Neighbourhood Health and Care Stakeholder Forum

The session focused on the emerging Neighbourhood Health priorities being developed across the Black Country and how these align with the work already taking place through the Walsall Together partnership. 

Key Updates 

National Neighbourhood Health Priorities 

Following publication of the national Neighbourhood Health Framework, Integrated Care Boards have been asked to assess progress against ten key components that will support the delivery of neighbourhood health over the next six to eighttee months. These cover: 

• Urgent, rehabilitation and reablement services 
• General practice access 
• Integrated neighbourhood teams 
• Elective care and outpatient transformation 
• Community waiting times 
• Pooled health and care funding 
• Primary and secondary care integration 
• Organisational leadership and accountability 
• Data sharing and digital enablement 
• Integrated Neighbourhood Teams.

Walsall is well positioned to respond to these requirements, with seven established neighbourhood footprints aligned to Primary Care Networks and existing multidisciplinary team arrangements already in place. 

Work is now focused on: 

• Strengthening integrated neighbourhood teams across health, mental health, social care and the voluntary sector. 
• Developing more proactive approaches to care. 
• Using population health and risk stratification tools to identify residents who may benefit from additional support before they reach crisis point. 
• Expanding support beyond the current cohort of residents with the most complex needs. 
• Urgent and Intermediate Care .

The forum heard how neighbourhood health priorities closely align with existing work in Walsall around: 

• Intermediate care 
• Admission avoidance 
• Hospital discharge 
• Urgent community response services 
• Supporting people to remain independent at home for longer. 

Future ambitions include greater integration between services and improved access to coordinated support when people need it most. 

Planned Care and Community Services 

Nationally there is increased focus on: 

• Delivering more care closer to home. 
• Exploring opportunities for some outpatient services to be delivered in community settings. 
• Reducing waits for community services. 
• Improving people's experience while waiting for treatment and support. 

Data and Digital 

Data sharing continues to be recognised as a key enabler of neighbourhood health. Current work includes: 

• Developing shared approaches to identifying residents who may benefit from proactive support. 
• Improving information sharing between organisations. 
• Supporting shared care planning and evaluation of outcomes. 

Discussion Highlights 

• The role of mental health within neighbourhood health models, including plans for 24/7 neighbourhood mental health centres. 
• The important contribution of voluntary, community and social enterprise organisations. 
• Opportunities for wider partners to become involved in neighbourhood health developments and future service design. 
• The distinction between integrated neighbourhood teams and the wider "healthy neighbourhoods" approach, recognising the importance of prevention, community assets and wider determinants of health. 

Please see slides shared at this meeting.

Next Steps 

During September, the partnership will assess local progress against the national neighbourhood health expectations and develop a delivery plan covering the next 6 and 18 months. An update on this work will be shared at a future Stakeholder Forum. 

Update

The session provided an update on national neighbourhood health developments, what these mean for Walsall, and the progress being made locally through the Walsall Together partnership.  

National Neighbourhood Health Update 

The forum highlighted the publication of the Department of Health and Social Care Neighbourhood Health Framework, which sets out the ambition to move towards a neighbourhood-based health service focused on prevention, community-based care and closer integration between health, social care, local authorities and the voluntary sector.   

The framework introduces a range of national expectations and targets, including: 

• More care delivered closer to home and within communities. 

• Improved access to GP services. 

• Reduced reliance on hospital outpatient appointments where appropriate. 

• Reduced unplanned hospital admissions, particularly for people living with frailty and those approaching the end of life. 

• Improved outcomes for people living with long-term conditions. 

• Stronger partnership working across health, care and community organisations.  

What This Means for Walsall 

The updates reinforce the direction already set out within the Walsall Together Strategy and strengthen the importance of working collaboratively across organisations to improve outcomes for local people. 

The forum discussed the growing role of local Health and Wellbeing Boards in shaping neighbourhood health priorities and ensuring services reflect the needs of local communities. There is also a clear emphasis nationally on aligning neighbourhood health with wider public sector reforms and initiatives that support wellbeing, independence and prevention.  

Neighbourhood Health Centres 

National guidance has now been published on Neighbourhood Health Centres, which will act as local hubs bringing together GP services, community services and wider health and care partners to deliver more integrated support closer to home. These centres are expected to serve populations of around 50,000 people. 

