Abstract
Background: Changing Futures Plymouth is 1 of 15 areas that received UK government funding to address multiple disadvantages within the local housing, substance misuse, mental health, criminal justice, and domestic abuse systems. Young people in transition to adult services are particularly vulnerable, and integrated care research is scarce. This is a case study of a co-produced, whole-system, and multidisciplinary partnership across multiple sectors.
Approach: The accountable care system in Plymouth adopted working towards 4 local principles: being trauma-informed, learning-based, an alliance commissioning ethos, and continuous workforce development. Built on these principles, qualitative and quantitative research with 25 services, a clinical audit of 40 casefiles, and appreciative enquiries with 4 young people were conducted by a practitioner researcher in a local youth enquiry charity to understand the current experiences of local people aged 17-25 years transitioning into adult services. This work evolved into a Trusted Professional Approach (TPA), that was then piloted. Peer researchers and embedded researchers-in-residence supported co-production and collective sense-making hosted within a unique academic-practice partnership, the National Institute of Health and Care (NIHR) Health Determinants Research Collaboration (HDRC) Plymouth.
Results: The TPA Pilot, followed 6 live cases of young people experiencing homelessness over 6 months and facilitating 3 real-time learning groups over the final 3 months with multi-agency professionals, materials were developed to support navigating system challenges, better tailor to young people's needs in trauma informed ways and improve the working and workforce resilience of integrated care partnerships. Monthly informal Continuous Professional Development and networking meetings (Transition Matrix) between professionals are ongoing, and the approach is adopted and further developed in other parts of the systems include; 1. Place-based working in Family Hubs. 2. Piloting the TPA within Plymouth Community Homes, the Plymouths largest social housing provider. 3. Presenting research on Transitions into adulthood to 100 staff at the Magistrates Court, dissemination to probation services planned. 4. Wider regional dissemination included the model being endorsed by the county-wide Integrated Care System. 5. Reports welcomed by and shared with Central Government, and led to being part of a mutual mentoring programme with a senior civil servant within Youth Directorate. 6. Bringing the work to academic publication and securing research funding.
Implications: Plymouth has a long history of integrated care practice with the collectively commissioned Plymouth Alliance, an example of a learning health and care system as a mechanism to advance cross-sector partnerships. Context and localised solutions matter, yet remain underreported, especially for underserved, and marginalised young people and third-sector partners. The Trusted Professional Approach is ripe for spread and scale and is a unique example of preventative, proactive approaches to care coordination and continuity between care settings. Innovative investment into academia-practice partnerships that nourish the unique contributions of the third sector and lived experience are crucial to making learning portable. This paper is an excellent example embedding knowledge and evidence to support integrated care in real-time and at all levels of design and delivery.