Our Work

Summary

We’re working to make it easier for you to understand where you can go when you have an urgent health need or healthcare emergency and ensure the treatment you receive is timely and of high quality.

Priorities and projects

• We will ensure that when you require urgent and emergency care you receive the right support in the right place – first time
• We want to connect urgent and emergency care services together to fully meet the physical, mental health and social care needs of everyone living in Staffordshire and Stoke-on-Trent
• We’re committed to providing a responsive, urgent health service outside of hospital so you no longer need to queue in hospital emergency departments
• We will ensure that adults and children with more serious or life threatening emergency needs receive treatment in centres with the right facilities, processes and expertise in order to maximise their chances of survival and a good recovery.

Aims and outcomes

• We want you to go to the right place, first time to meet your urgent and emergency care needs
• We’re working to connect urgent and emergency care services and deliver the national requirement for Urgent Treatment Centres
• We want a ‘single system’ approach to the way services are planned and delivered
• We want to ensure the right services are provided out of hospital to your home
• We’re making sure the correct processes and support are in place to enable you to be discharged from hospital in a safe and timely manner.

Introduction to the programme

Resources

Urgent and Emergency Care Programme Factsheet (January 2019)

Summary 

We want to deliver high quality and effective services safely in the right setting, at the right time and with the right health and care professional. We want people living in Staffordshire and Stoke-on-Trent to be able to access high quality elective care that is both clinically and financially sustainable. Furthermore, alliances of local providers working across organisational boundaries will deliver efficient health and care that is coordinated and collaborative.

Priorities and projects 

• We’re developing seven-day elective centres to ensure improvements in productivity, efficiency and the quality of care
• We’re looking to increase the uptake of cancer screening to improve early access and detection
• We’re promoting an increase in the uptake of self-care where appropriate
• We’re developing a Staffordshire and Stoke-on-Trent-wide sustainable model for outpatient and day case provision
• We’re also committed to developing fully consolidated diagnostic services.

Aims and outcomes

• By 2020, we want to see a system in place whereby you should only need to attend hospital to receive treatment that cannot be provided elsewhere – community ‘triage and treat’ services will be expanded, some through GP practices
• You will be empowered and supported to self-care
• We want non-emergency hospital services to be largely separated from the urgent care system, avoiding the cancellation of operations that can result from peaks in demand
• Your care will be delivered through a collaborative and joined up system that is accountable for the delivery of each step of your care, with no ‘hand offs’ or inconsistency of service.

Resources

Planned Care and Cancer Programme Factsheet (January 2019)

Summary

We have multiple objectives focused on improving maternity services alongside services for children and young people. With regards to maternity services, the Staffordshire and Stoke-on-Trent Maternity Transformation Programme is working in partnership with Together We’re Better and new parents to develop local services that meet the recommendations of NHS England’s Better Births report. In terms of children and young people, we’re developing an action plan to tackle those areas where services can be improved.

Summary

We’re working to enable you and your family to take control of and manage your own health and wellbeing so that health and care services can be there when you really need them.

Priorities and projects

• We want to simplify and connect services to ensure we have a local health and care system that promotes independence and wellbeing
• We’re working to create a ‘think family and community first’ culture so that you and your family are able to live independently and manage your own care needs
• We want to ensure you are able to access information that supports wellbeing and healthier lifestyles
• We are seeking to reduce the risks to your wellbeing by improving where and how you live.

Aims and outcomes

• We’re determined to reduce the risk of falls by supporting you to maintain and regain your independence and reduce the need for more complex care – helping to cut the risk of a visit to A&E and being admitted to hospital
• By supporting you to maintain good health or improve your wellbeing, we hope to see a reduction in the number of people who need health or social care support
• We’re seeking to reduce the level of diabetes, obesity and heart disease in Staffordshire and Stoke-on-Trent by working with you to avoid or reduce the risks of developing these conditions
• We’re also working with local government organisations, the Beat the Cold charity and EON to bid for money to address the cost of heating energy inefficient and cold homes.

Resources

Summary 

We’re committed to ensuring that older people, adults, young people and children in Staffordshire and Stoke-on-Trent are supported whether they find themselves in need of help in a mental health crisis, or whether their day-to-day mental health and wellbeing is affected. We’re working in a collaborative way to ensure your mental health and physical health needs receive equal priority and also ensure you receive help and support closer to your home and family.

Priorities and projects 

• Children and young people will not be unnecessarily admitted to hospital, while children with an eating disorder will receive a responsive service; furthermore we want to see a greater number of children and young people accessing mental health services when they need them
• You will experience services that are built around your needs, with mental health and physical health services working alongside primary, community and social care
• We have an ambition of zero suicides
• We will ensure you do not have to go out of the area to receive in-patient care as we aim to have enough beds across Staffordshire and Stoke-on-Trent
• If you are in mental crisis we want you to be able to access support 24/7 and ensure you know where you can access this support.

