Our monthly brief is designed to give you a overview of the latest partnership updates, some facts and figures, interesting reads and information about things that are coming up.
Intermediate Care
The review of Intermediate Care continues to ensure the service delivers timely, person-centred support, enabling faster recovery, reducing avoidable hospital admissions, and improving independence, while maintaining a financially sustainable model through a skilled, multidisciplinary workforce.
The review is focusing on the following areas:
Intermediate Care Staffing Investment
The service is showing real improvements. People receiving therapy within 72 hours of leaving hospital are recovering faster, with shorter lengths of stay and fewer care calls. 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 3.29-day reduction in length of stay, and these improvements are contributing to overall budget savings.
Dedicated Rehab Unit
A two-year review of rehabilitation services highlighted opportunities to enhance recovery and independence. Since June 2025, a pilot programme has been testing a dedicated rehabilitation approach designed to improve outcomes and efficiency. The pilot offers purpose-built, multidisciplinary support, including dedicated Pathway 2 rehabilitation beds, on-site therapy from day one, and ongoing collaboration with care home staff. Early results show faster, more coordinated recovery helps people to regain independence sooner. Feedback from staff and service users has been very positive, highlighting the benefits of this collaborative approach. A dedicated unit makes better use of the workforce and improves continuity of care. It demonstrates how structured, collaborative rehabilitation can support high-quality care closer to home. The unit is expected to open in the Summer, and outcomes from the pilot will continue to be monitored to guide the future model of service delivery.
West Midlands 5G (WM5G) Pilot
The Intermediate Care Discharge Team at Walsall Healthcare Trust is taking part in a Digital Discharge pilot to help medically optimised patients return home safely and quickly, supported by a simple, home-based technology solution. The pilot which is expected to commence in March-26 is supported by WM5G, a subsidiary of the West Midlands Combined Authority, and is being run alongside University Hospitals Coventry and Warwickshire. Patients taking part can use sensors to monitor movement at home and a tablet or app for video calls, check-ins, and medication reminders. Data from the sensors is sent to a secure dashboard, where a dedicated clinical team monitors progress for up to six weeks. The same clinical team manages discharge planning, ensures GP’s or other care providers are updated, and provides support throughout recovery. Around 200 patients across the two sites will be able to benefit from this digital approach, helping them stay safe, independent, and well-supported at home.
ICS Community Reablement
A new project is bringing together Community Reablement and ICS Pathway 1 Reablement services to help people recover and regain independence after hospital or short-term support. The new model will consolidate reablement services across the borough, providing more consistent, strengths-based support and reducing the need for ongoing care. Technology will also be used to personalise care, monitor progress, and support better outcomes. The project is designed to deliver high-quality care closer to home, helping people live independently for longer. The new model is expected to launch in July 2026.
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.
In Walsall, seven Neighbourhood Teams (NTs) aligned to PCN boundaries have been established. Five have agreed an initial cohort to be managed through weekly MDT meetings. The North NT runs Feel Good Friday clinics; West 1 and West 2 have active MDT meetings; East 2’s MDT starts on Monday 2nd February and will focus on frailty and dementia; South 2 is focusing on high-intensity users; and East 2 and South 2 are supporting the adult social care Live Well pilot.
The service specifications for the Live Well pilot have been finalised and they have received five tenders back from homecare providers. The University of Wolverhampton has also been confirmed as the Pilot Evaluation University Partner.
The second stakeholder forum was held on 21 January and was well attended. Q&As were recorded with copies available on request. The next event is taking place Wednesday 25 February from 3pm-4pm. You can book your place here.
We were delighted to welcome Dr Minal Bakhai MBE, Senior Responsible Officer for the National Neighbourhood Health Implementation Programme (NNHIP), to Walsall, where she spent time seeing first-hand how neighbourhood-based working is making a difference for local people.
Dr Bakhai visited the Feel Good Friday Clinics at the Stan Ball Centre and met with South and West 2 Integrated Neighbourhood Teams to see how coordinated, multidisciplinary approaches are supporting frail, housebound and high-need citizens through proactive, preventative care.
Reflecting on the atmosphere and sense of purpose created through this neighbourhood approach, she said: “This is what we are trying to bottle – you walk in and you feel it. What you’re doing is what communities respond better to, because it’s what actually matters to them, and that is really at the heart of neighbourhood health and wellbeing. So it was amazing to see.” Read the full story here.
The next Regional Learning Event is taking place on Tuesday 10 February in Edgbaston where we will be sharing best practice, learning from others and hearing more around the national direction.
