Person-Centred Coordinated Care (PCCC)


This programme combines the following activities in order to ensure learning contributes both to local service improvement and international knowledge:

  • reviews of literature
  • support for bottom up service redesign and implementation
  • evaluation of innovation and whole systems
  • synthesis of evidence to build practical theory about how to provide and implement PCCC.


There is now widespread recognition that the care provided by the NHS, social care and other associated community services should strive to be more person-centred i.e. both centred around and responsive to the needs of the individual. For this to be achieved effectively, services need to be better co-ordinated and, in some circumstances, integrated fully. Person-Centred Coordinated Care (PCCC) is perceived as a way of achieving better outcomes for patients and improved efficiency for health and care economies. We have defined person-centred and coordinated care as:

‘Care that is guided by and organised effectively around the needs and preferences of the individual’.

Work so far

PCCC is now a priority for all stakeholders (i.e. patients, carers, staff, commissioners, and policy makers). Our collaboration with the South West Academic Health Science Network (SW AHSN) aims to develop theory, innovation and a consistent evaluation framework for PCCC.

This began with a joint scoping project in 2014 to grapple with the complex conceptual challenges associated with integrated care. Through a process of critical examination of policy material and key literature we have moved away from the notion of ‘Integrated Care’, and have brought two key concepts together that represent key concerns and experiences of importance from the perspective of the individual receiving care: person-centred and coordinated care.

Anchoring our work in the perspective of the individual has enabled us to move towards a testable theoretical model and a shared understanding of the key constituent components to test for the delivery of PCCC. This work led to the development of:

  • a consistent evaluation and measurement framework which includes multi-level and multi perspective measures of experience of both patients and practitioners
  • the Person-Centred Coordinated Care Organisational Change Tool (P3C-OCT)
  • the further development of a measure to tap patient experiences of person centred coordinated care (P3CEQ).

Evaluation methods

We have since been commissioned to evaluate the following programmes:

The Newton Abbot Complex Care Hub, the Torquay Children and Families Hub (SWIFT), Torbay Integrated Care Organisation (ICO), Somerset Practice Quality Scheme (SPQS), Somerset Test and Learn Pilots, Integrated Care Exeter (ICE), Southwest Integrated Personal Commissioning (SW IPC). 

For these projects we are conducting mixed methods community co-creation action evaluations, with exploration of key implementation processes and issues. A core feature of the evaluations will be the collection of three levels of data on a subset of the wider cohort of patients involving qualitative interviews and observations with staff and community members; structured questionnaires on the experiences of care and mental health; and system-wide metrics service use data.

Engagement activities are key to the evaluations. If successful, this strategy will be maintained beyond one year. Structured questionnaires on patient experiences of care delivery (our P3CEQ) and our organisational change tool (P3C-OCT) to monitor coordinated activities will be completed by core staff where possible. We will also collect service use data, tracing this across health and social care by data linkage processes. This will build longer term internal evaluation capacity with external (research team) resourcing for qualitative input and data synthesis.

Analysis will focus both on investigation of the core components of the specific intervention model as well as seeking to understand implementation and barriers and facilitators to success. Feedback of results will be rapid contributing both to improve interventions/models of care and to more summative evaluation.

Anticipated outputs

Service development:

  • helping to implement new models and refine them (using data collected at baseline, 6 months and 12 months).


  • theory building, using data from evaluations, in relation to multi-professional working, locality based teams, enhanced primary care, personalised care etc
  • leading and supporting bids for external funding

Development of evaluation framework including:

  • Organisational Change Tool for PCCC (P3C-OCT)
  • psychometric testing of the Person Centred Coordinated Care Experiences Questionnaire (P3CEQ).