Find out more below about some of the work the partnership has being doing to join up services, make them easier to access and available closer to home. 

In order to provide more joined up care for the people of Walsall we have developed weekly virtual MDT meetings to support people with one or more health or social care needs.

These meetings are GP led and the other people involved in the meeting will depend on individual needs, but may include representitives from social care, mental health, pharmacy and the voluntary and community sector. 

During these meetings a person’s health and well-being needs are discussed and recommendations and decisions are made together on how best they can be supported.

This may be signposting to local community groups to help a person support and manage their own care, developing a care plan and organising regular reviews or organising access to more specialist care.

Anyone whose role involves working with someone who they believe will benefit from the support of an MDT can refer an individual into the service.

The referral will be reviewed and if it meets the appropriate criteria will be discussed during an MDT meeting and followed up with either the referrer or the individual.

For more information on MDT teams and how to refer contact Karvin Jhalli on 07814103357 or email: mdt.walsall@nhs.net

We want to make sure all women, their babies and their families experience safe, kind, compassionate and personalised care and can access support that is centred on their individual needs and circumstances. 

Through the Continuity of Carer initiative we ensure that pregnant ladies and their families have their own dedicated midwifery team supporting them throughout their pregnancy, during their birth and in the early stages of parenthood. 

This means that closer relationships are developed and moms to be are supported and informed at every stage of their pregnancy, enabling them to make decisions about their care based on what matters most to them and their family. 

It also allows for better co-ordination of care with a named midwife taking overall responsibility for ensuring all the needs of a woman and her baby are met and enables access to care closer to home through local community hubs.

The partnership launched its first continuity of carer midwifery service at Pelsall Village Centre (East locality) on 25 January 2021. A second location in the South locality has been identified and is expected to be up and running by August 2021.

The service has been introduced in response to the recommendations from the National Better Births Review (2016) and builds on the success of a Continuity of Carer model implemented by the Wyndlow Team within the Walsall Healthcare Trust Midwifery-led unit. 

The model has been shown to offer major benefits for mothers and babies including significant reduction in miscarriages and pre-term births. National evidence shows that women who receive continuity of carer are:

•    7 times more likely to be attended at birth by a known midwife
•    fewer antenatal admissions and shorter postnatal stay
•    16% less likely to lose their baby
•    24% less likely to experience pre-term birth

The aim is to have four fully established locality hubs delivering the continuity of carer model within Walsall by March 2022.

This is a service which enables patients with musculoskeletal (MSK) conditions to see a specialist physiotherapist within a GP practice has been rolled out across identified Primary Care Networks in the borough.

This will allow patients quicker access to assessments and treatment, improve recovery times and give patients a much better experience of care. 

It will also reduce the workload on GPs, who would usually be the first point of contact for a patient with an MSK condition, and for referrals to other services such as x-ray and scans.

The service was rolled out following a sucessful pilot scheme which was run at Anchor Meadow GP Practice.

As part of the pilot 93 patients were seen within two days of referral. Of these three were referred for x-ray, one for a MRI scan, one for blood test and the remaining 88 were given self-care treatment advice and exercises. None of the patients to date have returned to the GP practice with the same problem.

Following the success of the pilot scheme the partnership is now working with each Primary Care Network to implement a First Contact Physiotherapy Service within each locality within the next 18 months.
 

A stroke could happen to anyone at any time and is caused by either a block in a blood vessel that leads to the brain or by bleeding in or around the brain.

Following a stroke some people recover completely, others need rehabilitation and further support and others sadly do not survive.

Stroke rehabilitation is an important part of recovery after stroke. 

A patient’s journey will vary according to the nature and severity of their individual needs. 

Some patients will respond well to the care they have received in hospital and will be discharged home to receive rehabilitation services. Other patients will have greater levels of need and may need to receive rehabilitation as an inpatient in a community setting. 

Rehabilitation Services are provided by multi-disciplinary teams including doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, dietitians, psychologists, ophthalmologists, social workers and pharmacists.  

The aim is to help people who have suffered a stroke relearn the skills they lost, so they can live as independently as possible and have an improved quality of life. 

