Theme 2: The right pathways – which are designed from the perspective of the individual rather than the service. 

Individuals do not fit into neat areas of service provision. Their needs can be complex, both emotional and physical, evolve over time and require input from a number of different professionals. Optimised adult social care services ensure that the person is truly at the heart of everything they do, by designing pathways and provision that wrap around the individual in a holistic, consistent and joined-up way.

Where teams, services, and organisations work together in a coordinated and integrated way, the result is a system which works for the individual and their network. There are as few handoffs as possible, and the minimum number of individual practitioners and professionals are involved in the delivery of support. This means activity is not duplicated, and no one ‘falls through the gaps’.

This section of the report explores three focus areas:

1. Optimised health and social care systems break down organisational barriers and focus on the outcome for the individual
   
   ‍Individuals with social care needs also have healthcare needs; health and social care systems need to work together closely to ensure individuals receive joined up and efficient care. However, with significant differences between health and social care, for example in their values, culture and funding models (explored further in Theme 3), this can be challenging. 
   
   To deliver the best outcomes for individuals, optimised systems ensure that the best health and social care pathway for an individual is the ‘default’ pathway.

Key findings:

• In an optimised system, authorities create seamless health and social care pathways based around the individual, which enable the right professional to make the right intervention at the right time.
• To achieve the best outcomes, practitioners work in multi-disciplinary teams across organisations.
• Pathways are enabled by having clear roles and responsibilities, both operationally and clinically, supported by culture of achieving the most independent outcomes for people, which is backed by leadership across the whole system.

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2. ‍Young people transitioning to adulthood require a specific focus and a lifelong approach to managing disability and mental ill health
   
   ‍Transitioning to adulthood can represent a period of significant change for a young person with care and support needs. At the same time, this is typically the point where the management of the individual’s care and support ‘transitions’ from children’s services into adult social care. It is essential that children’s services and adult social care are communicating throughout the young person’s teenage years to ensure that they are achieving the best possible outcomes. 
   

Key findings:

• Optimised adult’s and children’s services challenge the notion of transitions to adulthood altogether, by creating a unified, lifelong disability pathway. 
• These services begin to rigorously plan for transition very early on. This is often as early as when the young person enters their teenage years, and an initial understanding of likely aspirations and potential, and subsequent ongoing care and support needs, can be developed.
• Services make excellent use of the data, insight and understanding they have about their young people, who are already known to the local authority, and use this to proactively plan and ensure the best provision is in place.
• Family and carers are never overlooked; services recognise that transitioning to adulthood is a challenging time for those caring for and supporting a young person. Appropriate support plans and provision are put in place to recognise this, including use of respite and carer support when required.

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3. ‍The primary purpose of an effective ‘front door’ into social care is to connect individuals to support available from their informal networks and local communities
   
   For those people who contact the ‘front door’ of the council – be it in person, by phone or online – the majority can be assisted with advice and guidance. This can either immediately resolve their concern or direct them to alternative services in the VCS. For those individuals that contact the service via the phone or in person, typically 60-70% of enquiries can be successfully resolved without the need for further formal intervention.

Key findings:

• Optimised adult social care services tailor their front door dependent on the population they are serving; the health and social care system they operate within; and their local network of community services.
• An effective front door is managed efficiently, without impacting on quality of delivery, and automated wherever possible – for instance by creating online platforms for people to ‘self-assess’ their own strengths and needs, without the need for any intervention from social care.
• Practitioners help individuals to understand what really matters to them and, where possible, individuals are supported to ‘self-serve’, by finding and accessing resources in their own informal networks and communities.
• Individuals and their network should not need to understand the complexity of the system and instead be offered simple pathways and referral routes through collaboration between all organisations across the system.

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