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 5,200 people living in care homes in the Black Country and West Birmingham. These people account for 7,500 A&E attendances, 4,300 emergency admissions and 39,300 emergency bed days. Unfortunately around 35-40% ofthese emergency admission 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 need 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

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    Heath bosses in the Black Country and West Birmingham are celebrating the role of carers as part of national Carers Week, especially because of the important contributions they have made during the coronavirus pandemic. This week (8-14 June 2020) is Carers Week – a national awareness initiative highlighting the important work being done by carers in the community – and local health leaders in the Black Country and West Birmingham are supporting this important campaign. Jonathan Fellows, Indepe...

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  • Health chiefs encourage people to visit pharmacies first

    As part of the national Help Us, Help You campaign, health bosses in the Black Country and West Birmingham are encouraging people to visit their pharmacy for advice on minor injuries and ailments. Research shows that 27 percent of general practice appointments in England could potentially be treated elsewhere. Approximately 18 million of these could be treated through self-care and community pharmacies. Many pharmacies are open late, making it easier than ever to get advice. They can advise yo...

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  • NHS rapid response team helps frail older patients

    Against a background of an ageing population and increasing frailty, one NHS Trust has identified opportunities to provide a service targeted at this patient group. The initiative is designed to prevent unnecessary hospital admissions through the emergency front door and keep frail older people safe in their own homes.  Emma Hibbs, Advanced Physiotherapist at Sandwell and West Birmingham Hospitals NHS Trust, explains: “We know that nationally around 50% of the population aged 65+ live with...

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  • Healthier Futures partnership secures funding to develop system-wide digital app

    The Healthier Futures partnership (Black Country & West Birmingham STP) has been awarded NHS funding following a successful pitch, to develop a healthcare app which will increase access to services for the local population. The NHS has identified funding to accelerate worthwhile projects across the country, inviting bids from all systems. A very limited number of organisations were invited to pitch to their respective regional digital teams and the Healthier Futures partnership has been su...

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  • It’s all aboard for popular NHS event

    The next stops for a popular NHS event have been confirmed in the Black Country. More than 200 people flocked to the big NHS red bus in Walsall City Centre to bag advice and freebies to help them keep well this Winter. NHS Clinical Commissioning Groups across the Black Country are behind the events, which aim to raise awareness of the simple steps people can take to keep well during winter. The importance of getting the flu vaccine, how keeping warm can help keep illnesses at bay and reminding...

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  • Check in on vulnerable people this Christmas

    People in the Black Country and West Birmingham are being advised to wrap up warm over the winter season and to look out for vulnerable people during the Christmas and New Year period. Local people are being asked to remember older relatives, friends and neighbours as well as other vulnerable people at this time of year. The over 65s and those with long-term health conditions or disabilities are at increased risk of illness during the winter months. It is important to regularly check in on ol...

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  • Black Country mental health employment service to expand support to local people

    A local service that helps people with severe mental illness to find employment, has successfully obtained additional funding from NHS England to expand its service in the Black Country. The NHS Five Year Forward View (2014) recognises that the employment rate of people with severe and enduring mental health problems is the lowest of all disability groups at just 7%. Furthermore, mental health problems now account for more than twice the number of Employment and Support Allowance and Incapacity...

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  • Dr Doreen Tipton says get the flu jab!

    Doreen Tipton joins health professionals to urge patients across the Black and West Birmingham to get their free flu jabs before the winter sets in. In a video launched by Futureproof Health, the Black Country comic icon Doreen Tipton, played by actress Gill Jordan reminds residents that it’s time for those at greatest risk from flu to protect themselves and their families with a free flu jab. Flu is a highly contagious infection that anyone can catch, and it can be a really serious illness fo...

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  • Service to cut A&E visits from “frequent callers” in the Black Country a Success

    Vulnerable patients are benefitting from a new frequent user project across the Black Country and West Birmingham. A one-year evaluation of the project commissioned by Dudley CCG and Dudley CVS has shown that in those patients who frequently attend A&E, there was a 33% reduction in attendances and a 41% reduction in inpatient admissions, saving the NHS more than £500,000. Delivered by the Dudley CVS Integrated Plus social prescribing team and match-funded by Dudley CCG and the Department o...

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  • Frailty assessment area relocated

    A hospital in Dudley has transformed the way it assesses frail elderly patients who arrive at its Emergency Department ensuring they receive optimal care from a dedicated frailty team providing comprehensive geriatric assessment. Russells Hall Hospital has moved its ward-based frailty assessment unit to the Emergency Department, in line with recommendation in the NHS Long Term Plan, enabling patients to get home sooner and maintaining their independence. Frail patients with complex health cond...

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