In 2017, following guidance set out in the National Stroke Strategy 2007, a review of Stroke Service in Walsall took place.  

You can read more about this including the outcomes and next steps below.

Background

It looked at the whole patient journey from stroke prevention, to specialist hospital care and rehabilitation services, to identify what needed to be done to improve the health outcomes of stroke patients.   

The views of patients, the public and leading clinicians were taken into account and a decision was made, in line with other national recommendations, that specialist acute services would be provided by The Royal Wolverhampton Trust and rehabilitation services should continue to be provided in the community by Walsall Healthcare Trust. 

At the time of the review, however, there was not an appropriate inpatient facility available in the community to provide Stroke Rehabilitation Services. As a temporary solution, it was agreed that these services would be provided at the Manor Hospital until a community base was found. 

In 2019 a suitable location - Holly Bank House - was identified and plans were in place to secure the building and make all the necessary arrangements to enable Stroke Rehabilitation services to be provided from there.

Following the outbreak of COVID-19 there became an urgent requirement to move vulnerable groups, including stroke rehabilitation patients, who did not need acute care out of the hospital in order to reduce their risk and free up much needed hospital bed space. 

In response partner organisations and volunteers worked together to make the building fit for purpose and arranged for the relocation of staff and the safe transfer of patients to the new site. 

Why Holly Bank House?

Walsall Together Partnership undertook a review of potential community hospital sites taking into consideration the internal and external environment, how easy the building could be adapted to ensure the sustainable delivery of services in the future and the safety of the site. 

It was decided that Holly Bank House provided the best opportunity to deliver Stroke Rehabilitation Services for the following reasons:

  • It was an existing in-patient facility with 21 rooms all with ensuite facilities
  • Minimal work was required to bring the building up to required standards 
  • Its easily accessible with free parking
  • It is the site of other community services allowing for better integrated care
  • It offers both physical and psychological benefits e.g. accessible outside space and a suitably large therapy space

What this means for patients 

By moving rehabilitation services out of the hospital we can improve the way specialist rehabilitation is provided and give our patients the greatest opportunity and time to recover. 

There are a number of benefits to patients including:

  • Access to support by a skilled multi-disciplinary team who are able to focus their time on providing more quality care based on individual needs
  • Better links to other community services including intermediate care , rapid response and The Community Neurological Rehabilitation Team who are based on site
  • Improved environment so patients are not receiving their rehabilitation in a busy hospital where staff are often asked to help support on other wards
  • Less risk of hospital associated infections and increased falls 
  • Reduced length of stay in hospital 
  • Reduced staff sickness levels and staff turnover resulting in better continuity of care 
  • Better long term health outcomes and levels of independence associated with improved levels of rehabilitation 

We have already seen improvements in patient outcomes for example:

The average length of stay for the 72 patients transferred to Holly Bank House between April 2020 and January 2021 is currently 26 days compared to an average length of stay on a hospital ward of 35 days.


Next Steps

The service has now been in running from Holly Bank House since April 2020 under a Tenancy at Will agreement and we are currently finalising a long term lease agreement. 

We plan to carry out some patient engagement following the transfer of patients to ensure the services are meeting patient needs and see if there is anything that can be done to improve the service.
 

Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) 

Improving personalised care in Walsall is one of the key priorities for the Walsall Together Partnership.

One of the ways we are aiming to achieve this is to replace the current Do Not Attempt Resuscitation (DNACPR) policy that is used across the borough, with the Resuscitation Council (UK) Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)

The ReSPECT process creates personalised recommendations, for clinical care in an emergency situation, when a person is not able to make decisions or express their wishes.

By using the ReSPECT process, we will be able to improve personalised care, by talking about much more than just resuscitation. We are able to engage with patients and their families and work together to make decisions and recommendations and effectively plan their care in the event of a situation where they are unable to express their own wishes.  

People with a ReSPECT plan in place are more likely to avoid unwanted and unnecessary interventions including hospital admissions and be cared for and die in the place of their choosing. 

The new policy came into effect as of 1 January 2021. 

 

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