Our new model of care in Dudley

Multispecialty Community Provider

Our New Model of Care

Dudley is one of 29 areas selected to test a new model of care following the publication of the Five Year Forward View (5YFV) in October 2014 which gives a clear message that the NHS needs to adapt and evolve to meet the challenges that it now faces.


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 NHS it is now recognised that to really meet these challenges we must take a longer view, they are not things that can be fixed overnight.

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

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

  1. Integrated Care – we want patients to be at the centre of their care. Patients registered with GPs in Dudley borough can be supported by a team that is made up of the GP, Community Nurse, Social worker, Mental Health worker and other teams that can help with health and wellbeing. This will be a multi-disciplinary team (MDT).
  2. Planned care – we know that when patients are referred by their GPs for nonemergency care, the experiences differ greatly. We are developing a programme to reduce the level of difference in hospital care, meaning the patient, and us as commissioner, has 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 greater focus on children this year and plan to change the provision of Child and Adolescent Mental Health Services (CAMHs) services to a 0-25 age profile, and develop a network of young health champions to promote health and wellbeing.

The Multispecialty Community Provider model will develop a network of integrated multidisciplinary teams (MDT) consisting of a GP, specialist nurses, social workers, mental health services and voluntary sector link workers.

These teams will be working together for the benefit of their patients, taking shared responsibility with them for delivering better health and wellbeing.


Model high res white background

How will the model work?

Under the new model a patient, for example with frailty & long-term conditions, registered with a GP in Dudley, will have their care overseen by a multi-disciplinary team in the community.

This will ensure a more rounded approach towards care that better meets all of the patient’s medical and social needs at one time in one place.

The links that we are developing with the voluntary sector also help to ensure that they have access to support and care from their local community.

If a patient needs help urgently there is a 24 hour community rapid response service and urgent care centre in Dudley. These provide co-ordinated points of access for urgent support which are clearer and easier to access.

As a result of the health and care system working better together in this way, patients are not only receiving the coordinated support necessary for their health needs but they are also linking to the wider network of care and social interaction in their community to help them to live more independently for longer.

You can watch a short film on how our teams are now working together to wrap care around people by clicking here or you can visit our You Tube Channel (Feet on the Street)




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Patient Opinion