Torbay has for many years been celebrated as a pioneer of integrated care and has a strong track record of investment in many of the priorities set out in the NHS Long Term Plan. But recent challenges have put the organisation under strain. Dawn Butler of Torbay and South Devon NHS Foundation Trust and Sarah Walter of the NHS Confederation explore what we can learn from Torbay’s experience as an integrated care organisation operating within a challenged national context.
Torbay and South Devon NHS Foundation Trust is known by many as a pioneer of integrated care. Torbay Care Trust was one of only five care trusts created in 2005 with responsibility for commissioning and providing all adult health and social care services for people of Torbay. The trust’s integration journey continued in 2015 with the creation of an integrated care organisation (ICO) – one of the first places in England to bring acute, community and social care together in a single organisation.
The trust’s focus on integration has seen it adopting many of the aspects of the NHS Long Term Plan long before these priorities were set out in the current national framework. This has included investment in primary and community care as the gateway to the care system, working with voluntary sector partners to create new health and wellbeing coordinators and adopting a range of tools and interventions that support people to take control of their health and wellbeing, and reduce isolation. Staff are enabled to work across care settings, improving continuity of care.
As an ICO, Torbay has also been an early adopter of many of the working practices anticipated for the new integrated care systems. The trust has already been working beyond traditional organisational boundaries with a wide range of local partners, pooling budgets and adopting a risk share agreement which encourages partners to act in the interests of the individuals they serve rather than their individual organisations and institutions.
The outcomes delivered by this integrated approach have been really encouraging. The trust has delivered significant improvements, with 40 per cent more people cared for at home, delayed transfers of care consistently amongst the lowest in the country, and more people saying that they have good social care related quality of life (compared to comparator group).
There is evidence too of the integrated care model helping to mitigate some of the impact of Torbay’s growing older population. For example, the trust has delivered a reduction in A&E attendances by the over 65s by 1.5 per cent from 2014/15 (when the trust became an ICO) to the last full financial year of 2017/18. This compares to a national context which has seen an increase of 13.8 per cent amongst the same age group. The investments in the integrated care model have also enabled the trust to support earlier discharge home with increased support to help people recover their independence when they are at home, leading to a reduction in length of stay.
Despite the impressive progress made, the trust is not protected from some of the wider critical system challenges that are impacting nationally across the health and social care landscape. System challenges such us fragility in the domiciliary care market and a hospital estate that is largely life expired and in excess of 50 years old resulting in core infrastructure failures.
So, what learning can we take from Torbay’s experiences?
Firstly, it’s clear that integration is no panacea. Despite the fantastic improvements that can be delivered for local people in an integrated system, integration itself cannot protect a system from some of its wider challenges. A lack of availability of capital investment leading to failure of core infrastructure, workforce challenges and fragility in other parts of the local health and care eco system can all have a critical effect on the ability of the system to maintain performance. Even the most effective integrated system will struggle in the face of these wider challenges.
Secondly, even when it feels the task of integration has been ‘achieved’ through integration of roles, systems, processes and communication channels, the Torbay Integrated Care Organisation has needed to pay attention to supporting teams to avoid reverting back to their organisational or professional siloes (particularly when the system is under pressure). Torbay’s learning is that integration requires constant attention and nurturing and leaders working in integrated systems need to guard against complacency and a sense that integration is a box that can be ticked.
Finally, the true test of an integrated system will be the longevity of the relationships within it. Strong relationships provide the foundation of any integrated system and will be the most important factor in helping it cope through times of crisis.
There is much to be proud of in Torbay, and the organisation’s journey to an integrated care organisation has delivered real impactful change for the population that it serves. It is clear however that the task is not (and arguably will never be) ‘complete’. The integration journey is an evolutionary and iterative one, and there will inevitably be challenges along the way. Torbay demonstrates a clear and collective sense of purpose underpinned by a strong set of local relationships. The insights of Torbay have much to teach us about the integrated journey that has the potential to reshape our national landscape of care.
Dawn Butler is programme director for integrated care, previously interim director of transformation and partnership, at Torbay and South Devon NHS Foundation Trust, and Sarah Walter is south west regional lead at the NHS Confederation.
Find out more about Torbay’s model of care in this short animation.