Unit 5: Meeting Individual Care and Support Needs (References document included )
D: Investigate the roles of professionals and how they work together to provide the care and
support necessary to meet individual needs
D.P6: Explain why meeting needs of the individuals requires the involvement of different agencies
D.M5: Assess the benefits of multi-agency and MDT working for people with care/support needs
D.D4: Evaluate how multi-agency and MDT working can meet the care/support needs of people
(D1): How agencies work together to meet individual’s care and support needs
Part 1: CCG, Local Authorities, Health & Wellbeing boards.
CCGs were formed following the Health and Social Care Act 2012. They replaced Primary Care Trusts
in 2013 and enabled Doctors to commission services for their local community along with other
health professionals.(1) CCG governing bodies are made up of GPs, Nurses and secondary care
representatives and at least two people who are not part of the NHS. All GP practices have to be a
member of a CCG in their local authority.
Local authorities commission social services to achieve community-based support that promotes
health and wellbeing by using skills and resources.(1) Local authorities work together with other
organisations, such as housing and NHS partners, using guidance such as the Adult Social Care
Outcomes Framework, Making it Real statements and the Public Health Outcomes Framework.
Health and wellbeing boards are a forum in which local Health & Social Care leaders work together
to integrate public services for Health & Social Care.(1) HWB enable different organisations to work
together in planning and delivering local services. HWB are where representatives from the health
and social care sector work together to improve the health and well-being of their local population.
They report to the clinical commissioning groups and local authorities.(153)
Part 1 : CCG, Local Authorities, Health & Wellbeing boards – applied to Valerie and Tremayne
Valerie - she will most importantly require community mental health and care services. It is
important that the CCG and the Local Authority work together to ensure that all of her needs are
met when she is discharged. Health and Wellbeing boards will enable health and social care
professionals and people from the community, i.e. an informal carer, to work together. For example,
to improve community mental health services in Valerie’s local area. This could be important for
Valerie as it will prevent her from ending up becoming severely ill and support her on a daily basis. In
addition, if a large number of the local population are obese, then they might set up initiatives such
as healthy eating campaigns to tackle obesity.(154) However, if the agencies do not work together to
organise new initiatives, then it may lead to services not being commissioned, which will affect
Valerie’s holistic needs being met. This may cause individuals’ health deteriorating as their needs are
not being met. For Valerie, her depression could worsen, leading to her being admitted to a
Psychiatric Unit. She may gain more weight which may lead to type 2 diabetes or heart disease(155).
For Tremayne, his mental and physical condition will need to be monitored when he returns home
by services commissioned by the CCG. The condition of his broken leg will need to be monitored by a
community physiotherapist, community nurse and a local GP. He will also have mental needs as he
has autism. Therefore, it is important that the CCG and the Local Authority work together to ensure
that all of his needs are met when he is discharged. Health and Wellbeing boards will enable health
,and social care professionals and people from the community, i.e. carers, to work together. For
example, to improve community care services in his local area. The must setup and plan new issues
to tackle issues such as adults with autism living alone. The Birmingham and Solihull CCG provides a
service called ‘Small Supports’. They are small, community-focused organisations that offer intensive
support that is bespoke to each individual and centred around their needs. This helps the person
with autism to have support shaped around them and their life in the community, which could
include work, volunteering, having friends and contributing to their community as citizens.(94) They
will help people with autism, such as Tremayne, to live in their own home with a bespoke support
team.(95) This will benefit Tremayne as he will have a small group of people who will monitor and
help him based on his specific needs and preferences. This will cause Tremayne to feel supported
and well looked after. This could reduce the chances of feeling angry or frustrated as he will be
happy more often because he now knows that he has a group of local community members that can
help him. Having this type of support group will be very important for Tremayne as he has complex
needs which can be met by this group of capable local individuals. If this service was not provided,
then it may mean that all his holistic needs may not be met fully by just simply carers for his personal
care and helping him with daily living activities. If this is not in place, it can lead to Tremayne’s
condition deteriorating as he may not have many people to talk to and may not have many family
and friends there to support him during challenging times for an autistic adult.
