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Connecting the dots

Connecting the dots
28 July 2015

Dudley is in the process of setting up a multispeciality community provider under the vanguard process

Dudley is in the process of setting up a multispeciality community provider under the vanguard process

Our vision is to put Dudley patients at the heart of properly integrated GP-led health and care services, with a focus on improved health and wellbeing, better outcomes and a more engaged community.
This demands a clinically-led, whole-system transformation of the way we commission health and social care. That aim has fresh impetus and sharper focus following our successful bid for Five Year Forward View’s vanguard status.
We are now moving ahead at pace with our multispecialty community provider (MCP) model. Our model is designed from the patient perspective. Through our consultations with them we have identified four key requirements:

  • Better communication both to patients and between staff.
  • Improved access to consultation and diagnostics.
  • Continuity of care in supporting the management of their long-term condition(s).
  • Effective coordination of care for the frail elderly and those with complex conditions.

To respond to this the focus of our model of care builds on a joined up network of GP-led, community-based multi-disciplinary teams (MDTs) that enable staff from health, social care and the voluntary sector to work better together.
The support for developing and implementing this model as a vanguard is also underpinning our work towards a complementary process – developing standardised best practice pathways of care so that all services provided outside of the MCP are commissioned in a way that incentivises optimum outcomes for the patient, maximises efficiency and enables effective communication back with the GP.
The CCG’s bid brought together our local authority (Dudley Council) and all our borough-based providers (Black Country Partnership NHS Foundation Trust, Dudley Group NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust) as well as Dudley Council for Voluntary Services and our local GP-provider company, Future Proof Health Ltd (see Figure 1 above).

Teams without walls
We are establishing across our borough (population circa 318,000) a joined up network of GP-led, community-based multi-disciplinary teams that enable health, social care and the voluntary sector to work together in “teams without walls” for shared benefits and outcomes.
These teams focus on delivering integrated care aimed particularly at a cohort of patients identified as being most at risk of emergency hospital admission. Practice-based MDTs include the GP, district nurse, assertive case manager, mental health worker, social worker and voluntary sector link worker.
To enable economies of scale these teams need to share resources and cover arrangements across a population of circa 60,000. We have therefore organised the practices and these teams into five localities and lead GPs are in place in each locality to provide overall coordination of the model of care.
All participating providers have restructured their services so that all front-line staff work to the same registered population as the GP practices or, for more specialist services, linking them in to the MDTs. As a result of these changes we are seeing improvement in morale of our staff working across all agencies, because they are working better together. This is having consequential positive benefits on care to our patients. In addition our work with the voluntary sector is helping people connect back into their own communities, which is having a genuinely transformative effect on their lives.

Aligning specialist community services
Phase two of the development of our MCP model expands the mutual network of care to fully incorporate all specialist community services and some aspects of urgent care.
This includes the establishment of a community rapid response service, designed to intervene in a crisis in the patient’s home – reducing the risk of A&E attendance and linking the patient back into their local network of care.
Our primary-care-led urgent care centre (opened earlier this year, co-located at our main provider’s A&E department) acts as a point of triage to help divert patients where appropriate into primary care services.

Community care led retrieval
The final development of our MCP model extends it to include current consultant-led services, which operate to support population health and wellbeing.
This includes specialties that support the management of long-term conditions such as diabetes. Consultants will work in partnership with GPs to the same outcome objectives for improving population health and wellbeing, providing better continuity of care to patients.
Similarly, the integrated MDT, with support from consultant physicians, will become responsible for the whole pathway of care for the frail elderly: from community, into hospital and back into the community – so that there are no longer any transfers of care. Patients will be retrieved back into the community rather than transferred from one team, or one organisation to another, thus ensuring better coordinated care.
What does this mean for our patients?
For many patients, the benefit will be in how the new model works seamlessly behind the scenes. Patients will continue to use the familiar point of access to the NHS – their GP – and it will be for the GP, through the practice based MDT, to ensure that a comprehensive package of care and support is agreed with, and delivered by, staff from partner health, care and voluntary organisations.
This will include not only ‘traditional’ health interventions, but also support to reduce social isolation, improve their life skills and encourage them to be active ‘health citizens’ who use services appropriately, make positive choices
about healthy lifestyles and use their expertise as patients. They will also be able to access better joined up services in each of our five localities.
Those requiring care outside the remit of the MCP will benefit from the consistency, agreed outcomes and whole pathway focus that will characterise the way care is commissioned, no matter who they choose to provide it.

The CCG’s role and contribution
The model we are implementing as a Five Year Forward View vanguard is very much based on a vision developed and refined by the CCG, with significant input from partners and with core elements co-commissioned with the local authority through the Better Care Fund.
We are one of the CCGs to take on full delegation of primary care commissioning with NHS England – another significant strength given the integral nature of primary care to the development and sustainability of our MCP model.
As a clinically led organisation with strong involvement from GPs across the borough, we can be confident that this is a model that has been developed with significant input from the clinicians who will be central to delivering it.
As lead, Dudley CCG can take an overview of how services need to be commissioned, now and in the future, in a holistic and unbiased way taking into account both the clinical need as well as population expectations on what should be provided.
This overview is also useful in working on the enablers of change – including a borough wide estates review, roll out of a single IT system and an overarching workforce plan, which transcends the organisational boundaries of the different agencies and professions in the system.
Ultimately we are creating a fully integrated, population-based organisation that is delivering better person-centred care that is better connected into our local communities.

Dr Jaswant Rathore, clinical executive, NHS Dudley CCG. Chair of the partnership board, which is leading and driving the MCP model development in Dudley. 

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