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Health and wellbeing strategy 2015 - 2020



Our vision

“Building Stafford and Surrounds’ Healthy Future by working together to support residents and communities take control of their own health and wellbeing.”

Making a difference to the health and wellbeing of the population is the responsibility of everyone. By working together and using a prevention model that focuses on partnership work and the use of local assets to build capacity and strengthen the resilience of communities, health outcomes and life experiences can be greatly improved. This approach is also vital if we are to manage demand for longer-term support and build a sustainable local health and social care economy.

The Stafford and Surrounds’ Health and Wellbeing Group believe their vision can be achieved by building on the partnerships knowledge, and experience gained through delivery of the first Health and Wellbeing Strategy to develop more efficient, and effective services which are targeted at those in most need.

This Strategy sets out how the Group plan to deliver their vision over the next five years. It provides strategic guidance and focus to enable organisations achieve the identified outcomes which will improve health and wellbeing of the local population. Key objectives of this Strategy are:

  • To support Commissioners collectively plan and commission integrated services that meet the needs of the local community.

  • To support providers’ work collectively across statutory and the voluntary sectors to deliver good quality outcomes.

  • To support communities to become more resilient and take an active role in shaping the services they need.



Context  Back to top

Stafford and Surrounds’ is a very attractive place to live, work, and visit with a high quality natural environment and excellent transport links. Rates of crime and anti-social behaviour are low, adult and youth unemployment is low. Educational attainment and development levels at early years are high, and Mosaic profiling suggests that the proportion of the population who are willing to volunteer for a good cause is higher than both county and national figures. (Stafford Borough Locality Profile 2015, Staffordshire Observatory).

However, viewing data at a District level does not show the true picture of health and wellbeing locally; there are four Lower Super Output Areas (LSOAs) that fall within the most deprived national quintile (Highfields and Western Downs, Littleworth, Manor and Penkside), and although life expectancy at birth continues to increase, men and women living in these areas are living seven and eight years less than those from less deprived areas.

There are also a number of key challenges to tackle locally such as:

  • The population is projected to see significant growth in people aged 65 and over (24%) and in particular those aged 85 and over (52%). The rate of increase in the number of older people in Stafford is faster than the England average and equates to 5,900 additional residents aged 75and over by 2023.

  • Based on the 2011 Rural and Urban Classification most of Stafford’s population live in a rural area (32%) compared with 17% nationally. Although living in a rural area has a positive association with people's satisfaction, it can also present difficulties in accessing services. Recent research also shows that loneliness and isolation is a significant risk factor to wellbeing and independence and equates a lack of social connections to smoking 15 cigarettes a day (Holt-Lunstad and Layton (2010).

  • The 2011 Census found that 18.2% (23,800 people) of the population had a limiting long-term illness (LLTI), this is higher than the England average. The prevalence of long-term conditions is also projected to increase given the ageing population and increases in unhealthy lifestyles placing an increased burden on future health and social care resources.

    GP disease registers show that the long-term conditions with the highest prevalence in Stafford are:

    • hypertension(15%)

    • obesity (9% of people aged 16 and over)

    • depression (6% of people aged 18 and over)

    • diabetes (6% of people aged 17 and over)

    • and asthma (6%).



Who are we  Back to top

Public Health was reformed through the Health and Social Care Act 2012 which intended to improve quality and efficiency by reforming the organisations that commission, regulate and support health and care services. Local authorities were given a much stronger role in shaping services and given responsibility for local population health improvement through the development of Health and Wellbeing Boards. Clinical Commissioning Groups (CCG) were also established to commission high quality services in the National Health Service (NHS).

To provide a local response to these changes, the Stafford and Surrounds’ Health and Wellbeing Group was established in July 2012. Chaired by the CCG and co-ordinated by the Borough Council it also includes representatives from:

  • Staffordshire University,

  • Support Staffordshire,

  • Voluntary Action Staffordshire and Stoke on Trent,

  • Healthwatch Staffordshire,

  • the county council,

  • Public Health,

  • and Stafford and Rural Homes.

The Group works closely with and has membership on; the Staffordshire Health and Wellbeing Board and the Stafford Borough Strategic Partnership (LSP). The Strategic Partnership also recognised the Group as the local delivery mechanism for health and wellbeing and delegated rights for locality commissioning to them in April 2015.

The Group is supported to deliver their vision by the ‘Building Stafford and Surrounds’ Healthy Future Partnership which is a network of 238 individuals and 66 organisations (figures as of July 2015).