Part 2 : CAF, National Eligibility Criteria
CAF - introduced under the agenda for Every Child Matters. A voluntary process requiring informed
consent from the child and their parents. A system for gathering information concerning a child’s
needs and assessing how these needs can be met by the relevant support services. This may include
occupational health, physiotherapy, counselling, education, etc.(156) CAF is a simple, intervention
process for gathering and recording information. CAF is for children in need of support in one or
more of three areas: Growth & development, Additional educational requirements, Family and
environment issues, any specific needs of a parent/carer.
Part 2 : CAF – applied to Valerie and Tremayne
Valerie – She may have had CAF when she was growing up because she had mental health issues and
her parents died when she was very young. The CAF would have also supported Valerie through
transition into adult mental health services (age 19 and 20). The CAF would have been completed by
her teacher and sent to MASH. This is a multi-agency safeguarding hub where it could have been
possible that both children’s social care and mental health services worked together to provide
support for Valerie as she had mental health issues and was still a child.(157) The purpose of the
MASH is to enhance information sharing across all organisations involved in safeguarding the welfare
of children - encompassing statutory, non-statutory and third sector sources. This would have been
important as it would have helped Valerie to overcome raising awareness and motivational
challenges throughout her childhood and transition into adulthood. If Valerie was not supported
whilst she was growing up then, it could have led to her mental health deteriorating as her parents
died when she was very young, so this would have given Valerie that extra support when growing up
such as emotional support through counselling. For example, Valerie would have had a CAF referral
from her teacher to a psychologist to support her with her mental health issues. Therefore, it is very
important that different agencies work together to meet the needs of individuals such as Valerie.
Also, by cooperating it can also help to raise issues which are affecting more people.
,CAF does not relate to Tremayne.
National eligibility criteria - if an adult has care and support needs, the Local authority will start by
carrying out a needs assessment to decide whether the person’s needs meet the national eligibility
criteria: that is whether their needs: are related to a physical/mental impairment or illness, make
them unable to achieve 2+ desired outcomes, mean there will be a major impact on their wellbeing
if these 2+ outcomes are not met.(1)
Part 2 : National Eligibility Criteria – applied to Valerie and Tremayne
Valerie - the Hospital Social Worker, who is working closely with Valerie, may feel that a care
package will be beneficial for her so they may carry out a needs assessment using the National
eligibility criteria(NEC).(158)They can assess whether Valerie meets the desired outcomes and is
eligible for care. This would enable both the Local Authority(LA) and mental health services to work
together to meet her needs. By working together, it will allow them to ensure they take a holistic
approach, as her mental health needs will be taken care of as well as her care needs. This is
important as it will help Valerie transition from the community hospital back into her home in the
local community. This means that Valerie will not need to worry about her mental health issues, and
she will receive care as she may struggle with day-to-day activities due to her appendix surgery.
However, if these different agencies do not work together to meet Valerie’s needs, then it means
that Valerie may not be eligible for a care package and thus Valerie’s mental health and care needs
may not be met effectively. This could increase her anxiety which could lead to her health
deteriorating as she is worried about returning home and nothing has been done to support her
transition back, its like she has been spat back into society without any support from the LA, leading
to poor quality of life.
Tremayne - he already has a care package. Therefore, he would meet the criteria to receive funding
from the LA to meet his needs.(158) For example, he may be able to use this funding on his social
and emotional needs. He could possibly join a gardening club in his local area, and they can work
together with the LA to ensure that Tremayne’s social needs are met. Tremayne can also use this
funding to employ a carer which he likes. This could allow the care staffing agency and the LA to
work together to ensure that Tremayne is happy with the care he receives. By the LA working with
these different agencies, it will help to ensure that Tremayne’s needs are being met, i.e. gardening is
proven to reduce stress and by letting Tremayne employ his carer, it will promote his independence
as he will feel that he has the autonomy to have a say in his care, because at the end of the day it
should have a positive impact on his life. However, if the different agencies do not work together,
they it could to Tremayne’s health deteriorating as his needs are not being met. This could lead to
him feeling frustrated as he does not know what to do and thus, he could get sectioned under the
Mental Health Act for being at risk of harming himself if he gets too angry. This could lead to poor
quality of life as his needs have not been met by the different agencies not working together.
