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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

  • United support for Breastfeeding Week

    Infant Feeding teams and midwives across the Black Country and West Birmingham will be supporting and encouraging mums this National Breastfeeding Week which runs from Monday 27 June until Friday 1 July. This year’s theme is “Everyone has a part to play in helping mums to breastfeed” with a focus on the difference that can be made if everyone supports breastfeeding. And the Black Country and West Birmingham Local Maternity and Neonatal System (LMNS) is highlighting the help that is available fo...
  • Mental health and learning disability chief confirmed to lead new NHS Board

    Respected local NHS leader Mark Axcell has been formally appointed as substantive Chief Executive Officer for the Black Country Integrated Care Board (ICB).  Following a successful recruitment process, Mr Axcell, who has held the position on an interim basis since November, will now officially become CEO on 1 July when the new NHS organisation launches.   Mr Axcell joins the ICB from his previous role as Chief Executive of Black Country Healthcare NHS Foundation Trust, the local...
  • Healthcare professionals encouraged to return to practice

    A special online event will be taking place in June for nurses and allied health professionals (AHPs) looking to return to practice. The Return to Practice Programme is for qualified nurses or AHPs who are no longer registered and wish to return to work. Those eligible must have been off the Health and Care Professions Council (HCPC) or Nursing and Midwifery Council (NMC) register for more than two years, or must not have registered within five years from the date of their qualification. Hoste...
  • Chief People Officer appointed to future NHS Board

    A Chief People Officer has been appointed to the executive team for the new Black Country Integrated Care Board (ICB). Mrs Shajeda Ahmed will take up the role once the ICB formally begins operation, moving to the Black Country from her current role as Executive Director of People, Organisational Development and Inclusion for North Staffordshire Combined Healthcare NHS Trust. As Chief People Officer, she will be responsible for all aspects of staff recruitment, training and wellbeing for the IC...
  • Putting our fantastic midwives in the spotlight

    Today (5 May) is International Day of the Midwife and the Black Country and West Birmingham Local Maternity and Neonatal System (LMNS) wants to thank those who make a difference to families across our communities. Sally Roberts, Chief Nursing Officer for NHS Black Country and West Birmingham CCG, said: “How fantastic that we can make today all about our wonderful midwives. “Once again, we find ourselves talking about another difficult year for them as they have supported mums-to-be a...
  • New appointment to future NHS Board

    The leadership team for the new Black Country Integrated Care Board (ICB) continues to take shape with the appointment of a new executive. The ICB, which will begin operation on 1 July 2022, has successfully appointed to the role of Chief Operating Officer.   The news follows last week’s announcement that the NHS had gone out to advert for a substantive Chief Executive Officer to lead the ICB. The role of Chief Operating Officer will be held by Mr Matthew Hartland, who is currently ...
  • More than 2.6 million COVID-19 vaccines delivered

    Since the start of the vaccination roll-out, more than 2.6 million vaccines have been administered in the Black Country and West Birmingham. More than 980,000 people have now received at least one dose of the vaccine, with almost 690,000 taking up at least three doses.   The spring booster programme is also continuing at pace, with almost 47,000 eligible people vaccinated since March. Those eligible for a spring booster include care home residents, people who are 75 and over and those age...
  • Signs and symptoms of asthma

    This World Asthma Day (Tuesday 3 May), health chiefs in the Black Country and West Birmingham are raising awareness of the signs and symptoms of asthma. World Asthma Day is organised by the Global Initiative for asthma, which aims to improve asthma awareness and care. Asthma is a common lung condition that causes occasional breathing difficulties. It affects people of all ages and often starts in childhood, although it can also develop for the first time in adults. The main symptoms are a whi...
  • NHS seeks to appoint leader to top system role

    The NHS has today gone out to advert for a substantive Chief Executive Officer to lead the new Black Country Integrated Care Board and play a pivotal role within the local health and care system. 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, coordinate services and plan in a way that improves the health of local people and reduces inequalities between different gr...
  • Local NHS leaders reflect on COVID-19 pandemic

    Two years on from the first UK lockdown, health chiefs across the Black Country and West Birmingham have paid tribute to staff and members of the public. The declaration of the pandemic was made by the World Health Organisation (WHO) in January 2020 and the UK went into full lockdown on Monday 23 March 2020. Since then, health and care staff from across the NHS, local authorities and the voluntary sector have worked in partnership to provide services and support communities, as well as standin...