The Long Term Conditions Agenda Networks/multi-disciplinary teams

1. The Long Term Conditions AgendaNetworks/multi-disciplinary teams Claire Whittington Commissioning Directorate

2. Aims • Overall context • Outline emerging proposals • Consider how multi-disciplinary teams/networks supports the delivery of LTC

3. The New Clinical Paradigm “While the global disease burden has been shifting towards chronic conditions, health systems have not evolved to meet this changing demand. Care is fragmented, focused on acute and emergent symptoms, and often provided without the benefit of complete medical information” WHO (2002) [1]

5. The NHS and Social Care Long Term Conditions Model Delivery System Better outcomes Infrastructure Case Management Community Resources Empowered and informed patients Decision support tools and clinical information system (NPfIT) Disease Management Creating Supporting Prepared and proactive health and social care teams Supported Self care Health and social system environment Promoting Better Health

7. Range of White Paper LTC commitments • Bigger emphasis on self care and integration • Requirement for multidisciplinary teams/networks • Universal case management for VHIUs • Personal Health and Care Plans • Whole System LTC Demonstrators • 24/7 single point of contact for people with complex needs

8. Direction of travel • Increasing emphasis on care outside hospital • Intelligent and Agile Commissioning • Patient and Client centred care • Information and technology as powerful enablers • Integration - key

9. “international research suggests that integration is most needed and works best when it focuses on a specifiable group of people with complex needs, and where the system is clear and readily understood by service users (and preferably designed with them as full partners).” - Integrated Care: a Guide, Integrated Care Network

10. White Paper commitment • 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 with long term conditions who have the most complex needs.

11. Elements of integration (WHO) • Horizontal integration: linking similar levels of care • Vertical integration: linking different levels of care • Continuity of care: user perspective: ideal experience • Integrated care: encompassing technological, managerial and economic aspects of service

12. Why focus on networks and teams ? • Principle of integrated teams been around for a long time • Networks to coordinate development of a service – more recent • Proven that both can deliver benefit YET • Establishment of teams fragmented • Networks not wide spread • Concept unclear • Expectations of what can be delivered through both confused

13. How to encourage wide scale development • Best practice guidance • Recognise that teams and networks are distinct but complementary; implement in parallel • Vision for how can be used locally • Consider barriers and how can overcome

14. Networks • Managed network involving clinicians, users, managers across health and social care • Role – identify needs of LTC population, look at care pathways to deliver optimal care and inform commissioning decisions • Led by Senior Officers/Directors of PCT/LA • All need to be accountable so governance critical

15. Patient Care Team (Starfield) ‘…..is a group of diverse clinicians who communicate with each other regularly about care of a defined group of patients and participate in that care’

16. Multi-disciplinary teams • Bring together individuals who plan and deliver care across organisational boundaries to particular groups of users • Combined potential of • Individual professions • Organisations • Third sector partners • Benefit: • More eyes and ears • Insights of different bodies of knowledge • Comprehensive, holistic view of user’s needs • Wider range of skills • Increased range and quality of services available – integrated and seamless • Effect: • Improved health outcomes • Reduced costs

17. What makes up a team ? • Different team components/different user needs • Practice/multiple practice • Practice/specialist acute care • Practice/specialist acute care/social care/housing/voluntary sector (significant benefit) • Mix of skilled clinicians/educators with clinical and self care support skills and public health

18. What makes up a team (2) • Not prescriptive • Consider different skills of • GPs • Practice nurse/specialist nurse/community matron • Medical specialists • Pharmacists • Social workers • Lay health workers • OTs • psychiatrists • Voluntary sector • Others • Based on needs of user

19. Challenges • Management structures • Breaking down professional silos • Training and preparation • Information sharing and communication • Insufficient nurturing of teams

20. Key factors for success • Shared core roles, goals and values • Understanding and respect for competencies of other team members • Need to learn from other disciplines and respect their different views and perspectives • Individual team members may need to reassess exclusive claims to specialist knowledge and authority • Team development training • Integrated management systems • Formulation of operational policies

21. Effectiveness of team care (Wagner) • Population based care • Care plans • Self care support • Sustained follow up • Also supports many of White Paper commitments • Also need to consider 24/7

22. An opportunity • How to provide a seamless and holistic service • Redesign user centred services • Significant role – people with long term conditions • Huge potential