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.