Health and Social Care Joint Working

Governing Principles of Joint Working

Guiding Principles

Vision principles and commitment

The following points relate to key elements required for joint working to prosper:

• The integrated service will work across existing or new organisational boundaries and place the user/patient/(carer) at the centre.
• Common definitions, protocols - reflecting professional governance requirements.
• A single pooled budget with single commissioning arrangements.
• Joint multi-agency planning.

Single Assessment Process (SAP) specific principles

• Whenever referring onto specialist services, all previous assessment information will be available to that service.
• For people with complex social and health care needs, the Older Peoples' Assessment and Care Management Teams and Younger Adults Assessment Teams (YAAT) will undertake the care coordination function.
• It is understood that single service response situations do not require care management and that the named professional system will suffice.

Definitions:

Specialist

A specific intervention / area undertaken by a professional whose knowledge, skills and competence meets the specific need and who also acts in an advisory capacity.

Care management

A care manager is someone who:

• Formulates and coordinates the care plan
• Coordinates the commissioning of services and people
• Monitors quality
• Reviews outcomes
• Audits against care standards
• Is responsible for overseeing the care package
• Is the link / named person

for individuals with complex care needs.

Named professional

Someone who provides a service and:

• Formulates the care plan
• Monitors quality
• Reviews outcomes
• Audits against care standards
• Is responsible for overseeing the care package
• Is the link/named person

for individuals with non-complex needs or those who may have complex health/single service needs.

Single service response

Where one or more services can be used, which do not require care management.

National governance (*) regarding best practice around the assessment process

1. When assessing older people the requirements of the Single Assessment Process and the National Service Framework should be observed and where necessary joint assessments involving health partners should be completed. Assessments for all adults with complex needs should take account of physical, cognitive, behavioural and social participation needs.
2. Full involvement of individuals and their carers in both assessment and care planning should be promoted. Carers are entitled, under the Carers and Disabled Children Act 2000, to request and assessment of their needs in supporting the person they care for. A carer's refusal of an offer of an assessment should not be used as a reason to exclude the carer from assisting with care planning.
3. There will be cases where the person whose care is being planned lacks the capacity to consent to the involvement of carers, or to the care plan itself. In these situations best practice suggests that the carers should be involved as much as possible. Currently local authorities have a responsibility to make decisions in the best interests of the person being cared for.
4. If disagreements occur between the person and their carer these should be handled sensitively, safeguarding the best interests of the individual and the carer. In many cases it may be appropriate for a resolution to be sought through independent or statutory advocacy.
5. If it is felt to be inappropriate to involve the carer, local authorities should retain a written account of why it was felt inappropriate. This should show that the carer's involvement has been actively considered and, if excluded from care planning, the reasons why. It is not enough to state that the reasons were considered, without recording those reasons.
6. Local authorities should continue to ensure that up to date and appropriate information on the range of support, entitlements and assistance available for carers is accessible in a variety of formats. This information should be offered to all carers, irrespective of whether the carer receives an assessment.

(*) The Community Care Assessment Directions 2004 - LAC (2004) 24