Devon’s complex care teams move from crisis response to self-managed care

Devon has a fully integrated health and social care service. Complex care teams (CCTs) comprise teams of health and social care staff, whose remit is to focus on people with complex and long-term conditions. These service users are often struggling in the community, reliant on family carers to get by. Although there will often be high input from health and social care services, clients’ needs are not always being met.

Consequently, people in these circumstances make frequent demands on GPs, social services, respite care and unplanned hospital admission. All of this is costly. It is unsatisfactory and there is often a strained relationship between the user or patient, their carers and the health and social care staff working to support them.

If we are going to shift the focus of care from crisis response to self-managed care, from a sickness-focused NHS to health and social care jointly promoting health and well-being, we have to do better. We have to work differently. We are doing that in Devon. We have integrated health and social care teams within an integrated management structure. The CCTs are linked to clusters of GPs and will combine the strengths of practice-based commissioning with social care commissioning. The real strength of the teams is in the partnership of health and social care frontline staff, and in the principle of promoting individualised care.

High needs

CCTs have time to be proactive and time to use case-finding tools to identify people with high needs. The practical experience of the teams, comprising local staff, working together is as good as any tool at case finding and early intervention. CCTs have been given protected time to be proactive. The care management reforms give them that time. In social care terms CCTs have 55% of our care management staff to focus on 25% of our care-managed population.

In one CCT pilot team there is a 3.5% reduction in unplanned hospital admissions a 50% reduction in GP contact time a £30k reduction in prescribing costs and significant improvement in personal well-being measured on an objective scale. In contrast, unplanned admissions and prescribing costs increased in the non-pilot areas. We expect the CCTs to drive the shift in the focus of health and social care away from high-cost, low-satisfaction crisis intervention to patient and user-led care which delivers more effective care at lower cost. This is putting into practice the positive reform scenario described in the Wanless report on the future funding of the NHS.

Electronic care records

Integrated teams require integrated information systems. We are introducing fully joined-up electronic care records for our health and social care teams. It’s not so difficult. The benefits will be enormous.

The transformation programme is successful. There is high user satisfaction. Staff working within the new model are enthusiastic and creative. As an organisation we are able to provide a better service to our public, have improved our performance and have made sizeable efficiency gains all of which are being reinvested into frontline services.

David Johnstone is director of adult and community services, Devon Council

• Reports on the transformation programme and videos of the CareDirect Plus and complex care teams

• Report describing the assessment project

• Analysis of Devon’s transformation at https://www.communitycare.co.uk/107906 and Torbay’s excellence model at https://www.communitycare.co.uk/108396

• Previous David Johnstone articles at https://www.communitycare.co.uk/108633 and https://www.communitycare.co.uk/108495