In Walsall, seven designated Neighbourhood Health Centres have been identified: 

• Blakenall Village Centre 

• Pelsall Village 

• Anchor Meadow 

• Hatherton Medical Centre 

• Beechdale Health Centre 

• Darlaston Health Centre 

• Keys Family Practice  

Alongside these centres, partners continue to explore opportunities to make greater use of trusted community venues to deliver services in ways that are accessible and familiar to local communities. 

Developing Integrated Neighbourhood Teams 

The forum provided an overview of the emerging model for Integrated Neighbourhood Teams (INTs). 

The aim is to move beyond traditional multidisciplinary meetings and develop stronger day-to-day collaboration between professionals working across community health, mental health, general practice and social care. This approach will support more proactive care for people who may be at risk of developing increasing health and care needs. 

The wider neighbourhood model will also recognise and connect with the many organisations, services and community groups already supporting residents across Walsall, including voluntary and community sector organisations, pharmacies, community groups and other local networks. 

A key principle is reducing unnecessary hand-offs between services and enabling more joined-up support through stronger relationships and improved communication between professionals. 

Future of the National Programme 

Walsall continues to be one of the 43 national Neighbourhood Health Implementation Programme sites. While the national programme is expected to continue in the short term, neighbourhood health is now moving beyond a pilot approach and becoming a core expectation for all areas of the country. This is expected to further increase the pace and scale of implementation over the coming years. 

Discussion Highlights 

The discussion session focused on several key areas: 

• Opportunities to strengthen support for people approaching the end of life, helping more people receive care in their preferred place and reducing avoidable hospital admissions. 

• The importance of intermediate care, admission avoidance and supporting people before they reach crisis point. 

• The role of physical activity, social prescribing, creative health and community-based support in prevention and wellbeing. 

• Ensuring voluntary and community organisations can connect into neighbourhood health developments and share the support they already provide. 

• Opportunities to make better use of neighbourhood health centres and community locations for services supporting children, young people and families. 

A strong theme throughout the discussion was the value of building on the excellent neighbourhood-based work that already exists across Walsall and ensuring local services, community organisations and residents are connected as part of a shared approach. 

Next Steps 

Slides from the session will be shared alongside this summary. Partners are encouraged to continue feeding in ideas, opportunities and examples of neighbourhood-based working. Further updates will be provided at future Stakeholder Forum meetings. 

For any questions or to get involved, please contact the Neighbourhood Health team via wht.walsall.together@nhs.net  

Focus on Digital  

National and Local Programme Updates 

The programme is continuing nationally, with Walsall remaining a key site.  

Recent national updates include:  

• The Neighbourhood Health Framework (published March)  

• Guidance on Neighbourhood Health Centres  

These emphasise shifting care into communities, improving coordination, and targeting local population needs. 

Strategic Direction for Digital (10-Year Plan) 

NHS focus includes three key shifts:  

• Hospital → community care 
• Treatment → prevention 
• Analogue → digital (major focus here) 

Two major national digital priorities:  

• NHS App expansion (citizen access to services and records) 
• Federated Data Platform (bringing data together for better decisions) 

Current Challenges in the System 

• Fragmented systems and limited data sharing 
• Manual processes still common 
• Reactive care model rather than proactive/preventative 
• Digital maturity varies across services 

Walsall Digital Strategy – Six Key Pillars 

Here are the six digital priorities for Neighbourhood health: 

1. Shared Care and Information Flow – Ensuring health and care professionals can access and share the right patient information seamlessly across organisations. 
2. Technology Enabled Care (TEC) – Using digital tools and remote monitoring to support people to stay independent and receive care at home. 
3. Digital Inclusion – Making sure everyone (patients and workforce) can access, understand and benefit from digital services, with choice maintained. 
4. Population Health and Intelligence – Using data and analytics to understand populations, identify needs, and improve outcomes through proactive care. 
5. Innovation and Automation – Adopting new technologies and automating processes to improve efficiency and transform how care is delivered. 
6. Interoperability (System Alignment) – Ensuring different IT systems can work together and share data effectively across the whole system. 

Please see attached slides for what have we got, what are we doing and what are the challenges in relation to the six priorities.  

