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Healthier Futures - Transforming 'out of hospital' care

In 2019 local Healthwatch organisations carried out engagement activity (questionnaires and focus groups) in the Black Country and West Birmingham to gain insight into how people view local health services. This activity uncovered strong support from local people for services that helped older people to stay in their own home for as long as it is safe to do so and people viewed communities as playing a central role in helping them to live their lives the way they wanted.

Focus group feedback identified gaps in primary care being able to consistently link people with community services that could support them to manage their conditions. Increased use of pharmacists in care management was also identified.

Our population is ageing. The number of local people aged 65+will increase by 14% over the next 10 years. We do not all age in the same way, some people are severely frail at 65+ while others are still fit at 95+. Caring for someone living with severe frailty is very costly and we know that if we can reduce the level of frailty we could reallocate resources to support more people.

People with frailty do not always get the care they need in the right setting and at the right time and we are committed to preventing inappropriate hospital admissions for these people. We are working together to identify the good practice in places with lower admissions and spreading this to other areas. 

Local people want as much care as possible in their local communities rather than in hospital. Transforming the care outside of the hospital setting and doing more in community and primary care to stop people needing to go into hospital is key. 

Admission to hospital and delayed discharge can affect people’s mental and physical wellbeing and make them increasingly dependent on support services. So it is also key to have services in place to get people out of hospital as soon as they are able to do so. We are committed to delivering improved community crisis response within two hours of referral, and reablement within two days. Reablement plays an important part of helping people relearn how to perform their daily activities, like cooking meals, washing and retaining their independence.

There are around 5,000 people living in care homes in the Black Country and West Birmingham. These people account for a large proportion of our A&E attendances, emergency admissions and emergency bed days. Unfortunately many ofthese emergency admissions are potentially avoidable. 

Evidence suggests that many people living in care homes are not having their needs assessed and addressed as well as they could be, often resulting in unnecessary, unplanned and avoidable admission to hospital. We are working to change this through:

  • Stronger links between PCNs and their local care homes, with all care homes supported by a consistent team of healthcare professionals.
  • Ensuring that individuals are supported to have good oral health, stay well hydrated and well-nourished and that they are supported by therapists and other professionals in rehabilitating when they have been unwell.
  • Care home residents getting regular clinical pharmacist-led medicine reviews.
  • Providing emergency support to care homes, including where advice or support is needed out of hours.
  • Easier, secure sharing of information between care homes and NHS Staff.

In the Black Country and West Birmingham we will transform out of hospital care through our efforts to:

  • Implement local models of care for each place that delivers improved access to local services for the whole population. This will give greater continuity of care for all people and help local teams to coordinate care for those most vulnerable in our communities. 
  • Create, a coordinated system of primary care by developing Primary Care Networks (PCNs)
  • Work together to transform primary care workforce, buildings and digital solutions
  • Act together in partnership to address the wider determinants of health such as employment, education and housing to understand where primary care can support this.

In The News

  • One record to improve health and care in the Black Country and West Birmingham

    People living in the Black Country and West Birmingham will soon get even better and safer care and treatment, thanks to the introduction of joined-up health and care records. One Health and Care is a new NHS shared care record launching later in the Spring, which will bring together all the separate records held by different local providers of health and social care – such as hospitals and GPs – in one secure, easy to read format. This will give authorised professionals who are directly respo...
  • Wash, wash, wash your hands

    As COVID-19 continues to spread in the area, people across the Black Country and West Birmingham are being reminded of the importance of washing their hands. Regular hand washing with soap and water remains an essential part of good hygiene and helps prevent the spread of COVID-19, as well as other winter illnesses such as colds, flu and stomach bugs. Hands should be washed with warm water and liquid soap for at least 20 seconds before rinsing and drying them thoroughly. If soap and water are ...
  • Executive Recruitment for the Black Country Integrated Care Board

    The Black Country Integrated Care System is looking for future Executives to lead the Integrated Care Board when it is established in July 2022. We are now live with the recruitment to 3 of our 6 future executive roles. Adverts are now live for the roles below: Chief Finance Officer  Chief Medical Officer  Chief Nursing Officer Recruitment to the other executive posts of, Chief Operating Officer, Chief Equality and Innovations Officer and Chief People Officer will start in th...
  • Future NHS Health Board seeks independent non-executives

    The recruitment is now underway to appoint four independent non-executive members to the Black Country Integrated Care Board (ICB). The Integrated Care Board will be formed in April 2022, subject to the passing of the new Health and Care Bill. These new roles represent an opportunity to be on the Governing Body for the future NHS ICB, where non-executive members will help to shape a long-term, viable plan for the delivery of the functions, duties, and objectives of the NHS locally. Their role...
  • Mental health chief named as interim lead for NHS Black Country Integrated Care Board

    Health leaders are delighted to announce the appointment of Mark Axcell as Interim Chief Executive Designate for the Black Country Integrated Care Board (ICB). Mr Axcell is currently Chief Executive of the local mental health and learning disabilities trust, Black Country Healthcare NHS Foundation Trust, and has more than 25 years’ experience within the NHS. He will take up the interim post from Monday (22 November) and will lead preparations for the launch of the new ICB next year, subject to...
  • Black Country and West Birmingham NHS pledges support to Armed Forces community

    On Monday 8 November, seven NHS organisations from the Black Country and West Birmingham Integrated Care System (ICS) signed the Armed Forces Covenant (AFC) at a virtual signing. The Black Country and West Birmingham ICS, the first ICS to sign up to the Covenant within the West Midland Reserve Forces & Cadets Association’s (RFCA) region, comprises 15 local health and care organisations who are jointly responsible for managing resources, delivering NHS standards, and improving the healt...
  • Online event for people living with diabetes

    Ahead of World Diabetes Day (Sunday 14 November), people living with diabetes across the Black Country and West Birmingham are invited to attend a special webinar taking place on Friday 12 November. Created by International Diabetes Federation (IDF) and the World Health Organisation (WHO), World Diabetes Day is celebrated worldwide and aims spread awareness of diabetes. This year marks 100 years since the discovery of insulin, a treatment that has saved millions of lives around the world. To c...
  • Accelerating recovery of diagnostic services with £8million investment

    Following a successful bid, we are pleased to confirm that local NHS trusts are taking part in a national programme to help the NHS further accelerate diagnostic activity and recover services from the impact of the COVID-19 pandemic as quickly as possible. Our colleagues across NHS services are working hard to recover services affected by the pandemic, now the vaccine programme has helped to significantly reduce the number of Covid patients needing care. Throughout the pandemic the NHS has con...
  • Walsall people encouraged to take part in ground-breaking blood test cancer trial

    Thousands of letters are being sent to adults in Walsall this week, inviting them to take part in the world’s largest trial of a revolutionary new cancer-detecting blood test. The potentially lifesaving Galleri™ test can detect more than 50 types of cancer before symptoms appear. The NHS-Galleri trial, the first of its kind, aims to recruit 140,000 volunteers nationally, including thousands in the West Midlands, to see how well the test works in the NHS. Walsall is the first location in the We...
  • Recruitment begins for the Black Country Integrated Care Board Chief Executive Officer

    NHS England is advertising for a Chief Executive Officer (CEO) to lead the future Black Country Integrated Care Board (ICB). Integrated Care Systems (ICSs) are partnerships of health and care organisations, local government and the voluntary sector. These partnerships aim to meet health and care needs, to coordinate services and to plan in a way that improves population health and reduces inequalities between different groups. From April 2022 (subject to legislation) ICSs will become statutory...