protected]  

 

Consultant Midwife 

East Suffolk and North Essex NHS Foundation Trust (ESNEFT) 

[email protected]  

May 2024