Data Sharing Focus 

Work is underway to clearly define what data can be shared, who is allowed to access it, and the rules for doing so. This is being built around strong principles like protecting patient privacy, making sure people have given consent, and ensuring all data is handled legally and securely. The plan is to introduce this in stages, working across different partner organisations so everyone is aligned. 

Recent Progress 

Walsall has been chosen as one of eight national areas to lead on digital and data improvements, which brings extra support and opportunities to test new approaches. Several pilot projects are already in progress, including tools to help identify patients who may need care earlier, better use of GP data to group patients by need, and technology that can capture clinical notes through voice during appointments. In addition, data dashboards and tools to track patient groups are continuing to improve, helping teams make more informed decisions. 

Update

Refresher on Neighbourhood Health Model 

Aimed at creating healthier communities, enabling people to live independent, active lives for longer. 

Focuses on:  

• Coordinated multi‑disciplinary support
• Reducing siloed referrals 
• “Team of teams” approach across health, social care, voluntary sector 
• Care delivered through conversations, not referrals.

Neighbourhood Structure 

• Seven Neighbourhood teams across four localities (North, South x 2, East x 2, West x 2). 
• Aligns with existing footprints for social care, community services, family hubs, and VCSE organisations. 

National Programme Expectations

Background 

• Walsall selected in September 2025 as a demonstrator site for the national implementation of Neighbourhood health 
• Programme aligns with government priorities:  
  • Shift from hospital to community 
  • Shift from treatment to prevention 
  • Shift from analog to digital.

There are three main areas of focus as a result of the National Neighbourhood Health Implementation Programme 

1. Local Delivery 

• Establishing Neighbourhood teams around priority cohorts (frailty, LTCs, high‑frequency service users) 
• Improving primary care access (modern general practice models) 
• Reducing bureaucracy between primary and secondary care 
• Coordinating urgent community responses 
• Modernising outpatient models. 

2. Baseline and Assessment Across All 43 Places 

• Honest assessment of progress 
• Identifying barriers requiring regional/national support 
• Developing a Neighbourhood Action Plan.

3. Influencing National Policy 

• Sharing learning from Walsall’s implementation 
• Helping shape national direction for community‑based care. 

Key Messages

• The programme builds on existing strong Neighbourhood working in Walsall rather than creating something new from scratch. 
• Keeping the approach simple and resident‑focused is essential. 

Progress Updates Across Workstreams 

Operations 

• Emerging principles – care by conversation, teams of teams 
• Developing an operating model to support the shift to day‑to‑day multidisciplinary working for community health services, community mental health, adult social care and general practice, to support individuals who need coordinated, cross‑organisational care as business‑as‑usual 
• Each Neighbourhood Team is building new models of support for identified cohorts. 

Estates 

• No national definition of a health hub – local work focused on aligning estates planning and making use of shared spaces e.g. Neighbourhood Hubs, Community Diagnostic Centres, and Family Hubs 
• Planning needs to consider wider developments and digital/tech infrastructure 
• A “teams of teams” model may involve multiple nearby buildings working together.

Commissioning and Funding 

• Strand focuses on developing a neighbourhood health and care plan, while awaiting national and ICB guidance on future commissioning 
• Despite uncertainties, work in Walsall remains unchanged, building on existing foundations, not starting anew. 

Data and Digital 

• NNHIP measurement guide and metrics embedded in delivery plan – complementary to the outcomes framework 
• Expression Of Interest submitted and successful – one of eight sites nationally to design a digital roadmap to support neighbourhood health (stakeholder forum in March) 
• Risk stratification work ongoing – testing available tools (currently health data).

Citizen Voice 

• Citizen Voice strand established 
• Targeted engagement capacity recruited to gain insights from marginalised and seldom heard groups 
• Insights informing design of future models.

Communications 

• Partnership comms group active 
• Clear internal and public‑facing materials in development 
• Stakeholder forum strengthening engagement. 

Questions, Offers and Discussion Highlights 

Training Needs 

• Training Hub interested in supporting workforce development as Neighbourhood MDT working grows. 
• Public Health highlighted availability of free prevention-focused training for all frontline workers. 

Data 

• Data for the national programme largely comes from GP systems, using risk stratification and national coding requirements. 
• National Section 251 approval will support data sharing. 

Community and Activity 

Questions raised about designing Neighbourhood Health Hubs as trusted community spaces to promote activity and reduce inactivity. 

