Walsall Together shortlisted for two HSJ Digital Awards

Frailty and Falls - Feel Good Friday Clinic

The Feel Good Friday Clinics were developed to proactively support older people living with frailty through early, holistic intervention, improving outcomes and independence while reducing avoidable emergency department attendances, pressure on intermediate care, and longer-term care costs.

The clinics launched on 17 October 2025 as a 12-week pilot in the North Locality. To date, seven clinics have been delivered, supporting 24 participants who meet defined frailty referral criteria. Delivered at the Stan Ball Centre, the clinics bring together a multidisciplinary health and social care team to undertake Comprehensive Geriatric Assessments and co-produce personalised care plans. Early feedback from service users and carers has been consistently positive, with people reporting improved confidence, better access to support, and highly valued social connection.

The pilot will conclude in January 2026, after which a full evaluation will assess impact and outcomes and inform decisions on potential expansion to additional localities. Subject to the findings, governance approvals will be progressed in February and March to enable a seamless transition from April, supported by business case development.

Delivery is led by a core multidisciplinary team including a GP, Pharmacist, Occupational Therapist, Community Frailty Nurses, and Social Prescribers, with physiotherapy recruitment underway to strengthen falls and mobility assessment. Community partners play a key role in engagement and social connection, with strategic oversight provided through the Falls and Frailty Steering Group.

Through earlier identification and proactive management of frailty we hope to is enable more older people to remain independent for longer, reducing avoidable emergency attendances and admissions, easing pressure on intermediate care services, and delivering better outcomes within a sustainable care model.

Insights:

• Pre/Post clinic surveys

• Face to face conversations with patients, families/carers and staff

• Follow up conversations aligned to the Walsall Well-Being Outcomes Framework

Here is what we have heard from staff, service users and family/carers:

“It is a wonderful service and very good” 

“Whole experience very good.  It is the first time we have been able to sit with anyone and explain any difficulties instead of waiting a month for a GP appointment” 

“The clinics were very good. Mom was able to get a prescription for better pain killers”

“This is true MDT working”

Case Study: Margaret Edwards, 86

When Margaret, 86, was invited to attend the Feel Good Friday Clinic, she felt unsure, saying she “didn’t know what to expect.” Having stopped driving, her opportunities to go out had become limited and life was beginning to feel like “looking at four walls.”

During her visit, she spoke with Ellen, the social prescriber, about transport options. With this support, she contacted Ring & Ride, enabling her to attend the Stan Ball Centre more regularly. She also shared her excitement about an upcoming Christmas coach trip to Cornwall.

That day, a Christmas party was taking place in the Bistro at the Centre. Although Margaret had arranged a taxi home, she asked if she could stay when she heard the singer performing. A staff nurse liaised with Centre staff so she could join the celebration.

Margaret left feeling happy, included, and socially connected. She later told a friend about the clinic, who was also keen to attend. Her story highlights how listening, flexible support, and accessible activities can make a meaningful difference to wellbeing.

Margaret’s visit shows how social support and accessible activities can reduce isolation. Attending the clinic and Centre activities helped her reconnect socially and move beyond feeling like she was “looking at four walls,” highlighting the value of flexible support and transport in improving wellbeing.

 

 

