The delivery of the newly integrated health and social care services is being led by a jointly appointed director who is responsible to both David Johnstone, Executive Director, Adult & Community Services and Dr Kevin Snee, Chief Executive, Devon Primary Care Trust

Sally Slade, Director of Integrated Health & Social Care Delivery

In the past we have asked you, our patients and service users, to tell us how you think we can improve and we have listened.  One of the most important things you told us was that you wanted health and social care staff to work more closely together and to stay local to where you live.

We have responded and are establishing joint health and social care teams for people who have chronic or long term health problems or who need more complex support.

We are working in partnership with

The integrated health and social care teams will work alongside primary care GP practices, delivering the service to practice populations within designated geographical communities or ‘clusters’.

Clusters are integrated health and social care services aligned with primary care services. In each cluster there will be one, or in some cases 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.  Here is a diagram showing how the integrated Complex Care Teams will work.

There will be 16 adult clusters and 23 complex care teams across Devon.

These new teams will support populations of around 30 – 35,000 (based on evidence from the Department of Health in relation to case management activities). Actual sizes reflect local needs and are influenced by the diverse geography of Devon.

Complex care teams will provide a responsive, co-ordinated, person focused service based on common values to improve outcomes for adults with long term conditions and/or complex needs.  Teams will work with adults and their carers to promote independence and choice in their own homes or close to home.  

The primary objectives for these teams will be to:

• Provide a single point of co-ordination.
• Deliver a responsive and timely service for the individual.
• Ensure a multi-disciplinary assessment and response to the needs of the individual and their carer.
• Provide a case management approach for people with long term conditions and / or complex needs as appropriate
• Work across organisational boundaries, with adults and their carers to promote independence and choice either in their own homes or as close to home as possible.
• Work in partnership with the Voluntary and Community Sector to facilitate access to community based services to support individual’s well-being reducing dependence on statutory interventions.
• Utilise a range of ‘case finding tools’ to proactively identify people who may be at risk of loss of independence or unnecessary hospital admission.
• Work with an enabling approach that supports self determination and independence – for example through the use of direct payments, self care, and self directed support

Complex Care Teams Service Specification

This report on the Cluster Service Model includes a diagram to show how they will work and some interesting case studies which illustrate the benefits of integrated working for the patient..

A performance report produced in March 2008 for the Department of Health shows actual figures compared with targets and performance indicators

There is also a powerpoint presentation entitled "Caring for Devon". which will help you understand the model.