Who might receive services from the complex care team?

If people have more than two health conditions and need extra help to live independently we say that they ‘complex needs’.

People with complex needs will be identified by care professionals and by looking at information such as

  • the illnesses and conditions that they have
  • their social situation such as whether someone lives alone
  • their age
  • how often they go to A&E or are admitted to hospital when it isn’t necessary
  • how at risk they are of having a crisis.

If the GP thinks that someone would benefit from the service and the person agrees to it, they will receive more support from a new ‘complex care team’.

Who will work in the complex care team?

The complex care team will have a number of different professionals working in it including a doctor, nurse, mental health nurse, pharmacist, a personal support navigator and social workers.

The team will complement existing services such as GP practices and community teams and work with them. It is not intended to replace any services.

What support will people get from the complex care team?

If you were assessed for support from the complex care team, the type of support they would offer is to:

    • Oversee all of your care and make sure that it is coordinated.
    • Help you to navigate health and care services and make sure you are receiving the services you need.
    • Support you to look after your health and mental and social wellbeing.
    • Assign a personal support navigator to be your main contact.
    • Make sure that you have a care plan, so that everyone involved in your care understands your circumstances and what you want.

What is a care plan?

A care plan is an agreement between a patient and their health professional (or social services) to help them manage their health day to day.

The care plan will be developed with the person, their carer (if they have one) and family. It will look at the person’s goals and wishes around care and incorporate this into how they receive care. The plan won’t just look at a person’s physical and mental health, but also their social circumstances, for example, whether they live alone.

The care plan will be used by all the health and social care teams involved in a person’s care and so they will all be involved in the development of the plan.

It will set out what will happen if the person’s symptoms deteriorate, or with the right care, if they improve and their needs reduce. People’s situation and their health change and so the care plan will be regularly updated.

Testing whether it works

If the support is working as it should, then people should feel more in control of their care and able to enjoy living independently for longer.

We are going to test this new complex care support for 12 months and so we really want to hear from patients and their carers about whether they think the extra support is making a difference to them. We can then decide whether to permanently commission complex care support out wider if it is working. If we find that it isn’t working, we will look at other ways to better support patients with complex needs. Find out more about the complex care pilot.