As the complexity and uniqueness of the needs of individuals and carers have changed, and expectations towards health, care and wellbeing have evolved, we need to work together to ensure people have relevant information that’s meaningful to them and they are supported to make informed decisions.

Shared decision making ensures that individuals are supported to make decisions that are right for them. It is a collaborative process through which a professional supports a person to reach a decision about their care.

The conversation brings together:

• The professional expertise such as care options, evidence, risks and benefits; and
• What the person knows best: their preferences, personal circumstances, goals, values and beliefs.

We need to work together to understand people’s strengths, their assets and their potential and support them to realise this by collectively working together to set realistic outcomes and goals, reducing a reliance on services and ensuring the right support goes to the right people at the right time.

To support this way of working, we are extending our approach to Personalised Care and Support Planning across the ICS. It is an umbrella term that covers the planning approaches that we use to have ‘What matters to you?' conversations with people.

We must also ensure the rights of the people we support are respected, and their wishes should always be at the forefront of our thinking. Intervention to safeguard and protect should be proportionate to the risk presented and sensitive to the need, where appropriate, for people to make their own decisions, even when that involves some risk.

'What matters to you?' conversations are a series of proportionate discussions that explore a person’s whole life and family situation at any relevant point in time. Asking ‘What matters to you?’ aims to discover what’s important to the person and their carers and to explore their strengths, wants, wishes and goals to live their best life.

Together, shared decision-making and ‘What matters to you?’ conversations can create a new relationship between people and professionals based on partnership and enable people to be central in making decisions about their own health, care and wellbeing.

To achieve this we will:

• Drive a change in the current culture and systems across the ICP towards shared decision-making and ‘What matters to you?’ conversations, working with people to make this happen.
  
  
• Prepare and support the people of Lincolnshire to feel confident in embedding personalised care and shared decision-making.
  
  
• Ensure strong professional and executive leadership, and that all relevant organisations ensure strength-based personalised care is an integral part of their recruitment, induction and training.
  
  
• Ensure a sustainable workforce programme in strength-based personalised care approaches that is accessible and tailored to the range of health, care and Voluntary, Community and Social Enterprise (VCSE) professionals across the system.
  
  
• Include personalised care and shared decision-making in local incentives, delivery and improvement plans, pathway redesign and assurance.
  
  
• Ensure everybody who wants a personalised care and support plan has one that they can view and that they can contribute to their own plans digitally.

We will work with people to encourage, support, and empower them to manage their own physical and mental health conditions themselves.

Our vision is for everyone in Lincolnshire with an ongoing physical or mental health condition or conditions to be empowered to live their best lives.

Supported self-management is a way of working with people that uses approaches and tools to proactively identify the knowledge, skills and confidence people have to manage their own health, care and wellbeing, and to help them grow their expertise and confidence to be more independent.

We will do this through:

• A range of staff such as Health and Wellbeing Coaches, establishing one-to-one partnerships with individuals in their care and wellbeing. They will take a supportive and non-judgemental approach to help people to become advocates for their own care so that they can achieve their health and wellbeing goals.
• Care Coordinators who work with people and their carers to ensure what’s important to and for them and their personal goals are addressed, and that appropriate support is identified by creating a single personalised care and support plan. Care Coordinators bring additional skills, expertise and capacity into Primary Care settings, enabling the person to have more time to explore what really matters to them.
  
  
• Peer support, provided through a range of approaches, through which people with similar health and care experiences can support each other to better understand their recovery or self management.
  
  
• Working with people to educate or train them to help develop the knowledge, skills and confidence they need to manage their own health and wellbeing effectively. This may be done independently or in partnership with the health and care system.
  
  
• Use of range of tools to have a better understanding of the individual’s level of skills, knowledge and confidence to be able to better look after their own health and wellbeing.

Recognising that people’s health and wellbeing are significantly influenced by a range of social, economic and environmental factors, through social prescribing and community-based support we will work with people in a holistic way and aim to support them to take greater control of these wider determinants of health and wellbeing.

We will enable health and care professionals to link the people they see with someone who will take the time to explore ‘what matters to them’. Social Prescribing Link Workers are employed to support people to access non-medical services, including the diverse range of groups and support provided by the local community, voluntary and social enterprise sector.

We will ensure Lincolnshire has a sustainable and resilient social prescribing offer through jointly commissioning and supporting our voluntary and community sector. We will do this through Social Prescribing Lincolnshire, which is a group of social prescribing service providers that includes Voluntary Centre Services (VCS), Lincolnshire Community and Voluntary Service (LCVS) and Primary Care Networks (PCNs) that employ Social Prescribing Link Workers, with support from Lincolnshire
Voluntary Engagement Team CIC (LVET). We will involve people with lived experience at every stage of development to co-design services and information.

We will work in an integrated way alongside other commissioned services such as healthy lifestyle support, carers service and Lincolnshire’s Wellbeing Service. We will identify opportunities and take action to enhance community-based provision, digital development and support a diverse VCSE sector to thrive and flourish.