Quality statement 3: Personalised plan

Quality statement

People with autism 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 people with autism 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 person with autism, 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 Community Care Assessments for adults.

Quality measures

Structure

Evidence of local arrangements to ensure that people with autism 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: Local data collection.

Process

a) The proportion of people with autism 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 of people 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: Local data collection.

b) The proportion of people with autism 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 of people 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 people with autism who have a personalised plan developed.

Data source: Local data collection

What the quality statement means for service providers, health and social care practitioners, and commissioners

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.

What the quality statement means for service users and carers

People with autism 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.

Source guidance

  • Autism: recognition, referral and diagnosis of children and young people on the autism spectrum (NICE clinical guideline 128), recommendations 1.5.5 (key priority for implementation) and 1.5.8

  • Autism: recognition, referral, diagnosis and management of adults on the autism spectrum (NICE clinical guideline 142), recommendation 1.2.13

  • Improving access to social care for adults with autism (SCIE guide 43), Personalising services section, page 37

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 Autism: recognition, referral, diagnosis and management of adults on the autism spectrum (NICE clinical guideline 142), recommendations 1.2.12 and 1.2.13; and Autism: the management and support of children and young people on the autism spectrum (NICE clinical guideline 170), recommendation 1.4.2]