1. Complex Care Teams Context The Department of Health white paper “Our Health, Our Care, Our Say” ‘By 2008 we expect all PCTs and local authorities to have established joint health and social care managed networks and/or teams to support those people with long term conditions who have the most complex needs.’

2. What are complex care teams? Health and social care front-line staff supported by voluntary sector working alongside primary care practices. Co-ordinated and timely response to individuals and their carers with long term conditions and/or complex care needs. Proactive approach to identification of people at risk and provision of a joined up response. Complex care teams will reflect the local needs and the diverse geography of Devon supporting populations of around 30 – 35,000 Built on existing best practice in place across Devon (Learning shared from a formally evaluated pilot in the St Thomas area of Exeter)

3. What are Clusters? Clusters are integrated health and social care services. Grouped together alongside primary care services for practice populations within designated geographical communities. At the core of a cluster there is a complex care team. It is possible in some larger clusters that there will be two complex care teams. Clusters will include services such as local community hospitals, some core community nursing services and some specialist NHS or social care services. The proposals indicate 16 adult clusters across Devon with 23 Complex Care Teams.

4. Key elements of complex care teams Provides a single point of co-ordination for referrers. Delivers a responsive and timely service for the individual. A case management approach for people with long term conditions and/or complex needs as appropriate. Works across organisational boundaries to promote independence and choice for adults either in their own homes or as close to home as possible.

5. How does it work? Partnerships with the Voluntary and Community Sector facilitate access to community based services to support individual’s well-being Reduces dependence on statutory interventions. Utilises a range of ‘case finding tools’ to proactively identify people who may be at risk of loss of independence or unnecessary hospital admission. Works with an enabling approach that supports self determination and independence, for example through the use of direct payments, self care, and self directed support

6. Key staff Community nurses Community matrons Occupational therapists Social workers Community care workers Domiciliary Pharmacists Representatives of local voluntary sector Assistant Practitioners Rapid Response staff Physiotherapists Community psychiatric nurses (for older people) Approved social workers (for older people Some public health provider staff Complex care team co-ordinator Joint agency administrative and clerical staff

7. Specialist staff Other specialist staff are likely to work across two or more complex care teams i.e. specialist therapists and nurses, or sensory workers. Some of these staff have other functions and areas of activity across the local health and social care cluster. Not all of these roles currently exist consistently across Devon and there is a need for further workforce planning and development. A joint health and social care manager ‘Cluster Manager’ will be responsible for the operational management of the complex care teams within a cluster.

8. Operational Issues Accommodation We are looking into the co-location of some of the functions and staff within a complex care team. Working arrangements There will be shared working processes and systems to support the work of the complex care teams enabling participation by GPs as well as other core team members and specialist workers, including practice nurses. Core multi-disciplinary assessment activity IT systems, telephony and accommodation will all play a vital part, Face to face working will need to be established in ways that recognise the geographical constraints, through meetings, such as those already well established, variously described as multi-disciplinary team meetings, core group meetings, SMART meetings, close to home meetings, Easicare Meetings.

9. Performance Indicators A range of shared health and social care outcomes are anticipated including: Emergency bed days reduced by 5% Reliance on secondary care services reduced Timely assessment and care / treatment plans delivered Reduced delayed hospital discharges Reduced avoidable admissions to long term care Provision of care in a primary, community or home environment increased. Individuals with long term conditions receiving high quality care personalised to meet their individual requirements. Improved support to carers to enable them to remain in a caring role. An effective, systematic approach to the care and support of people with a long term condition embedded into local health and social care communities.

10. When will these arrangements be in place? There is already good local evidence of integrated working in place across Devon. We expect the roll out of complex care teams to accelerate from Spring 2008. Completion will be by May 2009.

11. Thank you very much for listening Questions are very welcome