Coastal Locality: a case study in integrated care for complex, older patients


Published: 11/12/2019 12:09
Torbay & South Devon NHS Foundation Trust

This case study focuses on the impact of a Health and Well-being Hub created in March 2016 by the Integrated Care Organisation (ICO) in Torbay and South Devon.

The Hub integrates, GPs, pharmacists, social care, the voluntary sector and community services at a daily MDT to provide more person-centred, strengths-based coordinated care for complex, older patients in the community, whilst avoiding unnecessary ED admissions and facilitating earlier hospital discharge.

What's been done?

A Hub was set up in the former community hospital, with health and social care staff being collocated in one room.

This was achieved through disinvesting in local acute and community hospital beds (one community hospitals lost all its beds), rather than pump priming using national funding streams.

The voluntary sector involvement (Well-being Coordinators) was funded by the Trust, with additional funds from the national lottery and iBCF. The voluntary sector offices were also located in the entrance to former community hospital to improve communication and information with staff and patients

Locality Clinical Directors (GPs) were employed part-time by the Trust to build relations with primary care and negotiate a new contract with local GPs (five sessions per week) to input daily in the MDT.

The Trust also employed a pharmacist (four sessions per week) and two part-time Well-being Co-ordinators (voluntary sector representatives), and invested in an Intermediate Care lead together with additional community staff (nurses, occupational and physiotherapists), using the monies saved from not providing beds in the community hospitals.

The MDT meet seven days a week (since March 2016) to discuss and plan the care for approximately 30 high-risk or newly discharged patients each day.

Since November 2018 there has also been access to local GP practice databases (SystmOne), facilitating communication and coordination of care
Impact study 

A mixed-methods case study, using embedded Researchers-in-Residence (RiR), compared the performance and impact of the Coastal Health and Well-being hub with four other localities established a year later (natural experiment)

The study collected patient experience, service activity and system performance data (number, percentage, length of episode and rates).

This showed significant increase in referrals to the Hub (for intermediate care), with a growing proportion from GPs, more people being cared for at home and less in beds with shorter episode lengths, with good levels of person-centred co-ordinated care (as measured by the PC3-EQ), accompanied by reduced acute hospital admissions (5.5%) and bed-day rates.

The high degree of horizontal and vertical integration made for effective transitions between service and home and the provision of more, holistic responsive care.  This achieved through developing trusting relationships and good communication between acute, community and primary care, coupled with a combination of contextual and instrumental factors:

  • Population size (35,000), making the volume of referrals manageable within one MDT;
  • Having a vibrant voluntary sector. The psychological and social support provided by connecting people into the local community helped compensated for having weak input from MH services;
  • Close proximity and good transport links, making access to patients’ homes easier than in more sparse parts of TSD;
  • Co-location of teams and joint management, allowing informal MDT working, a risk-enabling, strengths-based and outcome-focused culture supporting regular communication and co-operation
  • Shared clinical leadership and GP engagement, supported by a GP who was also appointed as a locality clinical lead by the ICO and the CCG. 


Enhancing the capacity and capability of the Integrate Care team in a Health and Well-being Hub in a well-integrated system is showing promising signs of managing more complex patients in the community, with a notional average cost saving of £193 per referral.

However, in other localities the adoption and practice of EIC was influenced structural and behavioural factors that lessened its potential impact.