Ground-breaking health and social care collaboration flourishes

Liz Davenport.portrait
(Last Updated On: October 21, 2020)

The NHS and Torbay Council are marking five successful years of ground-breaking collaboration improving the lives of our more vulnerable residents this month.

In October 2015 the integrated care organisation (ICO) was born of an already close partnership between Torbay and South Devon NHS Foundation Trust and the council to ensure adult residents receive seamless social care by overcoming existing barriers.

This relationship, including the Devon Clinical commissioning Group (CCG), was one of the first in the country to integrate local health and social care teams and derived from an ambitious shared vision and long-term commitment to change.

Joint working to support older people and those with long-term conditions (which are neither just medical or social), includes working with GPs to provide care where people live. These services include preventative care, avoiding hospital admission, managing hospital acute care and helping them live independently in the community. This continues to end-of-life care.

Adult social care is one of the areas in which the ICO is making the biggest impact. The future is positive as we begin a new commitment this year to integrate Adult Social Care with local health services for a further three years.

A priority of the ICO is to help those who are experiencing problems with their mental health and helping everyone access their local community for support.

The ICO has had many successes in the last five years including helping the following residents through several community initiatives:

Using technology to enable residents to remain safely living at home with immediate support available: An elderly man and his family believed he should move into a care home because he was not coping at home. But installing remote monitoring equipment in his home gave everyone confidence he could stay at home

The HOPE programme run by health and social care workers and volunteers to help people with long-term conditions keep themselves well through mutual self-help: A mother who attended said: “I definitely feel a lot more positive, optimistic, confident and full of hope for the future in tackling the many challenges of my own mental wellbeing and stress related struggles looking after my disabled daughter.’’

An outreach network of ten Talking Points where the Trust and independent and voluntary sector partners engage with people in their community. A resident with diabetes and learning difficulties gained confidence to see a social worker at the meeting and then supported to help himself with cooking, budgeting, self-care, household management and self-confidence. He now helps others.

Young Adult Carer network: A carer who looked after her parent and a sibling improved her self-esteem and emotional wellbeing suffering emotionally and physically. She said; “I learned to address my nightmares and learn new skills and grow in confidence.’’ She was supported by the network and the Trust’s Healthy Lifestyles team through learning new skills.

The partnership has also achieved the following: Reducing the average length of stay for people admitted to Torbay Hospital in an emergency and further developing the ability to care for people at home – ‘the best bed is your own bed’

The pandemic accelerated ICO working through supporting thousands of residents with a helpline, emergency care parcels, a food alliance and enhanced care home response

Key to the delivery of localised care based on what people need is the formation of clusters of GPs and teams of social workers, community nurses, practice nurses, domiciliary care, occupational therapists working with specialist hospital doctors and nurses – all linking with residents through community co-ordinators, families and friends.

Liz Davenport, Chief Executive of Torbay and South Devon NHS Foundation Trust, said: “There’s been a history of innovative collaborative working in Torbay from our adaptable staff involving GPs, community and hospital care. This is evolving through shared vision from leaders working across sector boundaries to create an emerging integrated care system.

“It is very encouraging to mark five years’ of progress with the renewal of our Adult Social Care partnership. We continue to ensure the needs of our local communities remain centre stage.

“Our shared focus is to help people to choose their level of care in order to live as independently as they wish. This strategy is reducing demand for long-term residential care home beds.

“Our communities face a challenging future brought into focus by the pandemic, but we could not have a better partnership to respond.”

Steve Darling, Leader of Torbay Council, said: “I am glad we are able to continue with our commitment to integrate Adult Social Care with local health services for a further three years.

“The past five years has shown us the massive benefits working together brings for our residents and we want to continue with our long-standing shared delivery of services to make sure everyone gets the best care and support we can offer.

“We are also keen to build on the ethos of partnership working with the Trust and CCG and we will continue to show leadership when engaging with and supporting all involved in delivering great integrated care.”

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