Frail elderly patients: the case of Torbay

The health and social care for elderly people in Torbay (England) is fully integrated today (see the King's Fund document). In 2004 a pilot in one of the county’s districts was launched and soon spread to the entire area. Each of the 5 teams that were set up serves a population in a range from 25,000 to 40,000 inhabitants. In 2005 Torbay Care Trust was created.

The main objective of the service integration:

Maintaining the frail patients at home or in a community setting for as long as possible.

Key elements to achieve the objectives:

• Integration of health and social care professional teams
• Team budgets’ fusion
• Deployment (or purchase if appropriate) of a wide range of intermediate services that facilitates home support
• The enthusiastic support of family doctors (even though they have not been integrated)
• Institutional support, especially local support

Organizational model of integrated services:

The following charts show, schematically, the change of organizational model that evolves from the traditional with its segmented functions to the new integrated model. Note that it goes far beyond coordination:

The experience’s outcomes:

In the absence of a randomized study, the following figures show positive trends in reducing inappropriate use of resources by the frail and elderly patients, as an extra, of course, to the satisfaction always generated by the smooth running of local services:

• The use of hospital beds was reduced by 30% if the periods 2009 - 2010 and 1998 -1999 were compared.
• Emergency attendance to over 64 year olds in Torbay is 29% below the national average.
• The use of emergency services by people over 74 has fallen by 24% in 2008 compared with 2003 and in people over 84 years, the reduction was 32%.

The advice of Chris Ham, Chief Executive of the King’s Fund, starting from the experience of service integration in Torbay, is:

• One should have a clear view of what is appropriate in bringing the services closer to the real needs of complex patients, moreover one must also know how to maintain this view over time.
• You have to start at the bottom, align ideas and goals among patients, social workers, nurses and doctors.
• One must keep in mind, especially today, that joining social and health services is a very cheap experience and also gives good results. It is very cost-effective.
• One should keep faith in what one does, despite the difficulties of struggling with the established hierarchical model.

Jordi Varela
Editor