What have we delivered  Back to top

The Stafford and Surrounds’ Health and Wellbeing Group have made significant progress since launching their first Strategy in November 2013. The original Strategy monitored 18 priorities across six Life Stages which enabled the Group to consider the wider determinants of health and wellbeing, such as housing and employment, and build a diverse partnership with a wealth of knowledge and skills.

The Group monitored progress of their action plans through macro data indicators aligned to the Public Health Outcomes Framework and by using a set of Minimum Standards which monitored; engagement, use of evidence, and delivery.

Given the wide diversity of the priorities the Group also took an innovative step and invited the Stafford Borough Health Scrutiny Committee to evaluate the action plans; challenging each of the Priority Leads responsible for developing and delivering the priorities. The Committee also provided a level of local accountability and created a mechanism for elected member involvement in the health and wellbeing agenda.

The action plans demonstrated consistent progress, and Priority Leads showed on-going improvement against the Minimum Standards, with:

  • 93% stating their involvement had improved joint working,

  • 87% stating their involvement had increased their knowledge and understand of other services and support,

  • and 87% stating their involvement had improved their knowledge of local need and evidence.

Positive results (stayed the same or improved) were also shown in 23 out of the 30 macro public health indicators.

During 2013-15 the Stafford and Surrounds’ Health and Wellbeing Group have:

  • Developed a diverse network of local organisations and groups to aid delivery through the ‘Building Stafford and Surrounds’ Healthy Future Partnership’.

  • Produced two Enhanced Joint Strategic Needs Assessments to aid a needs-led approach and enhance the community voice.

  • Monitored and supported a programme of 14 action plans including 20 key projects.

  • Delivered a programme of training and learning opportunities to Priority Leads and the Partnership.

  • Established a Commissioning Hub and gained recognition and the delegated rights from the Stafford Borough Strategic Partnership to commission against health and wellbeing.

  • Aligned public sector grant pots to a pooled pot of over £400,000 publishing the Stafford and Surrounds’ Health and Wellbeing Commissioning Prospectus in November 2014.

  • Commissioned 14 projects focused on prevention and early interventions within targeted communities.

The work delivered through the 2013-15 Strategy was also recognised by the Municipal Journal as a National example of best practice. The judges selected it as a finalist in their Public Health Partnerships award category, stating;

“a strong programme of public health interventions across the borough has brought together partners from the public, voluntary and private sectors and has generated a clear vision for the improved health of residents in Stafford as well as making a strong impact in a number of priority areas.”

In November 2014 the Group held a Health and Wellbeing Summit, and key partners were asked to make a commitment to improve health and wellbeing going forwards by adopting key principles of a Partnership Pledge, these principles, which are shown below, will underpin all the work delivered through this Strategy.

Stafford and Surrounds’ Partnership Pledge key principles:

  1. To make a positive difference and improvement to the quality of life for people living in Stafford and Surrounds’.

  2. To promote and help people and communities take control of their own health and wellbeing and to support them to remain independent.

  3. To work together in new ways to add scale and value to our outcomes.

  4. To focus on local need and priorities.

  5. To use the Stafford and Surrounds’ £pound in a more effective way to build capacity and resilience.

The key objectives of the Summit were to share achievements, learning and the latest evidence and intelligence, to share and discuss future direction our local vision for health and wellbeing, and to launch the locality Commissioning Prospectus.



Our priority areas  Back to top

This Strategy is focused on prevention and primary interventions within community settings. The priorities for the next five years have been developed as a result of evaluating local public health data and evidence such as; the Stafford Borough Locality Profile 2015, and the Stafford Borough Health and Wellbeing Profile 2015, and comparing this data to community voice and partner feedback. This intelligence allowed the Group to review the importance of the original 18 priorities and identify any emerging issues.

The results were published in the Stafford and Surrounds’ Enhance Joint Strategic Needs Assessment (EJSNA) 2014. Following this, partners were invited to attend a ‘Future Direction’ and an ‘Implementation and Effective Delivery’ workshop, where they were given the EJSNA and asked to reflect upon the strengths and weaknesses of the first Strategy to identify improvements, and interventions which would make the most difference and the biggest impact.

This resulted in the Stafford and Surrounds’ Health and Wellbeing Strategy 2015-20 priorities shown below:

Start well 

  • Target Group: Children aged 0-5 and their families living in deprived areas of the Borough. 
  • Key Objective: To give young children the best start in life through safe and supportive environments. 
  • Key Issues: Unintentional injury and minor illness, breast-feeding prevalence, responsive parenting, aspirational parenting, emotional wellbeing, smoking and low birth weight babies.

