Kent Community Health NHS Foundation Trust (KCHFT) has launched a new resource to help care home staff better support residents with eating, drinking, and swallowing difficulties. The Kent Manual for Mealtimes, developed by NHS speech and language therapists and dietitians, is designed to improve mealtime experiences and reduce avoidable hospital admissions by equipping carers with practical, easy-to-follow guidance.

The manual provides step-by-step instructions to help staff identify common issues—such as swallowing difficulties or loss of appetite—and offers simple, effective strategies to address them. It includes templates for tracking progress and documenting care, which can also support Care Quality Commission (CQC) inspections. The resource also covers end-of-life care considerations, ensuring a compassionate and comprehensive approach.

This initiative reflects a broader shift from hospital-based interventions to proactive, community-based support. By empowering care home teams with the tools and confidence to manage mealtime challenges, the manual helps residents stay healthier and more comfortable in their familiar home environment. Early adopters, such as Lulworth House in Maidstone, have already reported increased staff confidence and a reduction in NHS referrals.

The manual is freely available to download and includes a short training video and customisable food and drink recommendation sheets, making it a valuable asset for care homes across Kent and beyond.

Home First is a joint initiative between Kent Community Health NHS Foundation Trust (KCHFT) and Kent County Council, designed to help people regain independence after a hospital stay. The service provides early support at home, ensuring patients receive the right care from the moment they are discharged.

By visiting patients on the day they return home and again after 72 hours, the team can assess progress, identify needs, and adjust support accordingly.

The Home First team includes support workers, assessors, and a team lead, all working closely with other health and social care services. Their first priority is to understand each person’s situation—how they were managing before their hospital stay and what they need to recover well at home. Together with the patient, they set achievable goals and create a tailored care plan. This might include arranging a regular carer, providing equipment to support mobility, or connecting the person with community organisations like Age UK.

This personalised approach helps people return home from hospital sooner and reduces the need for long-term care. It also improves recovery outcomes by ensuring patients feel safe, supported, and confident in their own environment.

The North Kent Community Diagnostic Centre (CDC) has officially opened its doors, marking the completion of a permanent, high-tech facility designed to serve the populations of Dartford, Gravesham, and Swanley.

The new centre replaces a temporary diagnostic building that had been operating since November 2023 and represents a major milestone in the national Community Diagnostic Centre programme.

Purpose-built to deliver modern, accessible care, the centre offers a wide range of diagnostic services—including MRI, CT, ultrasound, X-ray, phlebotomy, and cardiology investigations—all under one roof. By enabling more tests and checks to be carried out closer to home, the CDC is helping to reduce waiting times, accelerate diagnoses, and ease pressure on acute hospital sites.

The facility features state-of-the-art imaging suites and patient areas designed for comfort and accessibility, creating a calm and efficient environment for both patients and staff.

The opening was attended by Gravesham MP Lauren Sullivan, Dartford MP Jim Dickson, and Minister of State for Health Karin Smyth, who toured the new diagnostic suites and met with clinical and administrative teams. They heard how the service is already making a positive impact—providing quicker access to essential tests and improving the overall care experience for local people.

The launch of the North Kent CDC reflects the broader shift to move care into community settings and deliver preventative healthcare. With services available 12 hours a day, seven days a week, the centre is expanding its capacity across the local system, supporting earlier intervention, and helping to bring down waiting lists.

Oxford University Hospitals NHS Foundation Trust (OUH) is leading the way in shifting care from hospital to community settings through its breathlessness pathway pilot. Delivered at the Oxford Community Diagnostic Centre (CDC) in Cowley, this one-stop service offers patients with unexplained breathlessness a full suite of diagnostic tests, clinical review, and management advice—all in a single appointment.

Funded by NHS England and supported by BOB Integrated Care Board, the pathway is designed to reduce waiting times, avoid multiple hospital visits, and improve access for patients in areas of higher social deprivation. By locating the service in a community diagnostic centre rather than a hospital, OUH is making care more accessible, reducing travel burdens, and also helping to lower carbon emissions.

The pathway includes input from physicians and physiotherapists, alongside education on breathlessness and tobacco dependency. Patients are referred by their GP and receive same-day investigations and results, speeding up diagnosis and enabling earlier intervention.

This model supports NHS England’s ambition to deliver more care outside of hospitals, helping prevent disease progression and reduce acute admissions.

Patient feedback has been overwhelmingly positive, with many praising the efficiency, clarity, and compassion of the service. The breathlessness pathway is a clear example of how integrated, community-based diagnostics can improve outcomes, reduce pressure on hospitals, and make healthcare more equitable and responsive.