Neighbourhood Teams

Neighbourhood Teams (NTs) are multidisciplinary teams (MDT) that can share information and support people jointly to provide personalised and holistic care to prevent people from needing urgent/crisis support.  They aim to: empower individuals to manage their own health address health inequalities by making care more accessible focus on early intervention and prevention reduce pressure on current health and care services In Walsall, seven NTs have formed around Primary Care Network (PCN) boundaries with five out of seven have agreed an initial cohort for management through formal weekly MDT meetings. The North NT has established the Feel Good Friday clinics (as referenced above). West 1 and West 2 have an active MDT meeting. South 2 are looking at high intensity users. East 2 and South 2 have agreed to support the adult social care 'Live Well' pilot. The service specifications for the Live Well pilot have been finalised and put out to tender. There is a weighting towards quality over cost, including that providers must have a CQC rating of good or higher. Discussions have progressed with regards to delegation of healthcare tasks to care providers. Colleagues in Walsall Healthcare NHS Trust community are supporting with the identification of appropriate tasks, competency frameworks and training for the providers, as well as escalation pathways into community services when appropriate. In other news, a range of risk stratification tools are currently being trailed and evaluated. A Section 251 data sharing agreement is in progress across the Black Country. We also have a range of pilot solutions for shared care planning and Technology Enabled Care. We held the first stakeholder forum in December, which was very well attended. Q&As were recorded with copies available on request. Future sessions will take place monthly, bookable via Eventbrite, with the next one on 21 January at 3pm. The partnership has approved a small funding pot, from within its existing allocation, to support involvement and engagement. Recruitment of a Community Advisor, to act as the strategic lead for citizen voice for neighbourhood health and care, is in progress. The individual will have a specific focus on bringing the voice of those furthest away from services. Finally, the focus for January to March will include establishment of a dedicated operational group to produce a design blueprint for day-to-day integrated working across community services, community mental health, general practice and social care, to support around 10% of the local population, who are estimated to be able to benefit from multi-professional teams.

Intermediate Care

A review of Intermediate Care is taking place to ensure the service delivers timely, person-centred care that promotes rapid recovery, minimises avoidable hospital admissions, and achieves the best outcomes in a financially sustainable way through an effective, skilled multidisciplinary workforce.

In September, non-recurrent workforce funding was approved to test the model outlined in the investment case, and early results show a positive impact. Pathway 1 service users receiving therapy within 72 hours post-discharge had a 7-day shorter length of stay and fewer care calls, with some able to exit at the 72-hour review, avoiding unnecessary stays and reducing dependency. The home pathway also saw a 3.73-day reduction in length of stay, and these improvements are contributing to overall budget savings.

Due to the success of the non-recurrent investment, this funding is now being made recurrent, and the data will continue to be monitored to inform workforce requirements and future service improvements. The next phase of the Intermediate Care review will evaluate the Swan House pilot and develop a business case for a dedicated rehab unit, enabling faster functional recovery so people can return to their home sooner and with greater independence. Recruitment across Health and Social Care is essential to ensure a skilled, multidisciplinary workforce is in place to deliver the required outcomes.

This will enable more people to recover faster and return home sooner with greater independence, reducing avoidable hospital stays, lowering ongoing care needs, and delivering better outcomes within a sustainable financial model.

Modern General Practice

Modern General Practice is focussed on improving access to GP services. It is a core component of neighbourhood health, so whilst it remains an ICB/GP responsibility, we are now starting to report it through the partnership.

Overall compliance with GP access requirements is high across Walsall.92% (45 of 49 practices) are compliant with same-day online consultation response standards, while 84% (41 of 49 practices) are compliant with maintaining all three access routes during core hours.Non-compliance is limited to a small number of practices and is primarily linked to workforce and operational capacity pressures.

Targeted support and ongoing monitoring are in place, providing assurance that improvement actions are being actively managed.

Family Hubs

Family Hubs are part of a national programme supported by the

Department for Education and Department of Health and Social Care, running from 2022 to 2028. They focus on six key areas of action outlined in the Best Start in Life vision of 2021. They provide a wide range of social, health, and mental health services in a single, accessible facility targeting uptake in areas facing inequality or barriers to access.

Looking ahead to 2026–2029, a key target for Walsall is achieving a Good Level of Development (GLD) for all five-year-olds, ensuring that at least 74.7% of children in Walsall reach this level by the end of the 2027/28 academic year, with disadvantaged children benefiting equally.

