Dudley vanguard does away with walls

4 March 2016

Dudley’s new ”teams without walls” based in GP practices are setting about the transformation of care for people with long term conditions and the frail elderly.

Initially the multi-disciplinary teams, each led by a nominated GP in each locality, are focussing on the 2% of the population most likely to require an emergency hospital admission or readmission. With each team serving a population of around 60,000, the professionals are overseeing the care and support of around 1200 patients. Community and primary care health professionals are working alongside social care managers and voluntary sector link workers to improve prevention and provide support to these patients in their own homes. The teams are the central plank of the Dudley multispecialty community provider vanguard.

As part of the holistic approach the teams are taking, the third sector role includes helping vulnerable people develop new relationships and networks to reduce social isolation – including via referrals to an Age Concern befriending service or arranging patient support from charities such as Diabetes UK.

“The third sector coordinators are very much involved in long term conditions planning and reviews for patients.” says one of the lead GPs, Dr Tim Horsburgh.

The integrated teams will ultimately be responsible for the whole patient pathway for those groups. Such patients leaving hospital will be “retrieved” into the community by the multi-disciplinary team (MDT), supported by consultant physicians, rather than transferred from one team or organisation to another. This reflects the vanguard’s key aim to streamline and simplify patient pathways.

Horsburgh says: “We’ve been able to get providers contributing staff to the MDT with sign-up at chief executive and chair level because they can see the benefit of having long-term care planning processes. The providers are assured by us having all the GP practices involved and bringing in the community and voluntary sectors has added an extra dimension.”

The vanguard is already working on developing a single GP record across the system and new technologies to improve access and the continuity and coordination of care.

Before reaching that final phase, all specialist community services and some urgent care will be wrapped into the new way of working. Practical steps to reach that stage include a community rapid response service to treat and assess people in their own home during an emergency – reducing A&E attendance and providing some continuity of care for the patient by linking them and their carers to their local network of care. The CCG has also worked with the acute provider to develop a primary care-led urgent care centre next to the A&E that triages patients, diverting a number into primary care.

The vanguard design followed consultation with patients and carers which highlighted four key issues. They were:

  • Better communication, both with patients and between staff
  • Better access to consultants and diagnostics
  • Continuity of care in supporting the management of long term conditions
  • Effective coordination of care for the frail elderly and those with long term conditions.

The new working arrangements are not yet reflected in any contractual changes with providers but Horsburgh says the CCG is “waiting with interest for the national contract on long term conditions”. The CCG has been able to reshape the Quality and Outcomes Framework (QOF) to reflect the new emphasis on coordinated and planned care for people with LTCs.

“Our long term conditions framework rationalises the QOF system so it reflects the vanguard’s aim of moving the management of those patients out of the expensive acute sector to general practice and the community while also addressing the workload issues in general practice.”

The CCG’s expanded commissioning role also means it can develop coherent estates and workforce strategies that complement the drive to provide more care at scale in the community.
It is expected that as the new model beds in and develops, hospital consultants – particularly gerontologists, paediatricians and specialists in cardiology and rheumatology – will spend more time in practices. Horsburgh says their presence will ideally extend beyond practice-based outpatient clinics.

“We would like the consultants to be at the joint MDT meetings with the GPs. That can be an education opportunity as well as developing relationships between consultants and GPs which have been lost over recent years.” These learning and relationship-building opportunities are not confined to the medics, Horsburgh explains.

“Resources have got to come through the vanguard programme but we have got the teams, have shared learning together and we are now looking at a programme for joining education and training. There has been positive feedback from community nurses, district nurses, [community psychiatric nurses] and social workers all working round the table together and developing relationships. That gives a sense of purpose.”

This story appeared in the March issue of Commissioning Excellence.

Article Type
Case Studies
Topics & resources General Practice

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