Sussex Community NHS Foundation Trust has made significant progress in expanding access to Virtual Wards, a model of care that allows patients to receive hospital-level treatment in the comfort of their own homes. In March 2024, the Sussex Virtual Health programme shifted its focus toward admission avoidance, aligning with regional and national guidance. This led to the launch of a new general Virtual Ward model in August 2024, delivered by Hospital at Home (H@H) and Urgent Community Response (UCR) teams.

The impact has been substantial. In 2024, Virtual Ward admissions rose by 16%, with 6,921 patients supported—most of whom (83%) were aged over 65. Care is now provided for a wider range of conditions, with respiratory issues accounting for 33% of cases and 41% related to broader health factors.

Virtual Wards offer daily clinical reviews, either in person or via video, by multidisciplinary teams including GPs, nurses, paramedics, occupational therapists, and physiotherapists. Patients typically spend around seven days on the ward, receiving tailored support that helps them recover faster while avoiding hospital admission. For example, an 85-year-old patient showing early signs of infection was assessed and monitored at home, avoiding a hospital stay. Another patient with a suspected UTI was treated and discharged within four days.

By keeping care local and personalised, Virtual Wards are improving outcomes, preserving independence, and reducing pressure on hospital beds. Patients benefit from familiar surroundings, privacy, and the presence of loved ones—all while receiving expert care. This model is proving to be a vital part of the NHS’s future, delivering safe, effective treatment where it’s needed most.

In Oxfordshire, a collaborative initiative is transforming how patients leave hospital once they’re medically fit to go home. The Transfer of Care Hub, launched in January 2023, brings together staff from Oxford University Hospitals NHS Foundation Trust (OUH), Oxfordshire County Council, and local community services to ensure patients return home quickly, safely, and with the right support in place.

This joined-up approach has delivered impressive results. The number of patients occupying hospital beds while waiting for discharge has dropped from a peak of 135 in 2022 to fewer than 90 a day, with a recent low of just 59. More patients are also returning directly home—93% in 2024, up from 90% in 2022—and the average wait to leave hospital has been cut from 10 days to 6 days over the same period.

The hub acts as a central coordination point, enabling multidisciplinary teams to identify the most appropriate and timely discharge options. By working closely with NHS colleagues, social care, housing teams, and voluntary sector partners, the hub ensures that patients are supported not just to leave hospital, but to thrive once they’re home.

This model is a powerful example of how integrated care can improve patient outcomes, reduce pressure on hospital beds, and create a more responsive health and care system.

The Thanet Acute Response Team in East Kent is a pioneering neighbourhood service that has adopted a population health management (PHM) approach to deliver short-term, clinically led support in patients’ homes. Designed as an alternative to hospital admission, the service facilitates early discharge for people with complex needs, including those receiving palliative and end-of-life care. Operating in one of the most deprived areas of southeast England—with one of the lowest GP-to-patient ratios—the team’s holistic, proactive model is focused on improving quality of life.

Led by GPs and supported by a multidisciplinary team (MDT) spanning primary care, community services, and the voluntary sector, the team delivers care with a shared vision: meeting the needs of the person, not the organisation. Point-of-care testing enables timely interventions such as intravenous fluids and antibiotics, while co-location and integrated IT systems support seamless coordination.

The impact has been significant. Over the past three years, hospital deaths in East Kent have fallen by 16%, compared to a 6% average reduction across the southeast. Emergency medical overnight admissions for people over 75 are now the second lowest in the region, with a sustained decline to 8.62 admissions per 100,000 people per month. For those aged 85 and above, emergency department attendance in Thanet decreased by 0.9% between 2018 and 2024—contrasting sharply with a 108% rise in the rest of Kent and Medway and a 72% increase across the southeast.

The team’s success is rooted in cross-organisational working and a commitment to shared learning. Regular multidisciplinary meetings have enhanced professional support, reduced workforce burnout, and improved the experience for patients and carers alike. Thanet’s Acute Response Team is a leading example of how integrated, community-based care can deliver better outcomes in even the most challenging settings.

Launched in September 2023, the Heart Failure Virtual Ward has already supported over 250 patients, offering a transformative approach to care that helps individuals avoid unnecessary hospital admissions or return home sooner. By managing patients in their own homes, the service reduces the risks associated with prolonged hospital stays and promotes mobility, independence, and recovery in familiar surroundings.

Patients are reviewed daily by the Virtual Ward team and can receive intravenous diuretics at home. Their observations, weight, fluid levels, and kidney function are closely monitored to ensure safe and effective treatment. Led by Heart Failure Consultant Dr Hiten Patel, the service is delivered by specialist nurses Sarah Bradbury and Nicola Barrett, with support from Community Heart Failure teams and Virtual Ward GPs. This daily, personalised care enables timely escalation when needed and ensures continuity of support.

The Virtual Ward operates as a fully multi-disciplinary model, drawing on expertise from pharmacy, physiotherapy, occupational therapy, speech and language therapy, and dietetics. This holistic approach ensures that patients receive comprehensive care tailored to their individual needs.

