Table 3 Delphi study results

1

Co-ordinated

Connection and alignment between users, informal carers, professionals and organizations in the care chain, in order to reach a common focus matching the needs of the unique person.

2

Trustful

Enabling mutual trusting between users, informal carers, communities, professionals and organizations, in and across teams.

3

Shared responsibility and accountability

The acknowledgment that multiple actors are responsible and accountable for the quality and outcomes of care, based on collective ownership of actions, goals and objectives, between users, informal carers, professionals and providers.

4

Holistic

Putting users and informal carers in the centre of a service that is ‘whole person’ focused in terms of their physical, social, socio-economical, biomedical, psychological, spiritual and emotional needs.

5

Co-produced

Engaging users, informal carers and communities in the design, implementation and improvement of services, through partnerships, in collaboration with professionals and providers.

6

Continuous

Services that are consistent, coherent and connected, that address user’s needs across their life course.

7

Flexible

Care that is able to change quickly and effectively, to respond to the unique, evolving needs of users and informal carers, both in professional teams and organizations.

8

Empowering

Supporting people’s ability and responsibility to build on their strengths, make their own decisions and manage their own health, depending on their needs and capacities.

9

Person-centered^a

Valuing people through establishing and maintaining personal contact and relationships, to ensure that services and communication are based on the unique situations of users and informal carers.

10

Respectful

Treating people with respect and dignity, being aware of their experiences, feelings, perceptions, culture and social circumstances.

11

Led by whole-systems thinking

Taking interrelatedness and interconnectedness into account, realizing changes in one part of the system can affect other parts.

12

Comprehensive

Users and informal carers are provided with a full range of care services and resources designed to meet their evolving needs and preferences.

13

Collaborative

Establishing and maintaining good (working) relationships between users, informal carers, professionals and organizations – by working together across sectors, and in networks, teams and communities.

14

Preventative

There is an emphasis on promoting health and wellbeing and avoiding crises with timely detection and action by and with users, informal carers and communities.

15

Efficient^b

Using resources as wisely as possible and avoiding duplication.

16

Reciprocal

Care is based on interdependent relationships between users, informal carers, professionals and providers, and facilitates cooperative, mutual exchange of knowledge, information and other resources.

17

Transparently shared^a

Transparently sharing of information, decisions, consequences and results, between users, informal carers, professionals, providers, commissioners, funders, policy-makers and the public.

18

Effective^b

Ensuring that care is designed in such a way that outcomes serve health outcomes, costs, user experience and professional experience.