Part 3 : Department of Health, National Framework for NHS Continuing Healthcare, EHC plan
The Department of Health and Social Care supports ministers in leading the nation’s health and
social care to help people live more independent, healthier lives for longer. DHSC is a ministerial
department, supported by 28 agencies and public bodies: NHS England, Public Health England, NICE,
NHS Digital.(72) For example, The Department of Health provides information on the R value and the
growth rate so that the government can make informed decisions such as future lockdowns, to
increase the number of vaccines, increase the number of testing in high-risk areas, etc. This is just
one of the many things they do to control the spread of coronavirus in the UK.(102)
, Part 3 : Department of Health – applied to Valerie and Tremayne
With regards to Valerie & Tremayne, it is important that they follow all policies, legislation and
initiatives to control the spread of COVID-19 when they are discharged, i.e., HANDS. FACE. SPACE.
(74) The Department of Health and Social Care have overall responsibility for implementing new
policies, legislation and initiatives; there decisions made will affect the whole of the nation and both
Valerie & Tremayne. Therefore, for example, in the local GP clinic, there must be PPE to control the
spread of infections from patient to patient and to staff members. The Department of health must
work with the LA and CCG in their area to ensure that the local GP clinics are up to date with all of
the latest guidance on COVID-19 procedures. For example, PPE must be worn at all times by
professionals working with Valerie & Tremayne to ensure they and themselves and others in the
clinic minimise the spread of COVID-19 and health campaigns such as HANDS. FACE. SPACE. from the
Department of Health and Social Care help to support this and reinforce.(75) Therefore, it is very
important that all of these different agencies work together in order to reduce the spread of COVID-
19, for example. However, if these agencies do not work together then policies and procedures will
not be followed by both staff and patients. It can lead to the number of infections to spread rapidly,
leading to a higher death toll. Therefore, different agencies must work together to not only keep
local populations safe but also the whole nation.
NHS Continuing Healthcare - if an individual needs extra support from a healthcare setting there will
be an assessment by a professional using a screening tool called the NHS Continuing Healthcare
Checklist. NHS continuing healthcare is a package of care for people who are assessed as having
significant ongoing healthcare needs. It is arranged and funded by the NHS. If you receive NHS
continuing healthcare in a care home, the NHS pays your care home fees.(88) If results suggest that
the individual is eligible for NHS continuing healthcare, a full up-to-date assessment of their needs
will be arranged using a tool called the Decision Support Tool. Multi-disciplinary teams set out the
individual’s needs in relation to twelve care domains, and then make a recommendation as to
whether the person is entitled to NHS continuing health care.(1) 12 care domains in the DH Decision
Support Tool: Behaviour, Cognition, Psychological and emotional, Communication, Mobility,
Nutrition, Continence, Skin integrity, Breathing, Medication, Altered states of consciousness, other
needs. The level of need is assessed for each of the 12 care domains by assigning one of the
following six levels: Priority, Severe, High, Moderate, Low, No Needs. To be eligible for NHS
Continuing Healthcare, the client must have 1 priority and 2 severe or a mix; for being more likely
and more chances of them getting it.
Part 3 : National Framework for NHS Continuing Healthcare – Valerie & Tremayne
Tremayne has autism, anger issues, an allergy and broken leg. This means he has complex needs
which an individual must have to be eligible for NHS Continuing Healthcare. Tremayne must have 1
priority and 2 severe or a mix for the 12 domains; for being more likely and more chances of him
getting NHS Continuing Healthcare.(1) Tremayne may have cognition under priority as he has
complex autism needs. He may have behaviour and communication under severe as he must be able
to manage his anger and be supported with his communication as he is autistic, so he may find it
hard to express his needs and preferences. The NHS continuing healthcare will help agencies work
together as Tremayne’s local authority will provide funding for his care, for example, to a day centre
in order to improve his cognition, behaviour and communication. The day centre will be able to
provide Tremayne with activities to stimulate his mind which may improve his cognition. Also, he will
interact with others which may improve his behaviour and communication. The NHS Continuing
Healthcare will help agencies work together as they must use their resources to ensure that
