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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.
What we heard from people
We have received feedback on what is working well and what could be better about virtual wards and urgent response teams through a survey we carried out in October and November 2025. Participants welcomed 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.
Promoting better understanding across wider health and care services including NHS 111 and the London Ambulance Service, as well as with the public about what these services offer and which health and care professionals can provide care as part of them
Co-ordination between different services is key to support people at home and keep them out of hospital, particularly when people have complex needs or are coming to the end of their life.
To expand or change the hours of operation of the services.
The need to have access to advice and reassurance out of hours and especially over night and the importance of having a name coordinator when the person or the person being cared for has complex needs or is coming towards the end of their life
Having mental health specialist teams as part of virtual wards.
Use of technology is key to support people being cared for at home as well as timely access to results.
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.
Listening to local people
In October 2025 we attended the 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 care services.
We carried out a survey in October and November 2025 to understand the experiences of using urgent community response services or virtual wards. You can read the findings here. We explored these issues in more depth in a focus group in March 2025.
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.
Some key actions include:
Working with hospitals and community providers to standardise urgent community response and Virtual Ward/Hospital@Home services and join them up so that patients are able to move between service seamlessly.
Share the insight and findings with NHS England London team and also hospitals providing services to help focus on key areas of improvement.
Incorporate feedback received into the development of a single point of access/integrated care co-ordination hub.
Feedback to commissioners of 111 and 999 services to ensure that patient views are taken on board.
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.
What we heard from people
We have received feedback on what is working well and what could be better about virtual wards and urgent response teams through a survey we carried out in October and November 2025. Participants welcomed 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.
Promoting better understanding across wider health and care services including NHS 111 and the London Ambulance Service, as well as with the public about what these services offer and which health and care professionals can provide care as part of them
Co-ordination between different services is key to support people at home and keep them out of hospital, particularly when people have complex needs or are coming to the end of their life.
To expand or change the hours of operation of the services.
The need to have access to advice and reassurance out of hours and especially over night and the importance of having a name coordinator when the person or the person being cared for has complex needs or is coming towards the end of their life
Having mental health specialist teams as part of virtual wards.
Use of technology is key to support people being cared for at home as well as timely access to results.
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.
Listening to local people
In October 2025 we attended the 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 care services.
We carried out a survey in October and November 2025 to understand the experiences of using urgent community response services or virtual wards. You can read the findings here. We explored these issues in more depth in a focus group in March 2025.
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.
Some key actions include:
Working with hospitals and community providers to standardise urgent community response and Virtual Ward/Hospital@Home services and join them up so that patients are able to move between service seamlessly.
Share the insight and findings with NHS England London team and also hospitals providing services to help focus on key areas of improvement.
Incorporate feedback received into the development of a single point of access/integrated care co-ordination hub.
Feedback to commissioners of 111 and 999 services to ensure that patient views are taken on board.
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 February or March 2026, please complete this short form and we will send you more details.
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Page last updated: 13 Mar 2026, 06:04 PM
Project timeline
September - November 2025
Developing co-ordinated community-based care services to support people from being in hospital has finished this stage
Patient / carer survey to understand current experiences of services.
September and October 2025
Developing co-ordinated community-based care services to support people from being in hospital has finished this stage
Workshops with clinicians and managers, including the voluntary and community sector.
November 2025 - February 2026
Developing co-ordinated community-based care services to support people from being in hospital has finished this stage
Analysing and consider findings from survey and workshops to develop a case for change and action plan
March 2026
Developing co-ordinated community-based care services to support people from being in hospital is currently at this stage
On-line focus group with patients and cares to share findings from survey and consider issues in more depth
April 2026 onwards
this is an upcoming stage for Developing co-ordinated community-based care services to support people from being in hospital
Start developing the future service model based on the case for change and action plan
Summer 2026
this is an upcoming stage for Developing co-ordinated community-based care services to support people from being in hospital
Plan the implementation of the model to start from January – March 2027
