Integration with purpose: supporting Oliver and Dylan to live well

There’s a lot of talk about integration of services, and indeed, that is the direction of travel in the integration white paper, and the reason behind setting up integrated care systems (ICSs).

At Torbay and South Devon NHS Foundation Trust, we’re the first NHS trust in England to integrate our acute hospital care, community healthcare and adult social care. Our aim for this was always from a starting point of working between the organisations to help our people live better and receive the best support at the most appropriate time and in the right place.

We know it’s the right way to do things, as we can see the difference it’s making to people across the area we serve

We’re on the start of this journey and there will be more to come, when ICSs become organisations themselves. We know it’s the right way to do things, as we can see the difference it’s making to people across the area we serve.

Oliver

Oliver has lived in a care home for nearly a decade, where he’s looked after for his physical and mental health needs. There was a deterioration in his physical health, and the care home became concerned they may not be able to look after him. Oliver, and his family, wanted to do all they could to ensure he stayed in the care home, as he was settled.

NHS and social care professionals reached agreement with Oliver and his family that a move from the care home may impact negatively on Oliver’s mental health.

A social worker met Oliver, his family, care home staff and a care co-ordinator from a community mental health team. Assessments from occupational therapists and physiotherapists worked out what equipment Oliver would need so he could remain in the care home.

Afterwards, Oliver’s family wrote to us: “We were involved at all stages of the health and social care process and were able to provide valuable input. We felt listened to and came away feeling very supported and optimistic about the future of our loved one.”

Dylan

Dylan is a man in his thirties. He has complex mental health needs, including schizophrenia and Asperger’s. Dylan had been living in a residential care home, with stable mental health, for six years.

He has hopes and aspirations for his future, but acknowledged he’s been living in fear and remained in the care home because it was what he knew.

Dylan wanted independence and he wanted to grow. He talked about wanting to use his wings, and being able to fly.

His family was worried his mental health would deteriorate if he left the care home. The Torbay and South Devon community mental health team felt Dylan had scope to be more independent. They discussed with the family and Dylan how he could transition to more independent living, without compromising his mental health.

This approach gives an opportunity for individuals to be a citizen rather than a service user, if that’s what they want and it's right for them

Now he lives in a supported living placement with his own room, a shared lounge, kitchen and bathroom. There is background support from enabler care workers during the day. Dylan also has 20 hours’ one-to-one enabler support to discuss aspects of his life, including his weekly activities, diary commitments, expanding his support network, and education on budgeting and cooking. 

He has a voluntary job, goes to the gym, swims, attends a chess club, and is about to do a mindfulness course. He has aspirations to study at college. Through this integrated approach, Dylan has replaced his formal support network of care, and is building his own informal support network in the community.

Dylan, like many people, still has challenges, needs guidance and support, but he doesn’t need ‘a service’. He is in control of his living arrangements and support, rather than a service being in control of him.

This approach gives an opportunity for individuals to be a citizen rather than a service user, if that’s what they want and it's right for them.

What needs to happen?

As these examples show, by organisations working together, in partnership with people and their families, there are clear benefits. So the question is, what needs to happen to support the NHS working this way with social care and the third sector across the whole country?  

Sharon O’Reilly is deputy director of adult social services at Torbay and South Devon NHS Foundation Trust. You can follow the trust on Twitter @TorbaySDevonNHS