Quality standard

Quality statement 3: Personalised plan

Quality statement 3: Personalised plan

Quality statement

Autistic people have a personalised plan that is developed and implemented in a partnership between them and their family and carers (if appropriate) and the autism team.

Rationale

The needs of autistic people are varied, with some people needing complex levels of support from a range of professionals and some people not wanting or needing any ongoing support. A personalised plan that is informed by the full diagnostic assessment and the individual needs of the autistic person, and recognises their strengths, should ensure that the support provided is coordinated and focused on the person's needs and the best possible outcomes for them. The personalised plan will need to be updated and reviewed as the person's needs and circumstances change. It will also need to take into account, inform and be consistent with any other plans or care packages they may have, including education, health and care plans for children and young people and community care assessments for adults.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

Evidence of local arrangements to ensure that autistic people have a personalised plan that is developed and implemented in a partnership between them and their family and carers (if appropriate) and the autism team.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from service protocols.

Process

a) The proportion of autistic people who have a personalised plan that is developed in a partnership between them and their family and carers (if appropriate) and the autism team.

Numerator – the number in the denominator who have a personalised plan that is developed in a partnership between them and their family and carers (if appropriate) and the autism team.

Denominator – the number of people diagnosed with autism.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.

b) The proportion of autistic people who have their personalised plan implemented in a partnership between them and their family and carers (if appropriate) and the autism team.

Numerator – the number in the denominator who have their personalised plan implemented in a partnership between them and their family and carers (if appropriate) and the autism team.

Denominator – the number of autistic people who have a personalised plan developed.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.

What the quality statement means for different audiences

Service providers ensure that when a person is diagnosed with autism, the autism team works in partnership with them and (if appropriate) their family and carers to develop and implement a personalised plan that takes into account and is consistent with any other plans or packages of care they may have.

Health and social care practitioners ensure that they work in partnership with people diagnosed with autism and (if appropriate) their family and carers to develop and implement a personalised plan.

Commissioners from across health, social care and education agencies work together to commission services in which, when a person is diagnosed with autism, the autism team works in partnership with the person and (if appropriate) their family and carers to develop and implement a personalised plan.

Autistic people and (if appropriate) their family and carers have the opportunity to work together with their autism team to develop and implement a personalised plan that sets out what support they need and how best that support should be provided.

Definitions of terms used in this quality statement

Personalised plan

A personalised plan should be based on an assessment of needs, taking into account the person's strengths, skills, mental and physical impairment, family and social context, and for children and young people their educational context. The plan should cover:

  • any post-diagnostic support that the person and their family and carers need

  • what interventions, support and timescales are most appropriate for the person; these include clinical interventions and social support, such as support in relation to education, employment or housing

  • preventative action to address triggers that may provoke behaviour that challenges

  • any further interventions for identified coexisting conditions.

The plan should also include a risk management plan for people with behaviour that challenges or complex needs. For young people under 18 years the plan should also include managing the transition from child to adult services. [Adapted from NICE's guideline on autism spectrum disorder in adults: diagnosis and management, recommendations 1.2.12 and 1.2.13; and NICE's guideline on autism spectrum disorder in under 19s: support and management, recommendation 1.4.2]