Feedback from patients has been overwhelmingly positive, with many expressing how reassured and well-cared for they felt while remaining in the comfort of their own home. The Heart Failure Virtual Ward is proving to be a vital innovation in community-based care, improving outcomes and enhancing quality of life for patients across the region.

Dartford and Gravesham NHS Trust (DGT) is offering GTT@home, an innovative, home-based diabetes screening service, to improve access to gestational diabetes testing for pregnant women. This initiative addresses key barriers faced by expectant mothers, such as travel, childcare, and time off work, that can make in-clinic testing difficult. This helps to ensure that every woman at risk of gestational diabetes receives timely, essential care.

Gestational diabetes mellitus (GDM) affects up to 20% of pregnancies in the UK, and early detection is vital in preventing complications at birth, ill-health in newborns, and long-term health risks for both mother and child. Traditionally, the oral glucose tolerance test (OGTT) requires several hours in the hospital, often early in the morning while fasting. This process often requires arranging childcare, taking time off work, and managing transport. For many, these obstacles lead to missed appointments, delayed or missed diagnoses, and increased health risks. GTT@home eliminates these barriers, enabling women to conduct the same gold-standard OGTT from the comfort of their homes, on the day most convenient to them.

Tonbridge Primary Care Network (PCN) serves a population of approximately 68,000 people across West Kent, including 664 patients coded as housebound. With over 50 home visits conducted weekly, the PCN recognised the need to improve access and responsiveness for this vulnerable group. A patient survey revealed that 41% of housebound individuals found it difficult to make an appointment, and 27% felt they struggled to receive a home visit when needed—highlighting a gap in urgent and proactive care.

To address this, Tonbridge PCN partnered with Kent Community Health NHS Foundation Trust (KCHFT) to deploy two paramedics in joint posts with the Home Treatment Service. These mobile clinicians provide urgent home visits across the area, supported by GP supervision and enhanced clinical training through KCHFT. Their presence has strengthened the PCN’s ability to respond quickly to acute needs while building stronger links with community services.

In addition to urgent care, the PCN has invested in proactive support for patients with frailty and long-term conditions. Three complex care nurses manage caseloads of housebound individuals, offering continuity and direct contact during episodes of illness. This team is complemented by ten district nurses who deliver essential nursing care, with around one-third of referrals coming from outside primary care—including hospitals, hospices, and other community teams.

Together, this integrated approach is improving access, responsiveness, and continuity for housebound patients—ensuring that care is delivered where it’s needed most, and helping reduce avoidable hospital admissions.

Greystone House Surgery serves over 15,500 patients across Redhill, Reigate, and Merstham in East Surrey—a region marked by economic and social diversity. With Merstham among the more deprived areas in Surrey, the practice faces the dual challenge of meeting high levels of on-the-day demand while maintaining sustainable services for its clinical team. Like many general practices, balancing urgent care with routine appointments has become increasingly complex.

To address this, Greystone House Surgery implemented a redesigned access model that separates urgent and routine care, supported by a dedicated multidisciplinary team. At the heart of the model is a care navigation system that ensures patients are directed to the right service at the right time. A triage team assesses whether cases require immediate attention, same-day acute care, or are better suited to routine GP appointments or the anticipatory care hub for complex needs.

The benefits of this new way of working include a more holistic, multidisciplinary approach to patient care. Patients now receive input from a range of specialties, with advanced nurse practitioners, clinical pharmacists, and GP oversight teams working collaboratively in one space. This setup enables cohesive, face-to-face communication around patient scenarios, saving time for both the practice and its patients while creating a more efficient and personalised access pathway.

Technology plays a key role in streamlining operations. An administrative online platform allows staff to move tasks efficiently to clinical worklists, while a 24/7 patient portal enables patients to contact the practice at any time, including easier access on Mondays to manage weekend backlogs. The practice also offers same-day pharmacy bookings, ensuring care for minor ailments without delay.

For frail and complex patients, care coordinators and the anticipatory care hub provide continuity and personalised support. The practice uses real-time data to monitor performance and continuously refine its approach. Greystone House Surgery’s model has not only improved patient access and satisfaction but also supported staff wellbeing by creating a more manageable and responsive system.

In 2023, Sussex MSK Partnership launched a pilot called Community Appointment Days (CADs), designed to deliver musculoskeletal (MSK) care in a more accessible and patient-friendly way. Held in local leisure centres rather than clinical settings, CADs bring together a comprehensive range of services under one roof—including assessments, rehabilitation, health promotion, and support from community and voluntary sector partners. This non-medicalised environment helps put patients at ease while offering tailored care that reflects the needs of the local population.

