Walsall Together is an integrated care partnership between the organisations that plan and deliver health, mental health and social care services locally. They include:
- Walsall Healthcare Trust
- Walsall Clinical Commissioning Group (including local GPs)
- Black Country Healthcare NHS Foundation Trust
- Walsall Council
- One Walsall
Together, we want to help the population of Walsall stay well for longer, by supporting them to make better lifestyle choices to help them to live independent, active and healthy lives. We want to help people stay of out hospital when possible by providing accessible, co-ordinated and responsive care as close to home as possible.
- Improve the health and wellbeing outcomes of their population;
- Increase the quality of care provided; and
- Provide long term financial sustainability for the system.
Why do things need to change?
The health and social care needs of the population are ever-changing and that’s why the organisations that plan and deliver those services are changing too. We are seeing our population grow and people living longer. The demand on services is increasing due to long term conditions and more complex health needs and all this at a time when resources are limited.
A Walsall Together Partnership Board, with senior representation from each organisation, meets on a monthly basis to provide strategic oversight and operational coordination for the services in scope. All organisations have signed an alliance agreement which sets out how they will work together to deliver sustainable, effective and efficient services.
The Executive Director of Integration leads a Senior Management Team and Programme Office who are responsible for overseeing the operational delivery and co-ordination of services. A robust plan is in place that describes the remit, programme governance and outcomes of the individuals and teams tasked with delivering the new clinical model.
A Clinical and Professional Leadership Group (formally known as the Clinical Operating Model Group) is chaired by the Director of Public Health. They provide strategic clinical direction, assurance on the model of care as well as oversee and ensure effective engagement to enable the integration of services to work. This group also coordinates the selection of clinical pathway redesign based on population health needs
A new model of care has been designed which, puts the people of Walsall at the heart of health and social care, ensuring they receive the right level of care, at the right time and in the right place.
This new way of working will see all the people involved in a person’s care operating together within the community.
The model focusses on different levels of care, accessed via a single point, which acts as a navigation and co-ordination service for all health and social care services from GP appointments to support for carers. This Single Point can be accessed in person, via the telephone, a mobile app or online.
Resilient Communities – supporting people and the communities they live in to contribute towards and access locally based services to improve the health and wellbeing of themselves and their community. Focusing on prevention, health and social care professionals along with community groups and volunteers, will work together to ensure people are provided with the right advice, support and opportunities needed to live an independent, healthy and active life.
Tier one: General Practice and Integrated Health and Care Teams – people registered with GPs in Walsall will be supported by a team made up of GPs, community nursing, social care, mental health and the voluntary sector. They will work together to provide accessible, high quality co-ordinated care in citizen’s homes or communities. This may include a telephone call with a GP regarding a mental health issue, a home visit from a social worker regarding accessibility requirements or a group learning session for someone newly diagnosed with diabetes.
Tier Two/Three: Walsall-wide specialist and services – accessible, high quality care with local hospital teams working as part of a network of specialists to deliver outpatient, diagnostics and specialist care. Where a person requires immediate or urgent care that does not require hospital admission they can access services 24 hours a day through the single point of access allowing them to be seen by the most appropriate professional in the most appropriate setting.
Tier Four: Acute Hospital Services – access to this tier of care will largely remain the same with 24 hour A&E services available at the Manor Hospital for those requiring emergency medical treatment and secondary care services provided by the hospital. Shared Digital Records will allow clinicians and professionals involved in a person’s care to be accessed in real time allowing for more informed decisions to be made and better outcomes for the person. Once a person is at the hospital they will be assessed to determine if they require care in the community or should be admitted to hospital. If admitted teams will work together to ensure the person is discharged into a setting closer to home as soon as possible.
In order to develop and deliver a fully integrated care partnership we are investing in our communities, workforce, digital equipment, technology and estates:
Focusing on prevention rather than treatment, we are looking at ways we can support our communities by equipping them with the tools and resources they need to improve the health and wellbeing of their population.
We are working with Walsall Council and One Walsall to align our Resilient Communities Programmes, giving people better access to services such as social prescribers, Making Connections Walsall, housing, education and training information, Expert Patient Programme, Care Navigation and Co-ordination, carer support and opportunities to be involved in volunteering projects.
Healthwatch Walsall has also been commissioned to support Walsall Together in engaging and communicating with service users, carers and the people of Walsall about the evolving integrated ways of working.
They will take the lead in identifying and seeking the views of patients and the public on services delivered across the Walsall Together ICP, inform people of the benefits of integrated working and enable communities to be fully represented in the decision making process of future delivery of services and service change.
They attend the Walsall Together Partnership Board and provide patient and user stories that outline both the need and the benefits of integration.
Building on and bringing together existing workforce into new teams to enable them to work closely together to deliver each tier of care within the model.
This will include teams to support people to manage their own health and social care within the community, a single point of access team, expanding on existing community based service teams and creating a network of specialist teams to deliver outpatient and diagnostic services as well as a range of intermediate, unplanned and crisis services.
Secondary care consultants, advance practitioners, social prescribers, pharmacists and therapists are just a few examples of the services that are being invested in to ensure that the right support is in the right place at the right time for the population.
As well at the physical co-location of teams were are also investing in organisational and workforce development to ensure that all our staff fully engaged with the aims of the partnership and integrated working and are given the opportunity to train and develop their skills in order to deliver these.
Develop resources, digital tools and the infrastructure that will enable the integrated partnership to be effective and efficient in its delivery.
This includes the Single Point of Access which will support the different tiers in allowing people to access the self-care health and social care information they need, online applications such as telehealth, appointment booking and fitness trackers and access for health and social care professionals to data from individual records (with consent) to enable informed decision making and better outcomes for individuals.
Looking at how and where we can deliver the new model of care from.
This includes Health and Wellbeing Centres based across the four existing localities (North, South, East and West), a number of number of easily accessible buildings across the borough for integrated primary, social and community services as well as specialist services and Walsall Manor Hospital for high quality acute services including A&E.
Whilst some of these will be achievable in the short term, some will form part of the longer term deliverables over a five year period
For local people and their families it will mean they are better supported within a community setting to maintain their health and independence, the way their care is provided will be easier to understand and use, professionals will have access to individuals information so they don’t have to keep sharing their health and social care history and they will have more choice in who provides their care.
For our health and social care professionals they will be part of news ways of working that better meets the need of local people, will have flexibility in their roles and more development opportunities, the ability to access patient information quicker, improved communication between primary and secondary care.
For the health and care economy as a whole it will improve existing working relationships, allow for shared knowledge, resources and expertise between organisations, reduction of duplication, improved digital and technological support, ability to share resources to provider safer, more coordinated care that is sustainable in the future.
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