• Strong emphasis on integrating hubs with:  
  • Social prescribing 
  • Active Black Country 
  • Community assets.
• Story shared about “Margaret”, who recently attended the Feel Good Friday clinic in North neighbourhood, demonstrating how community-based clinic locations improve social participation and health. 

Funding Opportunity 

Crowdfund Walsall announced grants for community groups to deliver health, wellbeing and activity sessions. 

View slides shown at meeting.

Next Steps 

Next forum focus on: Digital development and Walsall’s role in designing the national digital roadmap.

Update

Session aimed to update partners on: 

• Progress of Neighbourhood Health and Care development in Walsall 
• The National Neighbourhood Health Implementation Programme (NNHIP) 
• Local neighbourhood models, with a spotlight on the North Walsall pilot.

National Context 

Following a change of government, NHS priorities shifted towards: 

• Analogue to digital 
• Treatment to prevention 
• Acute to community (left shift).

Walsall is one of 43 national pioneer sites in the NNHIP, focused on implementation, not just development. Participation gives early access to national policy direction but requires faster local delivery and measurable impact. 

What is Neighbourhood Health? 

Based on NHS England guidance (Feb 2025): 

• Focuses on healthy, independent living across all ages 
• Puts people at the centre, reducing fragmented (“siloed”) services.
• Emphasises: 
  • Integrated, multi-professional teams 
  • People telling their story once 
  • Planned and urgent care delivered close to home 
• Includes future development of Neighbourhood Health Centres/Hubs 
• Aligns with existing initiatives such as mental health centres, women’s hubs, and family hubs. 

Core Components  

• Population health management using neighbourhood-level data 
• Modern General Practice standards 
• Standardised community health services 
• Neighbourhood MDTs 
• Integrated intermediate care with a Home First approach (already established in Walsall) 
• Urgent neighbourhood services to prevent unnecessary hospital admissions. 

Why This Matters 

• Care coordinated around the individual, not services 
• Improved information sharing across health and social care 
• Earlier intervention and prevention 
• Stronger relationships between professionals within neighbourhood teams 
• A “team of teams” approach across acute, community, social care and voluntary sectors.

Neighbourhood Structure 

Walsall organised into seven neighbourhoods: 

• North (1) 
• East (2) 
• South (2) 
• West (2) 

Neighbourhood footprints reflect areas familiar to local residents and support workforce planning. 

Focus Area: Frailty and Falls 

Frailty identified as a key long-term condition 

Approach includes: 

• Risk stratification 
• Proactive assessments 
• Promotion of healthy ageing, independence, exercise, and social connection. 

North Walsall Pilot – Feel Good Friday Clinic 

Launched October, based on the Deep End / Jean Bishop model and locacated at Stan Ball Centre, Bloxwich. 

Weekly multi-agency clinic including: 

• GPs, community nurses, social care, OTs, social prescribers 
• Strong links to secondary care and urgent response services 
• Widely praised locally and nationally. 

Impact so far: 

• Average age: 86 
• 30% with high frailty risk; 41% at high fracture risk 
• 53% had medication stopped; 65% had medication changes 
• 52% referred for home hazard assessments or adaptations 
• Four hospital admissions avoided 
• Improved access to care navigation via “golden ticket” 
• Increased social connection and wellbeing 
• Very positive feedback from service users and staff 
• Plans to continue funding and expand borough-wide. 

National Programme Update (NNHIP) 

National Director (Dr Minal Bakhai) visiting Walsall (Friday 23 January). Visit includes Feel Good Friday clinic and Hatherton Medical Centre the largest GMS practice in the country.  

Other neighbourhood progress: 

• West MDTs operational (frailty and complex adults) 
• South focusing on high-intensity service users 
• East piloting “Live Well” model with domiciliary providers.

New national measurement framework introduced: 

• Pioneer sites must evidence impact 
• Benchmarking across sites. 

Ongoing work on: 

• Risk stratification approaches 
• Asset mapping and estates work for future neighbourhood health hubs 
• Development of a Neighbourhood Health & Care Plan (to be approved by the Health & Wellbeing Board by March).

View slides shown at the meeting.

