Developing co-ordinated community-based care services to support people from being in hospital

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NHS South East London is planning to further develop community-based services as alternatives to people having to be admitted to hospital. We know from earlier engagement work that people find it hard to know where to go to access care. As part of our approach we want to develop a central place through which people are referred to these services - this is called a single point of access or an integrated care co-ordination hub.

We have received feedback on what is working well and what could be better about virtual wards and urgent response teams. Participants welcome services at home, the kindness and compassion of people who visited and knowing how to contact the virtual ward team. We also heard that communication could be better in some circumstances including active listening to patient and carer views and knowing when people were going to visit. In some cases, carers had to spend a lot of time contacting different services to be able to get the right urgent response service . You can read the full report here.

The services we are further developing as part of this work include:

Community-based care services

Virtual wards (now known as Hospital at Home)

Hospital at Home supports patients who become ill whilst at home as well as patients who need support on discharge from hospital.

  • Patients receive hospital level care in their own homes (or in care home) as part of the virtual ward service.
  • Each patient is assessed to see whether a virtual ward is suitable for them and if it is, they are given an individual treatment plan.
  • Patients may also be provided with technology or devices that monitor key issues such as temperature, blood pressure and oxygen levels which is then reviewed by a clinical team regularly.
  • Patients on a virtual ward are reviewed daily by a clinical team either by a home visit or by a video call.

We already have a number of Hospital at Home services in south east London, which can provide services to around 580 people at any one time. Services are provided by a combination of clinicians from hospitals, community services, general practices and pharmacies, and hospices. Our virtual wards support patients with a range of needs including respiratory illness, palliative care and those requiring intravenous (IV) antibiotics or physiotherapy. We also have wards which specialise in helping children.

Urgent community response teams

Urgent community response teams provide urgent (within two hours) care to people in their homes helping them avoid having to be admitted to hospital and helping people live independently for longer.

  • Older people and adults with complex health needs, such as multiple long term conditions or who are very frail, who urgently need care, can get fast access to a range of health and social care professionals within two hours. This includes access to physiotherapy and occupational therapy, medication prescribing and reviews, and help with staying well-fed and hydrated.

These teams work from 8 am – 8 pm, seven days a week across all of south east London.


How can you get involved?

If you have experience of community-based care through an urgent community response team or virtual ward we would like to hear from you. We want to learn more about your experience of using these services to inform further development and improvements.

Listening to local people

On 4 October 2025 we attended Ageing well - festival in Bexley which gave us the opportunity to listen to local people and hear their stories and their views in Community-based are services.

Next steps

Your feedback and recommendations will be used to look at what works well and what we can improve. In addition to your feedback, we are working with clinicians and learning from similar services in other parts of London. Following this we will be developing a case for change and action plan. We will then develop a model of care which we will further test and review before implementation to ensure that the services provided are accessible and equitable.

NHS South East London is planning to further develop community-based services as alternatives to people having to be admitted to hospital. We know from earlier engagement work that people find it hard to know where to go to access care. As part of our approach we want to develop a central place through which people are referred to these services - this is called a single point of access or an integrated care co-ordination hub.

We have received feedback on what is working well and what could be better about virtual wards and urgent response teams. Participants welcome services at home, the kindness and compassion of people who visited and knowing how to contact the virtual ward team. We also heard that communication could be better in some circumstances including active listening to patient and carer views and knowing when people were going to visit. In some cases, carers had to spend a lot of time contacting different services to be able to get the right urgent response service . You can read the full report here.

The services we are further developing as part of this work include:

Community-based care services

Virtual wards (now known as Hospital at Home)

Hospital at Home supports patients who become ill whilst at home as well as patients who need support on discharge from hospital.

  • Patients receive hospital level care in their own homes (or in care home) as part of the virtual ward service.
  • Each patient is assessed to see whether a virtual ward is suitable for them and if it is, they are given an individual treatment plan.
  • Patients may also be provided with technology or devices that monitor key issues such as temperature, blood pressure and oxygen levels which is then reviewed by a clinical team regularly.
  • Patients on a virtual ward are reviewed daily by a clinical team either by a home visit or by a video call.

We already have a number of Hospital at Home services in south east London, which can provide services to around 580 people at any one time. Services are provided by a combination of clinicians from hospitals, community services, general practices and pharmacies, and hospices. Our virtual wards support patients with a range of needs including respiratory illness, palliative care and those requiring intravenous (IV) antibiotics or physiotherapy. We also have wards which specialise in helping children.

Urgent community response teams

Urgent community response teams provide urgent (within two hours) care to people in their homes helping them avoid having to be admitted to hospital and helping people live independently for longer.

  • Older people and adults with complex health needs, such as multiple long term conditions or who are very frail, who urgently need care, can get fast access to a range of health and social care professionals within two hours. This includes access to physiotherapy and occupational therapy, medication prescribing and reviews, and help with staying well-fed and hydrated.

These teams work from 8 am – 8 pm, seven days a week across all of south east London.


How can you get involved?

If you have experience of community-based care through an urgent community response team or virtual ward we would like to hear from you. We want to learn more about your experience of using these services to inform further development and improvements.

Listening to local people

On 4 October 2025 we attended Ageing well - festival in Bexley which gave us the opportunity to listen to local people and hear their stories and their views in Community-based are services.

Next steps

Your feedback and recommendations will be used to look at what works well and what we can improve. In addition to your feedback, we are working with clinicians and learning from similar services in other parts of London. Following this we will be developing a case for change and action plan. We will then develop a model of care which we will further test and review before implementation to ensure that the services provided are accessible and equitable.

  • CLOSED: This survey has now closed.

    Experience of virtual wards or urgent community response services

    NHS South East London is planning to further develop community-based services as alternatives to people having to be admitted to hospital.  We know from earlier engagement work that people find it hard to know where to go, so as part of this work, we also want to develop a central place through which people are referred to these services - this is called a single point of access or an integrated care co-ordination hub.  

    We want to understand your experiences, or the experiences of a person you look after, to help us do this. Please take a few minutes to fill in the short survey

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  • Sign up to help us developing co-ordinated community-based care services to support people from being in hospital

    If you have experience of community-based care through an urgent community response team or virtual ward  and are interested to be involved and attend one of focus group to take place in February or March 2026, please complete this short form and we will send you more details. 

    It takes two minutes to complete.

    Complete Form
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Page last updated: 17 Nov 2025, 12:38 PM