Live well

  • Target Group: Adults and families with sedentary lifestyles, unemployed adults, and lone parents. 
  • Key Objective: To improve health and wellbeing through reducing sedentary behaviour and improving accessibility and knowledge of healthy balanced diets. 
  • Key Issues: Sedentary behaviour and inactive adults, poor knowledge of healthy balanced meals, food poverty, access to healthy food choices, emotional wellbeing and low level mental ill health.

Age well

  • Target Group: Isolated older adults aged 65+.

  • Key Objective: To support older people remain healthy and independent through identification of those at risk of emergency admissions, and through improved communication pathways and collaborative working.

  • Key Issues: Falls prevention, fuel poverty and excess winter deaths, choice and control at end of life, flu vaccinations, isolation, loneliness, low level mental ill health.

In order to address the primary causes of poor health and wellbeing this Strategy will take a ‘person centred’ approach, focusing on improving overall ‘wellbeing’. It will work in a holistic way to identify root cause and address unhealthy behaviours by addressing a range of factors and empowering individuals and communities to engage with service providers and commissioners and take control of their own health and living environments.

Key public health issues that do not appear in our priorities such as smoking, alcohol consumption and worklessness will be addressed through this approach as factors affecting a person’s ability to improve their wellbeing and the Group will work in partnership with organisations and existing groups who have taken responsibility for these areas such as the Stafford Borough Safer Communities Partnership and Stafford Borough Growth and Infrastructure Board to address them.

These priorities also align the local strategic vision with the Stafford and Surrounds’ Commissioning Hub commissioning intensions highlighted in the 2015 Commissioning Prospectus which will allow future locality funding and the projects commissioned to directly support delivery of the Strategy.

Mental Health affects everyone at all stages of life as shown below, yet there is still a lack of understanding and stigma associated with it:

Start well

Maternal mental health, post-natal care, and effective parenting are key to promoting the positive development of children and lay the foundations for their future, particularly because half of life time mental health problems have already developed by the age of 14 years.

Live well

Physical activity, social interaction, leisure, involvement and awareness all contribute to a wider sense of wellbeing and belonging.

The ‘5 ways to mental wellbeing’ provide an evidence-based framework for developing mental wellbeing within communities:

  • Connect

  • Be active

  • Take notice

  • Keep learning

  • Give

Age well

As people live longer, problems associated with ageing; social isolation, physical health problems, grief and loss and increasingly the need for care and support lead to the increasing likelihood of mental health problems; especially depression.

These can lead to poor diet, confusion, falls, and increased dependence on care services.

Through partner consultation it was agreed that as mental wellbeing is so cross-cutting and contributory to good health across all the focus areas it should be embedded across the Strategy. To ensure this is done in a comprehensive way across all phases of development, delivery, and evaluation, the Group have included mental wellbeing as a Minimum Standard.



What we will deliver  Back to top

To be truly effective we need new solutions at a local level that are built upon the foundations of prevention and early intervention. Individuals and communities should be at the heart of every outcome and be able to articulate how interventions have impacted upon their health and wellbeing. We need to move away from traditional commissioning models towards an outcome-based approach that will really make a difference to residents and communities.

Community consultation and stakeholder engagement has always been seen by the Group as the key to success. The Group actively engages with local communities and partners in all the work it does, and the results are used to inform and enrich their work. Operating on a ‘top down – bottom up’ approach the Group has embedded the principal ‘nothing about me, without me’ in its approach, which is shown in the flow diagram below outlining the communications pathway:



The Delivery Mechanism for the Strategy will be through Steering and Task and Finish Groups. Each focus area will be co-ordinated by a Steering Group which to ensure continuity and productivity, will be chaired by a member of the Stafford and Surrounds’ Health and Wellbeing Group. The Steering Groups will develop and monitor action plans and provider led Task and Finish groups will implement and deliver key projects to address the key issues identified.

To ensure a needs-led approach is adopted the ‘community voice’ element will be enhanced through the development of community focus groups, and a health and wellbeing communication plan will also be developed to improve engagement.

The Stafford and Surrounds’ Health and Wellbeing Group will receive a progress report every six months and the Stafford Borough Council Health Scrutiny Committee will also hold the Group and members of the Steering and Task and Finish Groups to account through a Committee programme.

To ensure the Steering Groups work towards the Stafford and Surrounds’ Health and Wellbeing Group vision and are able to show impact against the focus areas. The Group has developed a new set of Minimum Standards based on the Partnership Pledge key principles to monitor them. These ‘lead indicators’ need to be in place to support achievement of the outcomes.

The Strategy monitoring process is as follows:

Lead indicators/minimum standards

  1. To raise awareness and understanding of local assets and support services available within communities.

  2. To add value to service delivery through enabling and facilitating joint work between organisations.

  3. To enable effective delivery by working with providers to review and shape services.

  4. To build capacity in communities through supporting individuals, and/or groups to develop the confidence, understanding, and skills required to engage with providers and influence service provision and delivery.