As part of the neighbourhood health approach, a wide range of community-based centres are already delivering prevention, early intervention and wellbeing support across Walsall. During the meeting we heard from some of our community representatives around how they contribute to integrated, person-centred care within local neighbourhoods.

 

INA Community Hub – St Matthew’s Ward, Walsall 

Runs Friday Women’s Wellbeing Clinics (started 2023, Core20PLUS funded initially). 

Focus areas: 

• Obesity, diabetes, heart conditions 
• Menopause support
• Mental health and talking therapies. 

Offers 30–60 minute appointments, improving access compared to GP waits. 

Led by an experienced NHS diabetes nurse (part-time, 20+ years’ experience). 

Provides: 

• Blood checks and health reviews 
• Medication and lifestyle advice 
• Early intervention (e.g. diabetes reversal for borderline cases). 

Strong signposting: 

• Internally within NHS (GPs, podiatry, cancer services) 
• Externally to local authority, public health, and third-sector partners. 

Supports women of all ages (up to 86+), with a strong focus on minority and disadvantaged communities. 

Complements clinical care with prevention activities: 

• Strength and balance sessions 
• Walking groups, cycling (seasonal) 
• Community gardening and green-space activities. 

Tackles loneliness and isolation through: 

• Intergenerational activities 
• Social connections and trips. 

Acts as a connector to wider borough activities rather than keeping people solely within the hub. 

 

Brownhills Women’s Health Hub 

Focuses on menopause and women’s health awareness. 

Activities include: 

• Community consultation on menopause experiences 
• Health education events (bladder, bowel, menopause impacts). 

Outputs: 

• Development of a theatre play based on women’s lived experiences 
• Distribution of menopause-related products to school nurses and community organisations. 

Supported by Walsall Together. 

Aims to reduce stigma and improve self-management and awareness. 

 

Walsall Community Network Centres (including Warm Walsall sites) 

Provide warm spaces and winter support. 

Run friendship groups addressing: 

• Loneliness and isolation 
• Mental wellbeing.

Deliver health awareness sessions on: 

• Cancer 
• Diabetes 
• Long-term conditions. 

Act as trusted community access points where residents: 

• Learn where to go for help 
• Are guided to appropriate services. 

Play a key role in early prevention and awareness raising. 

 

Active Black Country (Linked Support) 

Works alongside community and health services to: 

• Embed physical activity into health pathways 
• Support prevention and healthy ageing. 

Collaborates with hubs like INA to align exercise, strength, balance, and wellbeing initiatives. 

 

Purpose of the Forum 

This was the first Stakeholder Forum focused on Neighbourhood Health and Care in Walsall. The forum was established due to high local and national interest, particularly as Walsall is one of 43 areas in the National Neighbourhood Health Implementation Programme. The aim is to provide regular updates, share progress, and gather feedback from a wider group of stakeholders. 

Future sessions will include: 

• Short update presentations 
• Q&A 
• Opportunities to shape future topics and communication methods.

Overview of Walsall Together 

Walsall Together is a health and wellbeing partnership focused on improving outcomes for residents through integrated services. 

The model places communities at the centre, with: 

• Prevention, wellbeing, voluntary sector, and public health services 
• Neighbourhood and locality teams as the main point of contact with statutory services (e.g. GP practices, community health, adult social care) 
• Borough-level intermediate, urgent, and crisis care 
• Family hubs form part of the neighbourhood offer for children, young people, and families. 

Measuring Impact – Wellbeing Outcomes Framework 

The partnership uses the Walsall Wellbeing Outcomes Framework, co-designed with stakeholders and residents. It includes nine fundamentals of wellbeing, aligned with wider determinants of health (e.g. Marmot principles), expressed as resident-led “I” statements. 

The framework recognises: 

• Areas within direct influence (e.g. health) 
• Areas requiring partnership influence (e.g. housing, transport) 
• Building connections and relationships is a key but harder-to-measure outcome.

National Neighbourhood Health Context 

• NHS England published Neighbourhood Health guidance (February). 
• The national model includes six components, all already aligned with the Walsall Together strategy: 
  • Population health management and risk stratification 
  • Modern general practice and access 
  • Standardised community health services and commissioning
  • Multidisciplinary neighbourhood teams
  • Integrated intermediate care
  • Urgent neighbourhood services 

• Walsall’s approach is driven by local belief and experience, not just national policy: 

  • MDT working improves personalised, holistic care 
  • Prevents unnecessary hospital admissions 
  • Improves staff experience 
  • Makes better use of resources 

Neighbourhood Model in Walsall 

Seven neighbourhood teams, fully aligned to Primary Care Network (PCN) boundaries, across four localities: 

• North: one PCN / one team 
• East, South, West: two PCNs / two teams each. 

