Our Plans for the Future

Developing a New Model of Care in Dudley

Dudley is one of the areas selected to test a new model of care following the publication of the Five Year Forward View (5YFV), which gives a clear message that the NHS needs to adapt and evolve to meet the challenges that it now faces. Dudley Clinical Commissioning Group is working with partners in Health (The Dudley Group NHS Foundation Trust, Dudley & Walsall Mental Health Partnership Trust, Black Country Partnerships NHS Trust) Social Care (Dudley Council) and the voluntary sector (Dudley Council for Voluntary Services) to develop a new care model.

Challenges

The challenges set out nationally can be summarised as people living longer, with more complex health issues and these are no different in Dudley.

  • 1 in 5 people in Dudley have a limiting long term illness
  • A quarter of early deaths (40-59 age band) are due to smoking, obesity, cardiovascular disease and lack of physical activity
  • In two decades time there will be 25,100 more people aged 65+ and 9,900 more aged 85+
  • 20% of single person households are in 60+ age group


Across the health and care organisations, it is now recognised that to really meet these challenges we must look beyond the short term and work together to make the changes required.

We need to work together to find new ways of thinking and doing to make the difference that we have not been able to make to date.

Opportunities

Our new model of care is called a ‘Multispecialty Community Provider’ (MCP) and to tackle these problems locally we have focused on 3 main areas:

  1. Integrated Care – we want people to be at the centre of their care. People registered with a GP in Dudley borough can be supported by a multi-disciplinary team that is made up of the GP, Community Nurse, Social Worker, Mental Health Worker, voluntary sector Link Worker and other teams who can help with health and wellbeing. This is what we describe as the multi-disciplinary team (MDT) and it is further supported by the wider mutual network of care in our Multi-specialty Community Provider (MCP).
  2. Planned Care – We will support people to remain at home wherever possible by developing best practice pathways of care. We know that when people are referred by their GPs for non- emergency care, the experiences differ greatly. We are developing a programme to reduce the level of difference in hospital care, meaning the people have more certainty about the treatment they will receive.
  3. Urgent care – Building on the successful implementation of the Urgent Care Centre at Russells Hall Hospital and improving interventions with the frail elderly to limit the need for emergency admissions into hospital.

We will also have a focus on primary medical services (GP services) with a new outcomes framework for people with long term conditions to ensure continuity of person centred care, improved access and to facilitate GP led coordination of care.

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