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Why do health and care services need to change?

You may have seen stories in the newspaper about the growing pressures on hospitals and other health services.

People are living longer, which is good news, and so the number of older people is increasing. Advances in medical treatment means that more people with disabilities, long-term conditions or serious illnesses or injuries are surviving longer.

This means that the number of people who have more than one health condition and who need extra help to live independently is increasing – we say that these people have ‘complex needs’. 

The NHS has to save £20 billion by 2016 and if we are going to do this and cope with the growing pressures on health services, we need to find new ways of working and this is being referred to as new models of care.

How will services be different?

We know when older people spend too long in hospital after illness they find it harder to recover and become independent again.

So we need to do more to help people live healthy lives to avoid them becoming ill in the first place and we need to support people to look after their health (known as self care).

We need to provide better support at home and earlier treatment in the community so people don’t end up needing emergency care in hospital.

We know that people with complex care needs are often ‘handed off’ from one service to another. Each health condition is treated separately, rather than looking at the whole person.

So we need to make sure that care is individual to the needs of each person, not a one size fits all approach.

We know people sometimes have to repeat information to different professionals and services are often working in isolation, so there is duplication between them. People and their carers have told us that they find it frustrating trying to get services to talk to one another and work together.

We need to bring different services together – like hospitals, social care and GPs – so that they work in a more joined up way.

What happens next?

The new models of care programme is looking at new ways of working in different areas of health and social care, including the four projects listed here:

Open all +

Complex care

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.

Enhanced care

Some people who have a long term condition, like diabetes or asthma, may be using health services frequently and ending up in hospital. If we were able to do more to support them and help them self manage, they could just see staff at their GP practice and not need to go into hospital.

We want to better understand people’s issues and needs. We want to provide people and their families with more targeted support and help them set personal goals, such as being able to play football or feeling less anxious.

If people can get the care they need locally and earlier, it should stop their health from getting worse and they won’t need to go into hospital in the first place, which is better for everyone.


Self-care is about helping people to live healthy lives to avoid them becoming ill in the first place and supporting people to look after themselves.

We want to help people to feel more confident about looking after themselves, so that they know when they need to see a health professional and they feel more in control of their health.

We want health and social care professionals to have the skills, knowledge and time to encourage and support people to self care.

'Wrap around' (integrated community care)

Some people need support at home from services like community nurses/district nurses, therapists, and social care.  We are calling this “wrap around care”.  We want the services to work better together to meet the needs of the patient and their family.

Each person’s care will be individual to their needs, not a one size fits all approach. This means we need to listen to the patient and their family about what is important to them.

People will receive care in their own home so that they can live independently at home for as long as possible. This is no different to how people currently receive care, but people will be supported for a longer length of time and their care will be more joined up.

We will make sure that everyone has a care plan so that all the health and social care teams involved in a person’s care have the same information and understand a person’s situation and goals and wishes.

Evidence and research

We have done a lot of work to decide whether these new ways of working will have a positive impact for patients in our area.

There is a lot of national and local policy about the need for services to be more joined up (known as integration) and for care to be better quality and for patients to have a better experience of their care. The work that we are doing is in line with the national and local policy.

We have looked at the local data on who uses the most health services, how they use health services and how much is being spent on health services. This has helped us to decide which patients would benefit from more support.

We have also looked at examples from across the UK and internationally of services that have been set up to support people with complex needs and long term conditions.

How this links to the national pioneer programme

NHS England is running a national pioneer programme. Airedale, Wharfedale and Craven is one of 25 of the national pioneer sites. This means we can access advice and support and share learning with other areas who are taking similar approaches to join up health and social care services.