From Mike Bomford, Exeter 382173, April 09, 2008

Changes to health and social care services in Devon are speeding up access to care, providing better support for people with long-standing complex care requirements in their own homes, and reducing emergency hospital admissions.

For the past year Devon County Council and Devon Primary Care Trust has been developing and testing important changes to improve health and social care in Devon. The new method of care is based upon integrating health and social care staff in teams, which are linked to GP practices.

The new process works in three very simple stages designed to fast track people to the most appropriate care for their level of need.

The Council's customer service centre, My Devon, is the first point of contact for any new referrals. Trained staff quickly determine whether there are potential social service needs. If there are, they are introduced to one of the Care Direct Plus teams.

These teams complete assessments on the telephone and where appropriate arrange services. Often services are in place on the day of contact.

If the individual has long-term or complex needs, Care Direct Plus will involve the appropriate joint health and social care team who will then arrange face-to-face assessment of the person's needs. They will jointly plan with the individual and their family or friends how that care will be provided.

The complex care teams are fully integrated health and social care professionals, comprising Community Nurses and Matrons, Occupational Therapists, Social Workers, Community Care Workers, Domiciliary Pharmacists, Community Psychiatric Nurses, and representatives from the local voluntary sector.

Their role is to identify at an early stage people who, through frailty and ill health, are at risk of losing their independence. They will then provide vital support to help them continue living at home.

The complex care teams piloted in Exeter have successfully reduced the number of emergency hospital admissions.

Integrated teams, now being established across Devon, are centred around existing GP practices.

The combination of My Devon customer service centre, the Care Direct Plus teams and the new Complex Care Teams means that the public are able to get a faster and more responsive service.

Two case study examples:

One caller to My Devon requested an increase to their Direct Payments - a process by which the person chooses to receive the monetary value of the cost of their care and manage their care provision themselves rather than the County Council arranging their care for them. Payment was agreed and the process completed via links to the Council's Direct Payments team. The caller had his response with the hour, where otherwise it could have taken at least 2 days to complete.

Mr Smith (not his real name) was referred to his local Complex Care Team. He had been admitted to hospital 6 times over 6 months. His primary health problem was Chronic Obstructive Airways Disease. He was also a frequent visitor to his local surgery and suffered depression.

Mr Smith was dependent upon his wife for assistance with personal care, and he did not want other people caring for him.

The Community Matron from the complex care team discussed with the Smiths a care programme that met both their needs and respected their wish to be self reliant. As well as assessing Mr Smith's health, which ruled out some of his fears about his condition, educating him about the importance of self care and exercise was a key element of his care. The Community Matron also assessed the wife's needs.

The Occupational Therapist visited and ordered specialist equipment for his home, including additional banister rails, a raised toilet seat, chair raisers for example, to improve his independence.

A Community Pharmacist also visited to give Mr Smith advice on his medication.

Family members were used to give Mrs Smith some much needed time from her caring role.

The volunteer co-ordinator found a 'befriender' for Mr Smith who enjoyed the same interests as him.

10 months later and Mr Smith has gained weight. He exercises daily and completes an exercise log to monitor his level. Pain he had previously in his shoulders, thighs and stomach are now gone, leaving just minimal pain in his knees. He takes care of his own personal needs, and is able to help his wife with some household chores, and gardening. He had not required a hospital admission during this period and no longer needed to see his GP so frequently.

Mr Smith joined the Expert Patient Programme and this helped to build up his confidence and improve his management of his condition.

Councillor John Rawlinson, Devon County Council's Executive Member for Adult and Community Services, said:

"For some time now the County Council and the PCT has been working closer together and we have reached a significant step by establishing complex care teams across Devon.

"The public are not interested in whether they contact the County Council or the PCT for help, they want us to work together to give them the support they need with minimum bureaucracy, no duplication of effort and a fast, friendly response."

Devon Primary Care Trust's Chief Executive, Dr Kevin Snee, said a joint approach made perfect sense.

"Gone are the days when health and social care authorities would work completely independently of each other," he said.

"The complex care arrangements in Exeter have already been celebrated by Government as 'world class' and we are confident that partnership working will continue to improve services right across Devon so that they too are as good as they can possibly be."

To contact My Devon, telephone 0845 1551 007.