  5. People of all ages suffering from low level mental health problems are enabled to manage their condition through supportive community environments.

Enablers/proxy measures

  • Development of Focus Area steering groups.

  • Development of Focus Area provider task and finish groups.

  • Development of health and wellbeing communication plan.

  • Focus Area action plans developed.

  • Joint working opportunities identified.

  • Partner consultation opportunities.

  • Shared learning and review opportunities.

  • Forums developed for community engagement.

  • Community consultation.

Expected outcomes

  • Improved wellbeing.

  • Increased knowledge and understanding.

  • Improved confidence and self-esteem.

  • Reduced levels of stress, anxiety and/or depression.

  • Increased referrals between organisations and via self-referrals.

  • Increase in joint funding applications.

  • Improved social return on investment.

  • Improved community engagement.

  • Communities report improved levels of strength and resilience.

The Steering Groups will be monitored through the Minimum Standards, but individual projects delivered by the Task and Finish Groups will also be monitored against:

  • satisfaction,
  • impact,
  • and cost effectiveness.

Examples of expected outcomes and measures used for these projects are shown below:

Satisfaction (experience)

  • Improved feedback from service users, friends and family, referrers, stake holders, staff, volunteers etc.

  • Involvement of service users and carers as equal partners in person-centred (care) planning and decision making.

  • Increased level of confidence in services.

  • Better understanding and awareness.

  • Learning from poor experience.

  • Reduced frequency of poor experiences.

  • Effective public and service user participation in service development and redesign.


  • Timely identification of need, assessment, agreement of needs and development of intervention ‘plan’.

  • Improved quality of life.

  • Improved function / ability.

  • Increased level of participation in activities of life.

  • Reduced level of symptoms, disability, impairment.

  • More services delivered closer to home.

  • Reduced dependency on other services (medication etc).

  • Delayed need for more intense, or disruptive services

  • Increased ability to ‘self-manage’.

  • Prolonged ability to remain in normal place of residence.

  • Reduced need for unplanned or emergency services.

Cost effectiveness

  • More Effective Services for same level of resource or;

  • Equally Effective Services for less resources.

  • Added Value.

  • Effective use of existing assets.



Appendices  Back to top

Appendix 1: public health outcomes framework

With support from Staffordshire Public Health Intelligence and Staffordshire Observatory the Strategy will also continue to monitor trends in a range of Public Health Outcome Framework indicators which are shown here:

  • 0.1ii
    • Life expectancy at birth (male).

    • Life expectancy at birth (female).

  • 2.02ii
    • Breastfeeding prevalence at 6-8 weeks after birth.

  • 1.01ii
    • Children in poverty.

  • 1.02i
    • School Readiness: The percentage of children achieving a good level of development at the end of reception.

  • 2.06i
    • Excess weight in 4-5 and 10-11 year olds: 4-5 year olds.

  • 2.06ii
    • Excess weight in 4-5 and 10-11 year olds: 10-11 year olds.

  • 2.07i
    • Hospital admissions caused by unintentional and deliberate injuries in children (aged 0-4 years).

  • 1.03
    • Pupil absence.

  • 1.05
    • 16-18 year olds not in education, employment or training.

  • 1.16
    • Utilisation of outdoor space for exercise/health reasons.

  • 2.12
    • Excess weight in adults.

  • 2.13ii
    • Percentage of active and inactive adults - inactive.

  • 2.23v
    • Average Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) score.

  • 2.24ii
    • Injuries due to falls in people aged 65 and over: aged 65-79.

  • 1.17
    • Fuel poverty.

  • 4.5iii
    • Excess winter deaths index (3 years, all ages).

  • 3.03xiv
    • Population vaccination coverage - fly (aged 65+).

  • 4.14ii
    • Hip fractures in people aged 65 and over: aged 65-79.

  • 4.03
    • Mortality rate from causes considered preventable (persons).

Appendix 2: policy and guidance mapping

The strategy had been developed taking local and national strategy into consideration - as shown below:

Start well

  • Staffordshire Health and Wellbeing Board Strategy.

  • Strategic Young Persons Plan Staffordshire.

  • 1001 critical days (national guidance).

  • UNICEF Baby friendly initiative standards (national guidance).

  • NICE guidance – Maternal and child nutrition (national guidance refreshed 2014).

  • NICE guidance – Social and emotional wellbeing: early years (national guidance 2012).

  • NSPCC all babies count (national guidance).

Live well

  • Staffordshire Health and Wellbeing Board Strategy.