Aims and outcomes

• We want to increase the number of psychiatric intensive care beds and reduce significantly the number of patients being sent out of Staffordshire and Stoke-on-Trent to receive care
• We are committed to providing seven-day-a-week child and adolescent mental health services (CAMHS)
• We are expanding crisis and home treatment teams to ensure more people are treated in their own home, avoiding inpatient stays
• We are committed to reducing the number of people who take their own life or experience self-harm
• We want to reduce the number of people who frequently attend A&E with mental health concerns and also reduce the number of frequent callers to ambulance services
• We’re developing a 24/7 intensive outreach service that includes support to young people with eating disorders.

Introduction to the programme

Resources

Mental Health Programme Factsheet (January 2019)

Archive

Suicide Prevention Conference - November 2018

Summary

We’re developing health and care services that work in a fully joined up way across 23 localities in Staffordshire and Stoke-on-Trent, with a number of hubs providing GP services and other teams delivering more specialist care. We’re also seeking to redesign local community hospitals and develop more effective end of life services.

Priorities and projects

• We’re introducing Integrated Care Teams (ICTs) across 23 localities in Staffordshire and Stoke-on-Trent that bring together general practice, community and mental health services, alongside social care professionals and the voluntary and independent sector – each team will serve 30-70,000 people and be based around neighbouring GP practices
• We’re developing high quality, sustainable GP services based on an average registered population list of 10,000 people
• We’re redesigning Staffordshire and Stoke-on-Trent’s six Community Hospitals to reduce the variation in how beds are used – this will be supported by Integrated Care Teams
• We’re developing an end-of-life service that ensures equal access to consistent clinically appropriate care and services built around your needs.

Aims and outcomes

• We want ICTs to enable you to remain independent for longer by reducing the need to attend or stay in hospital – four early adopter ICT sites are located in Leek/Biddulph, Lichfield/Burntwood, Longton/Meir and Stafford, with more to follow across Staffordshire and Stoke-on-Trent
• We’re working to develop sustainable general practice services that provide extended access to your doctor and enable GPs to spend more time with patients with greater need
• We want to remove the variation in the use of community hospital beds
• We’re committed to providing greater support for people approaching the end of life, carers and those wishing to plan in advance for their own end of life care.

Introduction to the programme

Introducing Bill and his Integrated Care Team

Resources

Enchanced Primary and Community Care Programme Factsheet (January 2019)

Summary

We’re working with health and social care provider organisations, as well as the voluntary sector across Staffordshire and Stoke-on-Trent to deliver our three core priorities of sustainability, transformation and developing a future workforce.

Priorities and projects

• We’re developing a number of new recruitment initiatives, including UK/international recruitment, retention and flexible working, while also improving how temporary staff are used
• We’re supporting local health and social care services to become more joined up
• We’re helping to transform our ‘primary care’ workforce (staff providing the first point of contact in our healthcare system), while also delivering Health Education England’s ‘Facing the Facts, Shaping the Future’ workforce strategy
• We’re also focusing on developing our future health and care workforce by widening participation, for example nursing apprenticeships, and generating new opportunities, including training hubs and working more closely with the voluntary and independent sector.

Aims and outcomes

• We’ve developed a Together We’re Better Workforce Strategy which takes a system wide approach to workforce development, recruitment and retention
• The Redeployment Service has generated £3.6m of savings to date and stopped 150 people from being made redundant across health; local government organisations have recently joined the process
• We’re working to implement new roles to address skills gaps and patient needs more effectively and efficiently
• A Domiciliary Care Strategy has been developed and work is taking place across the system to address workforce gaps
• We’re developing a Careers Hub to encourage employees considering leaving the profession to receive advice, guidance and signposting
• We’re developing flexible apprenticeships for end of life, therapies and frailty care to enhance the quality of the service offered.

Introduction to the programme

Click here for information about this year’s Workforce Think Tank

Resources

Workforce Programme Factsheet (January 2019)

Summary

We’re utilising the latest digital technology to deliver new models of health and care across Staffordshire and Stoke-on-Trent. By supporting in the transformation of local health and care services, digital has the power to help people to live healthier lives, manage their own health and wellbeing and reduce the demand on local services.

Priorities and projects

• We’re excited to lead on the introduction of Your Care Connected, a new digital shared care record linking NHS and local government organisations to benefit patients and health and care professionals
• We want to develop a set of digital standards enabling efficient and equal access to health and care
• We want to see an improvement in frontline health and care services through the use of innovative apps and digital technologies
• We are seeking to establish a robust, future proof and state-of-the-art information technology infrastructure
• We’re developing a Staffordshire and Stoke-on-Trent informatics network that will share best practice and improve services.