Over the course of the year, Sussex MSK Partnership ran six large-scale CADs along with several smaller pop-up events. Feedback from both patients and clinicians was overwhelmingly positive, with many praising the convenience, atmosphere, and quality of care. According to an evaluation report, CADs also helped reduce waiting times significantly—52% of attendees received everything they needed on the day and were able to self-manage their condition without further appointments.

Building on this success, the programme now aims to roll out CADs consistently across Sussex, with monthly events planned in each area. The next phase will trial CADs as a first point of contact in the patient journey, offering early intervention and empowering individuals to take control of their MSK health from the outset.

The Urgent Community Response (UCR) Service in Sussex is transforming how patients receive care outside of hospital settings. Operating seven days a week, UCR teams deliver a two-hour crisis response to individuals whose health or mobility is deteriorating, helping prevent unnecessary hospital admissions. Care is provided in the patient’s home or usual place of residence, offering timely, personalised support that keeps people safe and independent.

In addition to crisis care, the service also offers a two-day response for those recovering from illness—helping patients rebuild confidence, regain essential skills, and avoid readmission. Since 2022, the Trust has worked in close partnership with South East Coast Ambulance Service (SECAmb), and in February 2024, launched a digital UCR portal across seven services. This portal enables clinicians to review lower-acuity 999 calls (category 3 and 4) and accept immediate referrals into the UCR caseload, streamlining access and improving responsiveness.

Between April 2024 and April 2025, UCR teams supported 23,225 people across Sussex—a 30% increase on the previous year. This growth reflects the service’s importance and its vital role in reducing pressure on hospitals by delivering compassionate, community-based care.

The Medway Crisis and Recovery House is a partnership project between the NHS in Kent and Medway, Pears Foundation and Hestia. The house is designed to offer a community-based alternative to hospital-based care for those experiencing a mental health crisis.

At the house, guests will be supported by highly trained mental health experts to develop coping skills, build resilience and take control of their lives so they can return home and keep well. During their stay, residents will be supported to establish their goals for recovery and encouraged to try activities that bring joy and social connection, such as creative art. Members of the team can also signpost other local services depending on individual needs.

The house is staffed 24 hours a day, seven days per week and offers private ensuite rooms as well as a communal kitchen, lounge and garden. As well as providing comfortable accommodation, guests can manage their own schedule, cook and access the community as they would in their own home.

Guests at the crisis house are referred by the mental health provider Kent and Medway NHS and Social Care Partnership Trust and by offering human-centred care in a non-clinical setting, the project not only eases pressure on inpatient units but also helps guests rediscover confidence and regain control of their lives.

Launched last year, the enhanced frailty service from Surrey and Sussex Healthcare Trust is helping to get older and frail patients the care they need quicker, and where possible keep them out of hospital.

The Frailty Same Day Emergency Care (SDEC) unit at East Surrey Hospital and its expanded Geriatric Medicine Integrated Initiative (GEMINI) Acute Frailty Service enable staff to rapidly identify people who are frail earlier and carry out comprehensive geriatric assessments and advanced care planning.

All of this means frail and elderly patients are given the care they need sooner, allowing them to return to their own home, improving their recovery and wellbeing. Since opening, the SDEC at East Surrey has enabled around 80% of elderly patients that attend to go home the same day they are treated.

The Primary Care Network (PCN), serving the coastal towns and villages of East Kent, has joined forces with its seven member practices to boost patient access and meet growing demand. At the heart of this transformation is an innovative federated model for online consultations, led by a dedicated team of advanced nurse practitioners based within the PCN itself.

Alongside its online consultation service, the PCN delivers 11 additional services on behalf of its member practices—ranging from minor illness clinics and mental health support to physiotherapy, pharmacy consultations, and care for care home residents.

Together, the PCN hub team manages approximately 5,000 online consultations and 1,000 minor illness appointments every month. This approach frees up GPs to focus on more complex patient needs while ensuring faster, more flexible care for the community.

South East Coast Ambulance Service (SECAamb) Unscheduled Care Navigation Hubs involve the Trust’s advanced paramedic practitioners and paramedics working alongside hospital consultants and practitioners as well as community specialists, including frailty leads, to ensure 999 calls receive the most appropriate response, avoid unnecessary trips to A&E, and reduce hospital admissions. Services are being delivered across key sites in Strood, Polegate, Brighton, Banstead, Tongham, Ashford, and Paddock Wood.

Since launch, the hub in West Kent has reduced ambulance conveyances to emergency departments by 8–9%, with ‘see and convey’ rates dropping from 62% (May–Sept 2023) to 52% (June 2025).

This success stems from a growing shift toward alternative care pathways, enabling more patients to be treated on scene or referred to services like SDEC, UCR, UTC, or specialist teams in oncology and falls care. Ambulance clinicians are supported by senior acute and community staff to assess patients holistically and guide them to the right care, first time.

This means frail and complex patients are increasingly cared for in the community—supporting the left shift and ensuring hospitals are reserved for those who truly need them.