Feel Good Friday Clinics
The Feel Good Friday Clinics were developed to proactivaly support older people living with frailty through early, holestic intervention, imporving outcomes and independance while reducing avoidable emergency department attendances, pressures on intermediate care and longer term care costs.
Just 11 weeks after launching they are already proving to be making a difference. So far, 39 out of 46 older people invited have attended a clinic. Each person received a Comprehensive Geriatric Assessment (CGA), which looks at physical health, medicines, mobility, home safety, and overall wellbeing. This holistic approach helps identify issues early and ensures the right support is put in place.
As a result:
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48% of people had medications safely stopped
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69% had changes made to their medicines
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36% received home safety assessments to reduce the risk of falls
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49% were connected to community services such as smoking cessation, weight management, and strength and balance activities
The clinics are also helping to reduce pressure on health services, with hospital admissions avoided and people supported through the Care Navigation Centre, preventing the need to contact their GP or emergency services.
Feedback from people using the service and from staff has been extremely positive. The clinic has now been extended until March 2026, and a new falls-prevention activity programme is planned to begin in April 2026, with further specialist support currently in development.
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.
Wellbeing Networks
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.
Physical activity: Social prescribers were given a tour of the Oak Park Living facility and considered effective ways to signpost people to available services. The group held wide-ranging discussions on strengthening links between primary care and the developing physical health strategy, and explored how existing guided walking schemes could be adapted to better engage those who would most benefit. Participants also discussed ways of linking physical activity with nature to enhance both meaning and health benefits. Active Black Country has a strategic lead focused on physical activity and long-term conditions, and this emerging partnership will become increasingly integrated into neighbourhood health approaches.
In other news…
From local impact to national honour: We are delighted to congratulate Janet Davies on being awarded a British Empire Medal (BEM) in the King’s New Year Honours List for services to the voluntary sector. This highly deserved recognition reflects Jan’s exceptional commitment to communities across Walsall and her long-standing leadership within the voluntary, community, faith and social enterprise (VCFSE) sector.
As our VCFSE Representative on the Board, Jan brings a strong and trusted community voice into partnership working. Her extensive knowledge, skills and experience are instrumental in supporting the development of neighbourhood teams, strengthening collaboration and helping to ensure that work remains focused on local need and reducing health inequalities.
West Midlands Mayor visits WorkWell programme at Blakenall Village Centre: The Mayor of the West Midlands has visited Blakenall Village Centre to see first-hand how the WorkWell programme is supporting Walsall residents with health conditions or disabilities to access and stay in employment. Read the full story here.
We Are Walsall 2040 - Building Our Business Future Event: This free event is filled with practical insights on Walsall’s future business growth and regeneration plans, and support available. Hear from keynote speakers and panels, and learn how other local businesses, Small and Medium Enterprises, and community interest companies have unlocked funding. It is taking place on Wednesday 11 February and will run from 9.30an-1.30pm. You can book your place by visiting the following link https://booking.wmbf.co.uk/we-are-walsall-2040/.
Market Place Event: Stakeholders, partners and colleagues are invited to meet key voluntary and community sector organisations from Walsall Community Network to find out more about the projects, activities and services being delivered across Walsall. Drop into Brownhills Community Centre, Pelsall Road, WS8 7JE, anytime between 10am-1pm on Tuesday 3 March.
Have your say on Drug and Alcohol Services in Walsall: Walsall Public Health are keen to understand the views and ideas of members of the public and stakeholders about the needs of local people affected by substance misuse and whether needs are being met by the local treatment system. You can have your say by completing a survey at https://online1.snapsurveys.com/nzf2xr. Please share this link as far and wide as possible and encourage members of the public, staff and volunteers to complete it by 20 Feb 2026. Paper copies of the questionnaire are available by contacting paul.hargrave@walsall.gov.uk.
Active Black Country Stakeholder Survey: Active Black Country believes that being active has the power to improve people’s lives, that it is everyone’s right to be active and play sport. The charity wants to ensure it has an even greater impact on people’s physical and mental wellbeing over the coming 12 months and beyond. Your voice is vital to this work. Have your say, fill in the form here - Active Black Country Stakeholder Survey
Walsall town centre is changing - Notice about Park Street disruption: From 26 January 2026, Butler’s Passage on Park Street will close, with construction hoardings going up around the buildings either side. This closure is essential to demolish the buildings as part of the Connected Gateway scheme. For more information visit: https://go.walsall.gov.uk/business/regeneration-and-investment/regenerating-walsall-town-centre
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:
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Pre/Post clinic surveys
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Face to face conversations with patients, families/carers and staff
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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 Health
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.
Monthly Brief June 2024
There was no monhtly brief published in November 2022
There was no monthly brief published in August
There was no monhtly brief in February
