Our work

We are focusing on prevention, early identification, proactive self care and wellbeing support services at both an individual and community level. The core of this approach is to ensure fairness and equitable access to all services and opportunities, creating an inclusive and supportive environment for everyone.

Our commitments:

• Develop a Voluntary Community Faith & Social Enterprise (VCFSE) and social housing alliance model for primary preventative health and wellbeing (tobacco, food, alcohol, and physical inactivity) with holistic wraparound support for wider determinants.
• Enable and support VCFSE and social housing providers to develop quality interventions that improve care
• Develop and embed social prescribing across neighbourhood and locality teams, and intermediate, unplanned and crisis care

Outcomes:

• Increase in workforce participation and economic engagement
• Increased frequency of meaningful interactions with family, friends, or community members
• Enhanced social connectivity and improved community engagement highlighting the positive effects of reducing social isolation, focusing on strengthening social ties and increasing participation in community activities
• Improved well-being and community engagement through expanded access to social prescribing services

We are developing integrated teams at neighbourhood and locality level to support adults, children, young people, and families. These teams bring together professionals from various providers to collaborate, share resources and information, and form multidisciplinary teams (MDTs). Their goal is to improve community outcomes and address health inequalities.

Our commitments:

• Develop integrated neighbourhood care teams, using population health management and risk stratification tools to ensure citizens are seen by the right person at the right time
• Establish multidisciplinary teams and active case management through integrated working, including data sharing across general practice, community health, mental health, social care, housing and wider services

Outcomes:

• Improved management of health conditions, leading to fewer preventable hospital admissions
• Improved healthcare management for high-intensity users, leading to fewer A&E visits
• Lower incidence of asthma in children through better prevention and management
• Families and caregivers feel adequately supported and involved in the care process.

We are Joining up health, mental health, social care and other specialist services to manage chronic and complex needs, provide crisis support and hospital avoidance as well as intermediate care. These services are delivered across the borough of Walsall.

Our Commitments:

• Review and further enhance the intermediate care service model to ensure it is sustainable, continuing to facilitate safe and timely discharges, promoting and optimising independence, and enabling people to live independently in their own homes or community settings
• Implement a collaborative therapies model across health and social care
• Integrate unplanned and crisis response services across hospital, community and primary care to support citizens to remain in the community

Outcomes:

• Support more people to be safely discharged from hospital within 48 hours of being declared medically stable and remain out of hospital
• Support more people to be cared for on virtual wards using appropriate technology
• Improve number of individuals who regain functional independence after illness, surgery, or injury
• Individuals remain in their homes or community-based settings rather than moving into long-term residential care

We are streamlining health, care and wellbeing access, navigation and coordination, including triage and service directories, to ensure citizens can get to the right part of the system, to the right service and to the right professional in an efficient and timely manner.

Our commitments:

• Streamline care navigation across hospital, community and primary care services including unplanned care, crisis support and hospital discharge
• Develop a model that recognises there will be a need for separate health and social care entry points, bringing together referrals that require integrated responses
• Enable shared records and directories of services that support citizens to navigate services, relative to relationships and networks across services and organisations

Outcomes:

• Improve patient experience and outcomes through care co-ordination and simplified access to services
• Increase access to well-being resources, leading to improved health and quality of life for citizens (Well-being directory, Walsall Connected Programme)

Walsall will be an inclusive borough where all partners work collaboratively to ensure children and young people get the right support at the right time.

Our Commitments:

• Implement Family Hubs and Families First for Children national delivery expectations
• Reduce the number of adolescents with complex needs reaching crisis and experiencing poor outcomes. Evaluate options to support young people through a whole family, systemic and trauma informed approach which links to the Family Safeguarding principles
• Develop a plan with children, parents/carers that meet the needs of children with SEND across health and the local authority.

Outcomes:

• Improved infant health and survival rates through enhanced prenatal and postnatal care
• Higher vaccination coverage leading to reduced preventable childhood diseases
• Improved childhood health and reduced obesity rates through healthier behaviour initiatives
• Improve Therapy Outcomes Measures in Speech and Language
• Improve breastfeeding rates
• Improved parental skills, confidence and wellbeing

We are supporting people to live well for longer with a focus on services and pathways that cut across all elements of our model of health, care and wellbeing in particular long term conditions and end of life.

Our Commitments:

• Implement a falls and frailty pathway including secondary prevention and reablement for those with moderate frailty
• Integrated services responsible for the primary assessment and support for people with dementia, considering links with Voluntary Community Faith & Social Enterprise where appropriate. Embed key messaging around dementia into universal primary prevention and wellbeing services
• Undertake a needs analysis for cardiovascular and chronic kidney disease. Develop improvement plans where necessary.
• Establish Diabetes prevention pathway and ensure the management pathway is sustainable
• Evaluation of End-of-Life care and support following implementation of national framework

Outcomes:

• Increase the participation and adoption rates in healthier behaviour programmes reducing the prevalence of health conditions
• Effective management of conditions like diabetes, arthritis, or cardiovascular disease to minimize complication
• Reduced incidence of falls among older adults
• Older adults retain the ability to maintain independently and engage in daily activities with minimal assistance
• Delayed onset of cognitive decline or dementia

We are joining up services for physical and mental health to reduce barriers for those with the least access to mental health and wellbeing services, while increasing preventative and early support in communities.

