The increased incident of people with long-term conditions is presenting a huge challenge to the National Health Service. This Government has a vision for providing the majority of their care within the community setting. For those people with several long-term conditions that can result in highly complex needs, new roles of Community Matrons have been introduced. These are clinical specialists who are to coordinate care with these patients and implement proactive management plans. The health and social care needs of these patients are intrinsically linked; this means that it is essential that care be planned across the agencies seamlessly. This report looks at establishing collaborative working between Community Matrons and Social Service Departments. Some of the barriers are explored and recommendations to overcome them. This is imperative if we are to embrace the challenge of caring for these patients within the community, and achieving the aims of improving quality of care and reducing unplanned avoidable hospital admissions.

1. Aim of the Report
The purpose of this report is to recommend changes in practice that will improve the provision of supportive care to patients with long-term conditions. The area of practice is collaborative working between Community Matrons and adult Social Services.

2. Introduction
All Registered nurses have a duty outlined in the Nursing and Midwifery Council (NMC) Code of conduct to “ help individuals and groups gain access to health and social care information and support relevant to their needs” (NMC 2002 p4). As can be seen from this statement Nurses are duty-bound to work with Social Services to meet the needs of patients. This report gives some background regarding the long-term condition (LTC) agenda, the Department of Health (DoH) strategy for tackling the issue, and an introduction to the Community Matrons’ role. Then it goes on to demonstrate the importance of working in collaboration with Social Services, some of the issues faced, and makes some recommendations for improving practice.

3. Rationale for Report
The Government’s current vision for providing high quality care of patients with LTCs is within the community setting; it proposes to achieve this by increasing the range of services provided in this setting (Our Health, our Care, our Say; a new direction for Community Services DoH 2006). Community Matrons are a


part of this strategy, and have recently been introduced with to case manage patients with complex health and social needs. This remit includes identifying those patients who have had frequent avoidable admissions to hospital, providing personalised managements plans, and aiming to reduce the number of emergencies admissions by 5% by 2008 (DH 2005a p1). In order to achieve this and meet the needs of these patients, the services they need to access will cross the boundaries between health and social care (Reid et al 2005 p2). The current arrangements for assessing need and providing services across the agencies can be inconsistent, cumbersome and duplication can occur. There are no clear pathways for joint working arrangements between Community matrons and Social Services in the geographical area of the report. The purpose of this report is to address some of these issues, in partnership with other key stakeholders and achieve successful collaborative working. This is seen as an interim step that needs to occur before the ultimate goal of integration of the services.

4. Literature Review
Over the last ten years Government policies have provided a strong direction towards an integrated provision of health and social care for adults within the UK. The notion of partnership working has been central to New Labours “Third way” (Hudson 2002 p7). Legislation has introduced requirements on both the National Health Service (NHS) and the Local Authorities to work together to achieve the co-operation needed to bring about improvements in health care (DoH 2003). A key driver for closer working between services has come from the increasing


number of people with several LTCs. These patients can have high levels of complex need that require services from several different professionals concurrently. In the UK it is estimated 17.5 million people live with a LTC, and 70% of people over 65 years of age are affected by more than one condition (Wilson 2005 p544). Further 25% is said to have three or more conditions (DoH 2004bp4). LTCs are those that limit the individual, require regular medical input, and the condition has lasts longer than a year (Hudson 2005 p378). Examples include diabetes, asthma, chronic obstructive airways disease, chronic heart disease and neurological diseases. The numbers of people who suffer from LTCs is escalating due an increasingly ageing population and advances in medical technology. The management of people with LTCs clearly presents one of the biggest challenges we have faced in the NHS (Pratt 2006 p234) and is one of the Government top priorities (Wilson 2006 p544).

In 2005 the Government published a report that pulled together countless previous documents (DoH 2004, 2005b, 2005c). The report: Supporting people with Long Term conditions – An NHS and Social Care Long Term Conditions model (DoH 2005a), recognised that the current model of care within Community services, was struggling to provide care to patients with LTCs in a way that proactively managed their needs (DoH 2005a p13). Other studies have also recognised that despite previous work to encourage agencies to work together it is still evident that divisions exist (Reid 2005p5). The model proposed a strategy for health and social care organisations to tackle the issue of LTCs together.