Families are supported through a coherent, joined-up Start for Life offer, including midwifery, health visiting, mental health support, infant feeding advice, safeguarding, and special Educational Needs and Disabilities services. Family hubs provide welcoming spaces for families to access these services physically, virtually, and through outreach, while digital and telephone offers ensure families can get information when they need it.

Complex Care

Adults with a learning disability die around 10 years earlier than the general population, with even poorer outcomes for people from minority ethnic groups. Cancer is one of the leading causes of death. There is a clear opportunity to improve bowel cancer prevention and screening in this population, helping to increase healthy life expectancy and reduce avoidable hospital admissions.

Improving bowel health for people with a learning disability requires action across several areas. These include universal health behaviours such as diet and physical activity; awareness and understanding of bowel health among people with a learning disability and their carers; and how health services communicate with, identify, screen, and treat people with a learning disability.

The partnership is scoping current practice around health checks in primary care, establishing the local and national data and evidence base, and seeking the views and experiences of people with a learning disability.

Wellbeing Networks

The Walsall Together model of health, care and wellbeing includes communities at its heart. As we develop our integrated neighbourhood teams, the partnership is keen to ensure we give sufficient focus to preventative and wellbeing services and support. Voluntary, Community, Faith, Social Enterprise and social housing providers support the wellbeing of the population by addressing the social determinants of health, the non-medical and economic factors such as loneliness, education and employment.

Wellbeing networks operate alongside neighbourhood teams and family hubs, connecting health, social care, and community services, and bringing together existing offers such as physical activity, healthy eating, creative health, and support for frail older people into a coordinated system that meets the needs of each neighbourhood.

Delivery relies on collaboration across statutory services, voluntary organisations, neighbourhood teams, and social prescribers, ensuring local ownership and reach while connecting people to the services they need.

In other news...

Five-year Food Plan: Walsall has unveiled a five-year plan driven by an ambitious vision to create a fairer, healthier and more sustainable food system across the borough. The aspirations around food will link well with emerging approaches to neighbourhood health and wider NHS provisions. For more information contact helen.billings@nhs.net

Physical Activity Strategy for Walsall: A new framework has launched, setting out a cross-sector approach to create more opportunities for residents to make physical activity a natural part of everyday life. The strategy aims to support healthier, happier, and more resilient communities.

The partnership, led by Active Black Country and Public Health, is now in the early stages of mobilisation. The approaches will be inclusive and go well beyond traditional ‘sports’ activities. Early priorities are closely aligned with Walsall Together and our emerging approach to neighbourhood working.

Creative Health: Creative health in Walsall is continuing to develop with an event being planned for late January/early February to mobilise further. In the meantime there are several new initiatives improving health and wellbeing. Walsall’s primary school children are taking part in an exciting creative health project for Children’s Mental Health Week. ‘Harmony’ is a fun 25-minute interactive video created in partnership with Walsall’s Music Education Team and Public Health to raise mental health awareness through music and connection. This offers simple wellbeing advice alongside engaging information on the 8 steps to wellbeing, breathing exercises, songs and a lively karaoke session.

Delivering neighbourhood health. How do you make the best use of your estate?: Catch up on this online event exploring how health and care leaders can optimise existing estates to support neighbourhood health, discussing ways to overcome funding, technical, and cultural barriers to maximise shared spaces and create environments that enhance service delivery.

Caring together - a joint vision for the future of cooperation between adult social care and the NHS: We’re proud to be featured in the newly published joint report with NHS Confederation the Association of Directors of Adult Social Services (ADASS) and RLDatix Caring Together: a joint vision for the future of co-operation between adult social care and the NHS.

Quit Smoking Support: Make 2026 the year we help more people quit smoking for good. Encourage friends, family, colleagues, and residents to take a positive step towards a smoke-free future. With free, expert support from Be Well Walsall, quitting is possible – even for those who’ve tried before. Refer or start a quit journey at www.bewellwalsall.co.uk or text SMOKEFREE to 60777.