Better Care Fund VCSE Integrated Wellbeing Pathways SC, HI & W/2025/93

Stoke-on-Trent City Council and Staffordshire and Stoke-on-Trent Integrated Care Board (ICB) are seeking providers within the local Voluntary, Community, Faith and Social Enterprise (VCFSE) sector to deliver the Better Care Fund (BCF) funded VCFSE Integrated Wellbeing Pathways service for adults aged 18+. The new model has been developed through engagement with VCFSE organisations and health and care partners and aims to provide a more integrated and person-centred approach to supporting local residents. The proposed contract term is 3 years, with the option to extend for a further two 1 year periods (3+1+1). The estimated annual contract value is up to £557,282.00 with a maximum potential contract value of £2,786,410.00 over the full contract term. The service will be delivered through two lots:

Lot 1: Community Support and Development

Annual Value: Approximately £285,282.00

A minimum of £30,000 per annum of the annual contract value above will be ring-fenced for use to support this approach. Through predominantly home visits, this lot provides responsive and preventative support that helps individuals maintain independence while fostering stronger community capacity and connections.

Providers will be expected to:

• Deliver responsive short-term wellbeing support, primarily through home visits.
• Support socially isolated, vulnerable and at-risk residents.
• Connect individuals with voluntary, community, faith and statutory services.
• Identify emerging unmet need within communities.
• Strengthen communities by working with local partners to develop sustainable community-based solutions and support networks.
• Deliver flexible and innovative approaches that respond to local needs and circumstances.
• Operate a responsive seven-day service model.

Lot 2: Integrated Hospital Discharge and Neighbourhood Support Pathway

Annual Value: Approximately £272,000.00

An agreed nominal value of £105,000 per annum of the annual contract value above will be ring-fenced for use to support this approach. This lot will support safe and timely hospital discharge, helping people recover, remain independent, and avoid unnecessary readmissions through coordinated community and VCFSE support.

Providers will be expected to:

• Work in partnership with hospital, community, primary care and social care teams.
• Support patient identification, discharge planning and same-day discharge where appropriate.
• Coordinate rapid access to community, VCFSE and Personal Health Budget (PHB) support.
• Deliver post-discharge follow-up to promote recovery and reduce readmissions.
• Develop and coordinate neighbourhood-based VCFSE support services.
• Identify gaps in provision and strengthen local community capacity and resilience.
• Operate a responsive seven-day service model.

What the service will deliver Across both lots, providers will work alongside people to help them:

• Live independently and confidently for longer.
• Improve their health, wellbeing and overall quality of life.
• Stay well at home and avoid unnecessary hospital admissions or readmissions.
• Access the right support at the right time, including safe and timely discharge from hospital.
• Maintain independence and delay or avoid the need for long-term care and support.
• Build meaningful connections, reduce isolation and strengthen support networks.

Providers will need strong links with local communities and referral partners, experience of collaborative working, and the ability to share outcomes and performance. Successful providers for Lots 1 and 2 will be expected to work together to create a seamless pathway for residents. Recognising the expertise of providers, outcomes, key performance measures and indicators will be agreed collaboratively during mobilisation to ensure measures are meaningful, outcome-focused and reflect local priorities. We welcome submissions from individual organisations, partnerships, consortia, or lead provider/subcontractor arrangements.