The Torbay Experience of Integration document discusses Torbay's integrated health and social care model. Key points include: - Torbay established one of the first five Care Trusts in the UK, integrating health and social care services. - Torbay has an aging population with high levels of people over 65 migrating to the area. - Services are organized around five integrated community teams centered around general practices. - The model focuses on proactive case management, single point of contact, and pooled budgets. - Performance metrics like wait times have significantly improved since implementing the integrated model.

1. The Torbay Experience of
Integration
Peter Colclough
Chief Executive / Director of Adult
Social Services

2. National Perspective on Integration
 5 Care Trusts: Northumberland, Braintree
Bexley, Torbay & Solihull
 Mental Health + Learning Disability …6
Care Trusts, several NHS Partnership
Trusts
 Major Partnerships: eg Knowsley*,
Swindon*,Peterborough, Southwark*,
Sedgefield (part Durham)

3. * Single
organisations
*
* *
!
** *
!
*

5. Demography of Torbay
In 2002/03, Torbay had the highest inward migration, within the South West region, of
people aged 65 and over
(source: South West Regional Health Observatory, 2005).
Comparative poulation structures over 55
50%
45%
Proportion of total population
40%
35%
30% 85+
75-84
25%
65-74
20% 55-64
15%
10%
5%
0%
England South West Torbay

6. Population and Economy
 Total Population 140,000
 23% over 65
 10,000 over 80
 Low Wage Economy
 Lowest GVA in South West

8. Finance
£M
 Pooled Budget 95
 Commissioned Healthcare 130
 Prescribing 25
 Primary Care 30
 Public Health 5
 Total Revenue 285

9. Why a Care Trust
 Previous history of good relations
between PCT and Council
 Co-terminous boundaries
 Political support
 Kaiser Permanente Demonstration Site
 Joint desire to improve performance and
service delivery
 Most importantly – improving services to
Mrs Smith…

10. Social
Community
Worker General
Psychiatric Nurse
Practitioner
Practice
Nurse
Domiciliary
Care
Physiotherapist
District
Nurse
Occupational
Therapist
Occupational
Therapist
Diabetologist
Family &
Carers Cardiologist

11. Key Features of Integrated Service
 Integrated frontline teams (5) centred around
of General Practice
 Single Management of each team
 Lead professional in each team
 Social work
 District nursing
 Occupational Therapy
 Physiotherapy
 Single Assessment Process
 Single point of contact – Health and Social Care
Coordinators
 Pooled budgets

13. Key drivers in each team
 Know your population
 Proactive sharing of cases across professionals
in partnership with GPs
 Focus on the most vulnerable
 Teams deal with all cases – long term
conditions, palliative care, disabilities etc
 Manage their care
 Proactive Case Management
 Yellow folders
 Community Matrons

14. Know your population
Case Management
Self care and
Professional
Assistance
Self Care

15. Previous referral process for social care
GP to District Nurse…
…to Social Services (Central Office)…
…to Referral Coordinator…
…to Service Manager for allocation…
…to Care Manager…
…to Service Manager for signing off…
…to (eg) Home Care Service Manager
…to Carer
= very slow; linear and bureaucratic; waiting-lists to
even out demand; poor feedback

16. …as it is evolving now
With SAP in place, FACS widely understood, budget
delegated, brokerage support etc
DN-----------------to------------------Service
provider
|
|
Facilitated by
Health and Social Care Coordinator
= much faster, face-to-face, no duplication, creative
solutions and simpler for service user

17. Performance Improvements
What Improvements have we had?
Area Apr 06 Oct 08
Community equipment within 7 days of request 90% 99%
Patients assessed within 28 days of referral 72% 83%
Care packages in place within 28 days of assessment 67% 97%
• Intermediate care teams in place allowing access to OTs, physio,
and district nurses within:
• 3½ hours if urgent (approx. 25% of caseload)
• 5 working days, if appropriate
• recently commenced a weekend working pilot
• Developing ‘SWIC’ roles to further improve access to services
(SWIC = Support Worker in Intermediate Care)

18. What improvements have we
had?
 Improved CSCI Rating
 Improved Staff Satisfaction
 Improved User Satisfaction

19. Other Factors
 Governance Arrangements
 TUPE and Agenda for Change
 Regulation Changes

20. Other factors
o Cultural Difference
o Direct Payments
 Individual budgets
o Professional Implications

21. Other factors
 World Class Commissioning
 Purchase/Provider Split
 PBC and Personal Care
services commissioning
 Focus on inequalities

22. Integrated Team
SAP
Family and Specialist
Friends Services