Models of care for those with complex issues

A firm conclusion from the work to develop this resource is that personalised care and support planning (PCSP) for people with health and social care is best carried out within multidisciplinary teams, often but not always revolving around general practice.

These teams should have:

• staff with a range of clinical and professional expertise
• strong organisation and coordination
• input from the voluntary sector and from volunteers.

While multi-disciplinary teams exist in a variety of settings, the person-centred culture and flexibility for different roles to be interchangeable depending on people's needs and preferences is not currently common.

The exact configuration of a multi-disciplinary team to undertake effective personalised care and support planning for people with health and social care needs will depend on the local context and the population for whom planning will be offered.

Matrix of roles in an integrated care and support planning team for people living with long term conditions.

The matrix of roles in an integrated care and support planning team (opens new window) for people living with long-term conditions identifies a number of possible roles in a MDT geared to deliver personal care and support planning. It also shows the roles and stages on the personal care and support planning journey.

The matrix is not intended to be comprehensive or to limit local adaptation. It is an illustration of the kinds of flexibility needed for assisting with local planning and decision making in service design.