The Unique Care team at Bracknell Forest worked with colleagues from the PCT, social services, hospital trust and GP practices. In their local pilot approach to Unique Care, the community matrons (or primary care clinical nurse specialists) are integrated with the district nursing teams and have good links with social services and the voluntary sector.

One of the community matrons indicates how this integration has enabled her to manage a greater number of complex patients proactively:

"Managing long-term conditions is around delivering holistic care which encompasses health, social and psychological elements. To do this, community matrons need to work closely with community nursing, thus increasing patients' standards of care and preventing further fragmentation of the nursing service.

"By working more closely together we can share the workload, providing opportunities for everyone to provide proactive care and opportunities for everyone to learn new skills."

The team has achieved a 20% reduction in unplanned admissions in the entire over-65 population practice and a reduction of 40% in unplanned admissions over the two-year programme.