Aims and outcomes

• We’re working to ensure health and care information is available to health and care professionals as and when they need it, regardless of their location and organisation
• We want to fully utilise digital technologies so you can manage your own care, including your families, friends and carers
• We’re working to best use digital technology to improve efficiency and care coordination
• We want to see a more proactive healthcare management system in place that really works for you.

Introduction to the programme

Resources

Digital Programme Factsheet (January 2019)

Summary

We want to develop leaders who have the skills and resilience to work in an integrated health and care system that more effectively supports local people. We’re working with other Together We’re Better programmes to ensure frontline staff are fully engaged and have the tools and techniques they need to continuously improve care and evidence their practice. There is also the need for enhanced partnership working and joint accountability.

Priorities and projects

• We want to identify and develop aspiring talent, ensuring as many excellent candidates as possible have the opportunity to fill senior level vacancies
• We’re supporting Together We’re Better’s engagement of health and care professionals
• We want to develop leaders who are engaging and committed to empowering their staff to be the best that they can
• We are continuing to support compassion recognition schemes.

Aims and outcomes

• We’ve successfully bid to become an early adopter pilot for the NHS Leadership Academy’s High Potential Scheme, which is aimed at identifying talented members of our workforce to succeed in senior roles
• An innovative Black, Asian and Minority Ethnic (BAME) Leadership Programme is proving to be a great success in seeking to address imbalances in BAME representation in leadership roles at every level, with all available places filled
• An NHS compassion recognition scheme is in place across NHS trusts in Staffordshire and Stoke-on-Trent, with hundreds of staff having received praise from colleagues and service users.

Staffordshire Stepping Up Black, Asian and Minority Ethnic (BAME) Leadership Programme

Resources

Organisational Development and Leadership Programme Factsheet (January 2019)

Summary

Our partners are working closely together to achieve this transformation through a series of work programmes. Each programme is clinically-led and focussed on its own aims and objectives to ensure local people have access to high quality, sustainable services for the future.

Priorities and projects

• We’re supporting Together We’re Better’s five capital priority projects – Outwoods health and care campus in Burton, additional bed capacity in our acute hospitals, Longton South, urgent care and detoxification, and maternity and neonatal
• We’re seeking to reform and upgrade our estate to support the transformation of local health and care services
• We’re working to identify surplus land and housing opportunities
• We’re supporting the development of new models of care through new Community Hubs

Aims and outcomes

• We are committed to delivering the right services, in the right places, that are locality focused and offer fully joined up health and care services
• Our approach is one of prevention and wellness, developing resilience and reducing the future cost of care with a clear focus on housing
• We’re working with other Together We’re Better programmes to ensure changes are made to the way we work, enabling savings to be made in the efficient use of our estate
• We will continuously review of our long-term estate, ensuring Local Improvement Finance Trust (LIFT) and Private Finance Initiative (PFI) properties are fully utilised
• We want to use our estate flexibly to ensure it is being fully utilised, including seven day working
• We want to address and reduce the backlog of maintenance, duplication and underutilised estate.

Introduction to the programme

Resources

Estates Programme Factsheet (January 2019)

About One Health and Care

One Health and Care is a confidential digital shared care record used within the West Midlands for people who are registered with a GP in the following areas:

• Staffordshire and Stoke-on-Trent
• Shropshire and Telford/Wrekin (Going live during 2021)

One Health and Care brings data together from the different organisations involved in health and social care. It allows doctors, nurses and other registered health and social care professionals directly involved in patient/client care to view relevant information in order to provide better and safer care. The One Health and Care system go live began Summer 2020.

Partner organisations

When you visit any of the organisations listed below, or use services provided by them, staff directly involved in their care will have access to the important information from health and social care records.

The organisations across Staffordshire and Stoke-on-Trent that are participating in One Health and Care are:

• Staffordshire and Stoke-on-Trent GP practices
• University Hospitals of North Midlands NHS Trust
• University Hospitals of Derby and Burton NHS Foundation Trust
• Midlands Partnership NHS Foundation Trust
• North Staffordshire Combined Healthcare NHS Trust
• Staffordshire County Council (Social Care)
• Stoke-on-Trent City Council (Social Care)
• Continuing Healthcare Services provided by MLCSU
• West Midlands Ambulance Service

A full list of all GP practices in Staffordshire and Stoke-on-Trent can be found here. 

During 2021 our neighbouring partner organisations in Shropshire Telford and Wrekin will be contributing data to One Health and Care.