Neighbourhood teams aim to: 

• Provide coordinated, holistic support 
• Empower people to manage their health 
• Address health inequalities 
• Focus on early intervention and prevention.

Borough-level services (e.g. intermediate and crisis care) link closely with neighbourhood teams. 

Current Focus and Progress 

Initial programme focus: Adults with multiple long-term conditions. Rationale: shift activity and resources from hospital to community care to enable investment in earlier intervention and prevention. 

Progress to date: 

• Outcomes framework with measurable metrics nearing final sign-off 
• Monthly meetings in place for all neighbourhood teams 
• Five of seven teams have formally agreed an initial population cohort (all seven expected by end of January) 
• Ongoing testing of risk stratification tools and development of a borough-wide population health management approach 
• Data sharing agreements progressing 
• Early work underway to develop a scaled MDT operating model (beyond small weekly MDT meetings).

Digital and Future Development 

Strong focus on aligning digital strategies to support shared care planning and MDT working. 

Short-term aim: ensure digital investments support integrated teams. 

Beyond this financial year: 

• Greater emphasis on prevention and early intervention 
• Expansion of partners involved, including: 
• Voluntary sector 
• Pharmacy (including community pharmacy) 
• Other potential partners yet to be identified.

View slides shown at meeting.

Q&As / Comments 

Q1: “There was a National Audit Office report out last week about the health dangers and the impact of early intervention for people living in cold, damp homes. We do energy awareness and home visits. We look at the home as a whole and give energy saving advice and climate advice, and we help people with cold homes. 

We can refer people into other organisations that can provide energy saving devices for free, but we need you guys to be able to refer into us so we can do this. 

97% of children that live in a cold, damp home fail to achieve in schools, and those go on to become the needs of tomorrow. A 1% drop in temperature below 5 degrees increases GP consultations for respiratory illness in older people by 20%, which then leads to bed blocking, mental health issues, everything. 

We can help with these early interventions, but we need you to know that we exist and to use our service.” 

Response:  “I’m more than happy to have a follow-up call so that we can make the connection to the teams themselves and make sure that they have that awareness. I think it should be quite an easy fix.” 

Q2: “Family Hubs are keen to learn more around the plan for neighbourhood assets in communities and how we could work together with Family Hubs in those key areas, and the opportunity to deliver more 0–5 support.” 

Response: “In parallel to the adults offer, we also need to think about how we connect a really robust children and young people’s offer. 

The Family Hubs offer in Walsall is absolutely fantastic and has already delivered huge improvements in outcomes for children and families. The opportunity to connect that now to neighbourhood teams and the national focus around neighbourhood health is really there for Walsall. 

Nationally, there’s recognition of the need to align neighbourhood health with Best Start in Life and Family Hubs work. I’ve already started talking to some neighbourhood teams about who might be interested in piloting some approaches alongside children’s services and Family Hubs. 

We’ve also had workshops in all four localities looking at social prescribing and aligning the offer for children and families with neighbourhood teams. There’s been really good learning from those, particularly around neighbourhood priorities. We do need to follow up and agree how we take that forward, but I’m hopeful we can identify a couple of areas for targeted work for children and young people.” 

Reflections from the Partnership (Patrick Vernon – Independent Chair of Walsall Together) 

 “This is a good moment for us as a partnership. We’ve been working for several years to bring together the NHS, local government and the third sector in a powerful way to improve health and life chances in Walsall. 

We’ve now been given this opportunity, endorsed by government, which is fantastic. We need to build on our collective spirit and energy. If you’re wondering ‘should I be here?’ the answer is yes. 

If there are organisations you think should be part of this conversation, please let the team know. We want an inclusive approach to neighbourhood health. Issues like fuel poverty and housing absolutely matter, and we recognise that. 

This is everyday business for all of us. Thank you for being part of this social movement to improve health and wellbeing in Walsall, and please bring others into the conversation.”