Our Commitments:

• Implement measures and interventions to understand and reduce the barriers facing those with least access to mental health and wellbeing services
• Embedding shared care arrangements (e.g.for attention deficit hyperactivity disorder) across primary and secondary care services
• Coordinated programme across partners that meets targets for Serious Mental Illness physical health checks and offers pro-active intervention/preventative opportunities to improve/prioritise access for at risk groups
• Roll out national ‘Reasonable Adjustments’ requirements for Learning Disabilities and Autism cohort across all health and care partners
• Increase range of preventative and early help interventions delivered through the Voluntary, Community, Faith, Social Enterprise sector close to local communities, linked to prevention concordat
• Establish and sustain primary care mental health workforce to improve access and outcomes

Outcomes:

• Decrease the prevalence of diagnosed depression among adults through increased access to mental health services and early interventions.
• Reduction in premature mortality in adults with severe mental illness
• Increase stable housing and employment for people with severe mental illness
• Increase the access through Primary Care in General Practices's and Primary Care Networks’s who operate mental health shared care practices
• Reduced waiting times for Getting Help+ Children Young People Mental Health services

Working across multiple sectors enables the partnership to strengthen and support the health and care workforce as well as ensure work and health are linked creating as more holistic approach to workforce development, wellbeing and social care. The partnership emphasis and priority on workforce will support the delivery of a number of related workstreams and projects with and for our formal partners and other informal partners such as Walsall College and the West Midlands Combined Authority, leading to greater cohesion and impact for workforce efforts.

Our Commitments:

• Evidence, clarify and communicate our Walsall offer regarding the health and care workforce, to support local people to navigate the system, raise awareness of opportunities and entry routes into jobs
• Identify opportunities and pressures around recruitment and retention
• Enable an increasing number of skilled volunteers to support health and wellbeing

Digital Transformation is the integration of digital technologies into healthcare and social care systems to improve services, enhance citizen/patient outcomes, increase efficiency, and empower both citizens and professionals. It's about using technology to modernise and streamline how care is delivered, managed, and experienced.

Our Commitments:

• Ensure there is digital inclusion in everything we do. 
• Deliver technology enabled care to enable more people to remain in their usual place of residence, supported by remote monitoring and rapid access to professional support when needed
• Identify shared and common commissioning/procurement opportunities from digital perspective such as Artificial Intelligence, Technology Enabled Care, Robotic Process Automation and ever emerging technological advance

We have a wealth of quantitative data and qualitative insights about the population of Walsall across our collective systems and organisations. We also have the tools available to enable us to proactively manage and support our population. This can facilitate a shift in focus away from short-term, often organisational-based returns on investment to measure our wider impact on health and economic prosperity, over longer periods of time. Our insights work encompasses the citizen voice, research and quantitative data about our population.

Our Commitments:

• Utilising the Walsall Wellbeing Outcomes Framework to identify priorities that incorporate research, quantitative evidence from local data and qualitative insight through the citizen voice
• Develop integrated reporting to demonstrate the impact of the partnership across operational services, commissioning and transformation, and finance
• Implement a population health platform with care coordination functionality that uses joined up and shared data to support planning, proactive population health management and public health. Use improved IT systems to identify at-risk groups and target interventions appropriately being mindful of both intersectionality and some risks in our data approaches  

The Health and Care Act 2022 and associated policy guidance is designed to increase collaboration and integration across all health and care organisations. It involves the integration of planning, commissioning and delivery, facilitated by the aligning and pooling of resources, digital transformation and changes to regulation.

The partnership governance operates under a Host Provider model, which is a specific variation on a Lead Provider model. Walsall Healthcare NHS Trust acts as the host organisation. There is an established Partnership Board, which is a formal sub-committee of the Walsall Healthcare Trust Board, and a hosted management structure which sits within the framework of the Trust’s corporate structure.

We continue to lead the way from a governance perspective in building on existing arrangements and are seeking to increase the level of collaboration on both strategic planning and delivery of integrated health and care. Such changes require a shift in the provider/commissioning landscape and the way resources are allocated and therefore a significant change in culture. A focus on organisational development is therefore required with board members and senior teams dedicating time to reflect on the current position and future direction of the partnership to ensure we develop and role-model collaborative behaviours.

Our Commitments:

• Establish robust governance arrangements underpinned by a culture of collaborative decision-making on all areas of responsibility delegated from the Integrated Care Board and the Health & Wellbeing Board
• Implement an organisational development plan to support increased collaboration of service planning and design across commissioning and provider organisations, identifying opportunities for pooled budgets and population-based budgeting where there is evidence it will help to improve poor outcomes within the challenging financial context
• Develop a Return on Investment framework that will help to identify opportunities to reinvest resources into prevention and wellbeing
• Embed wellbeing and equalities/fairness into all strategies, policies and programmes