The organisations across Shropshire Telford and Wrekin that are participating in One Health and Care are:

• Shropshire, Telford and Wrekin GP practices
• Shropshire Community Health NHS Trust
• Midlands Partnership NHS Foundation Trust
• Shropshire Council (Social Care)
• Telford and Wrekin Council (Social Care)
• Shrewsbury and Telford Hospital NHS Trust
• Robert Jones & Agnes Hunt Orthopaedic Hospital

A full list of all GP practices in Shropshire, Telford and Wrekin can be found  here . 

You can find 111 first resources to share with your stakeholders and communities  here in this folder , including social media materials, large scale graphics and toolkits. These can be shared using your online platforms and within your physical settings.

111 First Resource Folder

In Staffordshire and Stoke-on-Trent, we’re providing a new and improved way for you to access urgent NHS care when you need it.

The enhanced offer will enable the 111 service to directly book patients into time slots for Emergency Departments and Same Day Emergency Care services, when clinically appropriate.  In line with the national plan, residents of Staffordshire and Stoke-on-Trent will benefit from this service from early December 2020.

This need has always been present but has been brought into focus during the coronavirus pandemic, which now moving to the endemic phase is a catalyst for such change to occur more quickly.

By triaging a greater number of patients through 111 first we can reduce unnecessary attendances at Emergency Departments and help keep staff and patients safe in waiting rooms - maintaining social distancing during the COVID-19 pandemic. Importantly, our priority is to help people get to the right service for their needs in the quickest way.  The ambition over time is that more patients will use the 111 service so we can make sure they get to the right part of the NHS first time.

We want to reassure people that nobody who attends an Emergency Department without having contacted NHS 111 beforehand will be turned away without support.

What will be different for patients?

Patients will be encouraged to call NHS 111 or visit NHS 111 online before they attend an Emergency Department if their requirements are not a life-threatening emergency.

Emergency patients who have a life-threatening emergency should continue to call 999. Nobody who attends an Emergency Department without having contacted NHS 111 beforehand will be turned away without support.

Patients calling NHS 111 or visiting NHS 111 online will have their symptoms triaged and they will be provided with advice about which NHS service to use.  Sometimes, this might be the Emergency Department, but NHS 111 will also be able to offer appointment slots for other services, such as Same Day Emergency Care (SDEC) as well as providing advice that a patient might need to visit a pharmacy or another service. NHS 111 will be able to advise certain patients to bypass the Emergency Department and directly attend a specialty clinic within a hospital. For example, a patient experiencing possible blood clot symptoms (Deep Vein Thrombosis or DVT) will be given a timeslot direct into the SDEC clinic. Previously, they would have been signposted to wait in an Emergency Department, triaged and then sent onto the SDEC service to potentially have a further wait. By offering direct access, the patient will go straight into the relevant clinic, reducing waiting times and unnecessary steps in the patient’s journey.

For any further information, or if you would like to support the 111 First campaign across your network then please contact This email address is being protected from spambots. You need JavaScript enabled to view it.

Ambitious plans to transform the way adult community mental health care and support is provided in Staffordshire and Stoke-on-Trent are underway.

This three-year transformation, taking place between 2021-2024 supports the priorities set out within the NHS Long Term Plan and is being bolstered with the help of multi-million pound national funding.

The Long Term Plan also stresses the need for these services to be delivered within Primary Care Network (PCN) – geographical networks of GP practices. There are a total of 24 PCNs in Staffordshire and Stoke-on-Trent.

The new funding will help to create a new proactive model of community-based mental health care, based within PCNs, with mental health NHS trusts working in partnership with GPs, commissioners, local authorities and voluntary and community organisations – alongside people with lived experience, their families and carers.

Aims and ambitions

This work will focus on serious mental illness, with work programmes focusing in particular on transforming personality disorder, eating disorders and community rehabilitation for adults.

The infographic below provides an overview of the aims and ambitions of the programme in Staffordshire and Stoke-on-Trent. Highlights include:

• Introducing a single point of access for mental health concerns – delivered in ​partnership with voluntary and community sector organisations​

• Having a ‘no wrong door’ approach to accessing streamlined and person-centred care between different organisations that removes the need for multiple assessments​

• Introducing new digital platforms and technologies

• Self-referrals

Our partners

The infographic below provides a summary of the partners involved and the eight PCNs taking part in the first phase of the programme (2021-22). A further eight PCNs will come on board in phase two (2022-23), with the remaining PCNs joining in phase three (2023-24).

The focus over the next three years will be to develop fully integrated teams of health, social care and voluntary and community staff to work in new ways, with the support of people with lived experience to deliver services that more effectively meet the needs of the communities they serve.

The video provides more information about the transformation.