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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.
The services we are further developing as part of this work include:
Community-based care services
Virtual wards
Virtual wards support 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 virtual wards 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.
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 testing and reviewing the model of care to ensure 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.
The services we are further developing as part of this work include:
Community-based care services
Virtual wards
Virtual wards support 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 virtual wards 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.
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 testing and reviewing the model of care to ensure 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, 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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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 January 2026, please complete this short form and we will send you more details.
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Page last updated: 22 Sep 2025, 04:33 PM
Project timeline
September - November 2025
Developing co-ordinated community-based care services to support people from being in hospital is currently at this stage
Patient / carer survey to understand current experiences of services.
September and October 2025
this is an upcoming stage for Developing co-ordinated community-based care services to support people from being in hospital
Workshops with clinicians and managers, including the voluntary and community sector.
November and December 2025
this is an upcoming stage for Developing co-ordinated community-based care services to support people from being in hospital
Analysing and consider findings from survey and workshops and start developing the model.
January 2026
this is an upcoming stage for Developing co-ordinated community-based care services to support people from being in hospital
On-line focus group with patients and carers to share findings from survey and workshops and take views on emerging model.
February - March 2026
this is an upcoming stage for Developing co-ordinated community-based care services to support people from being in hospital
Organising stakeholders workshops to refine model.
April 2026 onwards
this is an upcoming stage for Developing co-ordinated community-based care services to support people from being in hospital
Consider findings and further develop model.
Summer 2026
this is an upcoming stage for Developing co-ordinated community-based care services to support people from being in hospital