  • Sport Across Staffordshire Annual Review 2014/15.

  • Health- Sixth Report ‘Impact of Physical Activity and diet on health’ (March 2015).

  • Nice Guidance – Maintaining a healthy weight and preventing excess weight gain among adults and children (March 2015).

Age well

  • Staffordshire Health and Wellbeing Board Strategy.

  • Healthy Ageing in Staffordshire: Adding Life to Years and Years to Life 2014/15.

  • Staffordshire Frail Elderly Strategy.

  • NICE Guidelines Excess winter deaths and morbidity and the health risks associated with cold homes (NG6), Falls in older people: assessment after a fall and preventing further falls (QS86).

  • Age UK, Healthy Ageing Evidence Review.

Appendix 3: Stafford and surrounds partnership

Stafford and surrounds health and wellbeing group members

  • Andrew Donald (Chair)
    Stafford and Surrounds' Clinical Commissioning Group

  • Jonathan Bletcher (Deputy Chair)
    Stafford and Surrounds' Clinical Commissioning Group

  • Kate Harrold (Responsible Officer)
    Stafford Borough Council

  • Wayne Coombe
    Staffordshire County Council

  • Howard Thomas
    Stafford Borough Council

  • Mike Calverley
    Staffordshire Public Health

  • Jane Sampson
    Staffordshire University

  • Garry Jones
    Support Staffordshire

  • Andrew Thompson
    Voluntary Action Staffordshire

  • Hester Parsons
    Healthwatch Staffordshire

  • Debbie Emmitt
    Stafford and Rural Homes

Stafford and Surrounds' Commissioning Hub Members

  • Wayne Coombes (Chair)
    Staffordshire County Council

  • Kate Harrold (Deputy Chair)
    Stafford Borough Council

  • Narinder Reehal
    Staffordshire County Council

  • Vicki Hancock
    Staffordshire County Council

  • Mike Calverley
    Staffordshire Public Health

  • Tracy Redpath
    Stafford Borough Council

  • Nicky Bromage
    Staffordshire County Council

  • Clair Greenwood
    Sports Across Staffordshire and Stoke on Trent

  • Jonathan Bletcher
    Stafford and Surrounds' Clinical Commissioning Group

  • Harriett Summerfield
    Staffordshire County Council

Building Stafford and Surrounds' Healthy Future Partnership Provider Organisations

  • Age UK South Staffordshire

  • Age UK Stafford District

  • Alzheimers Society

  • Back2bikes

  • Beat the Cold

  • Beth Johnson Foundation

  • Brighter Futures

  • British Red Cross

  • Bromford Group

  • The Carers Association Southern Staffordshire

  • Chamber of Commerce

  • Child and Adolescent Mental Health Service

  • A Child of Mine

  • Citizens Advice Bureau

  • The Community Council of Staffordshire

  • Community Pharmacies

  • Donna Louise Trust

  • Douglas Macmillan Hospice

  • The Dove Service

  • Engaging Communities Staffordshire

  • Entrust

  • Families First

  • Healthwatch Staffordshire

  • Holmcroft Youth and Community Centre

  • House of Bread

  • Housing Plus

  • Job Centre Plus

  • Katherine House Hospice

  • Konnektiv Arts

  • Lloyds Pharmacy

  • The MASE Group

  • Midland Heart

  • Mid Staffordshire MIND

  • Northfields Hub

  • NOVA training

  • One Recovery

  • Penkside Champions

  • The Ramblers

  • Revival

  • Richmond Fellowship

  • Rising Brook Baptist Church

  • Sandon Road Baptist Church Redevelopment Group

  • Signpost Centred Ltd

  • South Staffordshire Network for Mental Health

  • Sports Across Staffordshire and Stoke on Trent

  • Stafford Borough Council

  • Stafford College

  • Stafford Enterprise

  • Stafford Mental Health-Changes

  • Stafford and Rural Homes

  • Stafford Sports Academy

  • Stafford Street Pastors

  • Stafford and Surrounds' Clinical Commissioning Group

  • Staffordshire Council of Voluntary Youth Services

  • Staffordshire County Council

  • Staffordshire Fire and Rescue

  • Staffordshire Housing Association
  • Staffordshire Police

  • Staffordshire and Stoke on Trent Partnership NHS Trust

  • Staffordshire University

  • Staffordshire Women's Aid

  • The Stroke Association

  • Support Staffordshire Stafford District

  • U3A

  • Voluntary Action Staffordshire and Stoke on Trent

  • West Midlands Ambulance Service

  • Wrekin Housing Trust



Printable version  Back to top

This strategy is also available as a printable PDF:

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