Case study: Dudley. All Together Better

Dudley is a metropolitan borough to the west of Birmingham. It has a population of 318,000 and in two decades’ time there will be 25,100 more people aged 65 and over, and 9,900 more aged 85 and over. While Dudley itself is relatively affluent, there is disparity in levels of deprivation across the borough with 24% of the population living in areas that are in the 20% most deprived in England.

The Dudley Multispecialty Community Provider (MCP) vanguard – All Together Better – is a new partnership between local NHS and care organisations, general practitioners and the voluntary sector in the borough. The MCP model in Dudley aims to develop a network of integrated, GP-led providers across health and social care, each working at a level of 60,000 people. One of the key areas that will be transformed through the development of a multi-specialty community provider model is end of life care.

The wicked issue for Dudley Multi-specialty Community Provider

When someone comes to the end stages of life the complexity of care required can increase significantly and therefore the potential for multiple organisations to be involved also increases. Coupled with this is the problem that many staff and patients struggle to have conversations about death, making it more difficult to plan for this. Significant costs are incurred in the last two years of an individual’s life, further compounded by the fact that the numbers dying in acute hospitals remains high, despite this often not being a person’s preferred place of death.

Dudley has identified a number of areas that require improvement including:

The Dudley Group NHS Foundation Trust, Dudley Clinical Commissioning Group, Dudley Council and Mary Stevens Hospice are working in partnership to transform the way they care for dying patients and families or carers. To facilitate these improvements, All Together Better is currently developing a new End of Life Care Strategy to support its service transformation.

Brokering constructive conversations

Dudley recognises that communication, involvement and engagement need to be at the heart of the service transformation it is trying to achieve to make it sustainable for the future and responsive to the needs of the Dudley population. It has embarked on a significant programme of communication and engagement regarding the development and implementation of the MCP, involving multiple events with the public, research and online engagement.

Building on five years of work by Dudley Council for Voluntary Service (CVS) in experimenting with new approaches to active citizenship in the borough, the partnership has been testing out innovative ways of involving people in coproducing new ideas for how health and care can be better provided locally. In doing this, it has sought to promote an asset-based approach, which is an approach to service development that seeks to build on people’s natural skills, knowledge and assets, rather than seeing them as people with problems to fix.

Building on this, Dudley has been taking a proactive approach to involving people in constructive conversations about end of life care. This began during Dying Matters Week in 2014 when Dudley convened a Public Healthcare Forum meeting, attended by around 70 members of the public, to have a conversation about how Dudley could help ensure that at the end of life, patients die in the way they want to, where they want to and with the right support and help to make important decisions. This public meeting was followed up in 2015 with an initiative Dudley call ‘Feet on the street’, which is where they approach individuals on the street and try to engage them in a videoed conversation about a range of different health and care issues; this one in particular was about end of life planning.

The CCG has most recently (June 2016) made efforts to engage the public in the development of the new End of Life Care Strategy by holding a workshop to understand peoples’ experiences and perceptions around end of life care in terms of what works well and what could be improved; to help All Together Better take stock of how current services are delivered; and to explore how things could be improved.

Some of the key findings from the workshop included: the need for more recognition of cultural beliefs; families having more of an awareness of what support is available; improved communication between all relevant teams and a person’s family and friends; talking positively to one another; and respecting patients’ end of life wishes and their rights. These point to the importance of having constructive conversations with individuals and their carer and families about advanced care planning.

The learning

The findings from the workshop were fed back by the lead commissioner to the End of Life Strategy Group, to inform the emerging strategy. A group discussion followed. It was based on the findings from the workshop and it was agreed that additional areas should be included in the Implementation Plan including: organ donation; paediatric end of life care; supporting people to die in a care home if that is their preference and normal place of residence; and engaging seldomheard groups. There are plans to hold further conversations with the public as the strategy and implementation plan develops.

Dudley says it is already starting to see the impact of its efforts to transform end of life care. It is reporting an eight per cent drop in the number of people who die in hospital compared to their preferred place of care.

One of the key outcomes the locality hopes to achieve, through continued engagement efforts, is supporting health and care leaders and teams to develop the skills, knowledge and confidence to facilitate the co-production of health and care services.