Within the model there are three levels of care: level one supported care, level two specialised disease management and level three case management for the highly complex patients this is known as the Kieser Permanente triangle (DoH 2005a p10). This model advocated that case managers are appointed for those patients at level three, who were are high intensity users of the health service especially secondary care. These were called Community Matrons and are central to the Government’s policy for management of LTCs (DoH 2005bp13). A national target for 3,000 Community Matrons to be in post by March 2007 was made (DoH 2005b p6). Case management of patients with high level needs moves away from the disease specific National Service Frameworks, to a more generic holistic model of care (Wilson 2005 p545 & Hudson 2005 p378). Case management is not a new concept in itself as Social Workers have undertaken this role since the Community Care Act of 1990 (DoH 1990). However Community Matrons have a remit that is seen as unique, combining complex case management with complex clinical management in one role (Clegg & Bee 2006 p12).

Community Matrons are to provide a case management approach that includes the proactive assessment of health and social care needs, the development of personalised care plans, and co ordination of care and services with the individual and their carers (DoH 2006a p17). Therefore, the patient’s health will remain as stable as possible, they will feel well and the seamless provision of services contributes to these goals (DoH 2005b p13). Currently it is estimated


that around half of the people with LTCs are not aware of support and treatment plans available to them, and they do not have information and care plans that help them manage their condition better (DoH 2007 p18). Community Matrons will address these issues in partnership with the patient, and empower them to take control of their health. Research demonstrates that clients of health services prefer their care to be provided be one person who is highly skilled in co coordinating services (McKenna & Keeley 2004 p22). They also are reported to favour integration as a way of reducing the complexities of accessing services and enhancing provision of services (Reid 2005p2) In order to achieve this it is crucial that partnership working with the patient and other professionals is undertaken to meet needs effectively (Pratt 2006 p234).

Traditionally there are several factors that have hindered health and social care agencies working together. In the past achieving seamless care has not been achieved easily, and can be fraught with difficulties (Hudson 2005 p381). The reasons for these can be divided into historical, professional, administrative, and financial barriers (Reed et al 2005 p5). Studies have found that when some of the structural, organisational and financial barriers are removed this does assist working closer together (Glendinning 2003 p151). However barriers can still be evident between professionals and they can be protective over their roles resulting in “Turf war” (Reid 2005 p6). It could also be stated that top down policy models can be criticised for failing to appreciate the influence front line staff have Hudson (2002 p9).


Some authors have commented that although the health and social care model is welcomed in principle, there is a danger of it being “unduly medically focused” (Hudson 2005 p378). For example the term “patient” is used throughout the document. Hunter goes on to comment that the report’s most radical proposal, the introduction of Community Matrons, is a clear failure to acknowledge Social workers’ skills. The world of social care may also feel undervalued by the direction the model has taken: as it does not acknowledge the skills and experience that Social Workers have developed (Hunter 2005 p24, Hudson 2005 p383). Further, there are concerns expressed that the Governments LTC policies are on the whole about keeping people out of hospital, rather than the improving quality of life of those affected Hudson (2005p382). Hudson also argues that the title Community Matron was reinvented to achieve political gain, and in order for them to be successful it will be essential for them to seek out and work closely with partners and not attempt to impose leadership (Hudson 2005p383).

5. Recommendations
To set up a group of key stakeholders with a remit: To explore how to achieve collaborative working between Community Matrons and Social Services Suggested areas of change • An improved understanding of working collaboratively


Standardised practice of joint assessment of patients with complex needs and the development of individualised multi disciplinary care packages

Community Matrons are given the authority to commission care packages and admit patients to community respite beds. (Community matrons are in a strong position for holding the budgets for Health and Social care for patients with LTCs (Young 2005 p 12)).

Co location of Community Matrons with Social Services Care Managers

Proposed strategy for implementation
The setting up of a group of key stakeholder is recognised as important in order to develop commitment to the success of the improvement (Cook 2005p13). The stakeholders group would include a representative from: • • • • • • • • • Community matrons Head of community nursing Social Services Management Discharge management team Continued health care team Intermediate care therapists Specialist nurses District nursing including the Out of Hours Service Patient participation and involvement group


The involvement of the Social Services Department from the onset is seen as crucial to gaining the commitment needed to built relationships and work together (DoH 2005b p20). Further the active involvement of patients, carers and the public is also seen as vital to the success of the initiative as they have valuable knowledge of services from their own experiences (DoH 2005b p19 &DoH 2007 p20). This ensures that rather than concentrating on the disease and its treatment, what is important to the patients it is taken into account. This is the key to achieving patient satisfaction and ensures that the service is patient centred (Cook 2005 p23). This project will also incorporate the work of the District Nursing teams. This is important as unless the provision of services for patients is improved across the board, then this model could mean a small minority of clients get a lot of resources, at the sacrifice of others resulting in inequity of care (The Long Term Medical Conditions Alliance 2005).

