Tools and resources

Roles, responsibilities, and multidisciplinary working

Roles, responsibilities, and multidisciplinary working

Figure 1 – the web of care

Figure 1 - the web of care

Working together to ensure care and support is coordinated is crucial. The different roles and responsibilities involved in care at home need to be carefully defined. People involved may include home care managers and workers, carers, healthcare practitioners (for example, district nurses and GPs); social workers; workers from voluntary or community organisations; and advocates.

This diagram is based on the experiences of a carer, Barbara Pointon, whose husband Malcolm had Alzheimer's disease. It shows how many people may be involved in one person's care.

Key resource

The guideline can encourage communication across boundaries. The NICE Collaborating Centre for Social Care (NCCSC) held a 'roundtable' event bringing together lots of different perspectives on home care to discuss the guideline. The report of this event also contains information on holding your own local roundtable event.

Named care coordinator

The named care coordinator should: (recommendations 1.3.6–1.3.9 and 1.3.14)

  • lead home care planning and coordinate care

  • ensure everyone involved in delivering care and support knows what they should be providing and when

  • ensure everyone involved in delivering care and support is communicating regularly.

The care coordinator should also be responsible for ensuring the person's care diary is kept up‑to‑date and that it remains fit for purpose. This person is someone already involved in the person's care (not an 'extra' person). It could be any of the practitioners, a carer, a family member, or the person themselves: often, there will already be an unofficial care coordinator. The person who accepts the care coordinator role should do so willingly, and everyone involved in the care should know, and respect, the care coordinator's responsibilities.

Working together

The guideline explicitly states that health and social care workers should liaise regularly to deliver person-centred care (recommendation 1.5.3). This is in line with the Care Act (2014) placing a duty on local authorities to promote integration of care with health services. Working together can be cost effective or even cost saving (see the costing statement) – because seamless care at home reduces overlap and duplication. A series of quick guides from NHS England and partners can be used to implement solutions to commonly experienced issues in health and social care integration.

Local leadership across the health and social care sector is the foundation of coordinated working. Local health and wellbeing boards provide a forum for health and social care leaders to work together at a strategic level. Setting an example in this way should encourage working together throughout the system. Some areas have other opportunities for leaders to meet together, such as quality forums and provider alliances.

Key resource

Different practitioners have their own cultures and languages. Bridging these can be a challenge: there is often a need to change relationships and shift perceptions. SCIE has produced a tool, Integrated working for better practice. It will help you ask questions about what is and is not working in your communication and coordination.

Case study

South Devon and Torbay Clinical Commissioning Group expanded 'community virtual wards' (integrated health and social care teams) across GP practices in 2012. These teams identified people at risk of unnecessary hospital admissions, with the aim of reducing duplication, improving continuity and quality of care across providers and maximising community resources. Proactive case management using the community virtual ward and the Devon Predictive Model (King's Fund resource) explains the system in detail.


Effective communication is fundamental to safeguarding (recommendations 1.6.1–1.6.6). Sharing information means that safeguarding issues are more likely to be identified at an early stage. Missed and late visits and a lack of continuity of care can also have a negative impact on safety. It is important to see effective safeguarding as a marker of good care, not as an outcome of poor care.

Key resource

Providers and commissioners' organisational attitudes to, and perceptions of, risk vary. Talking to older people about their experiences is central to effective safeguarding. SCIE's adult safeguarding hub provides guides and learning materials on all aspects of adult safeguarding, including ensuring safeguarding policies and procedures are person‑centred.

CQC Regulation 13 relates to safeguarding people using services from abuse and improper treatment.

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