6. Change Management Strategies
Once the steering group of interested parties is established, improved ways of working will be explored through regular planned meetings and workshops. It is envisaged that this will open up challenges of communication and address ways of overcoming potential barriers. The management of organisational change is a complex event, which needs careful planning in order to succeed (Broome 1998 p44). Initially a SWOT analysis of the proposed new ways of working will be


undertaken, this will include looking at the strengths, weaknesses, opportunities and threats (originally developed by Ansoff 1965).

Strengths /Benefits
To the service users • An improved service for patients and carers, that is seamless across services. • Potential reductions in unnecessary hospital admission as patient’s needs are anticipated and care is planned proactively in a joint and co coordinated manner. To the professional • • • • An increase in job satisfaction for professionals involved /improved morale For the Nurses, an ability to work and deliver NMC statement goal Good team relationships Provision of care in the most appropriate place as Community Matrons have the ability to access community beds

• The information technology systems currently in place restrict the sharing of patient information, as they are not accessible across the different services. So despite single assessment process being in place the duplication of assessments is a major issue.


• • Staff will gain new knowledge and skills It will provide clarity and an improvement in patient services

• • • Different cultures / resentment of community matron role Not enough evaluation of role As with any new way of working there are potential barriers with the implementation process. • • • Barriers to the LTCs model could come from Health and Social Services. Time of uncertainty within health service with restructuring Resistance to change and different ways of working

Actions needed
With the help of the SWOT analysis discussion will take place in the stakeholders group to identify the key issues. This enables the project leads to identify the key areas that need to be addressed, and is extremely useful when developing a project plan with key milestones (Iles 2005p132). Broome (1998 p19) suggests that an effective change must: • • • • • Link activities to goals Be specific Be integrated so that the parts are effective Be time specific with logical steps with dates Be flexible to take into account changes 11

Establishing regular communication, and an involvement process, will be vital in order to gain an understanding and acceptance of the need for change and better working together (Perry 1997p8). Community Matrons and Care Managers will need to develop a team approach, and an understanding that shared planning and decision-making is prerequisites to achieving successful collaboration (Henneman et al 1995 p104). This will require each party involved to establish mutual respect for each professional’s expertise, and prevent any parties feeling under threat. Gaining a clear understanding of each other’s roles will help prevent any misunderstandings and confusion (Henneman et al 1995 p106). Looking at examples of how other areas have achieved success to get ideas would be beneficial. For example Hudson describes of an integrated team where strong bonds developed between multi disciplinary professionals (2007p315). They found common values with the patient at the centre, and gained a greater understanding of each other roles (Hudson 2007 p10). Having a shared work environment appears to have been a key component to the success of the project and led to a more effective service being delivered. Hudson stated that this example demonstrated that the outlook for achieving integration is not as pessimistic as has been previously been reported.

7. Resource Implications
Identifying the resources needed to implement this project is difficult, because resources are predominantly staff hours. However, if successful implementation


takes place there may be a reduction in the number of emergency calls for ambulances and in costs for secondary care, as inappropriate bed days will be avoided. Alternatively, costs in the community may rise as patients with high needs are identified and the services needed to provide care in their own homes or in the community increases (Wilson 2006 p551).

8. Conclusion
Patients’ health and social care needs are intrinsically linked. Achieving successful collaborative working will be crucial to achieving an improved quality of life for patients (Henneman et al 1995 p108), and high standards of coordinated care in the community. Community Matrons have been given a new and innovative role; the successful implementation of this role is a considerable challenge. For this to succeed, commitment and investment from the Primary Care Trust and Social Services are key factors (Lyton 2006 p17). For Community Matrons to reach their full potential, then it is essential that successful partnerships are formed and new ways of working established. Undoubtedly Community Matrons and Social workers have a wealth of knowledge and experience to share. This report presents the argument that improved collaboration can be successful with a change management strategy and commitment from all the partners involved. Finally the belief is held that the potential benefits to the clients of the service achieving joint approaches will outweigh any difficulties faced.


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