Community services

We are transforming community services and building capacity so we can deliver more care at home or closer to home, and to improve hospital discharge. Helping people get the care they need, when and where they need it, will help us to keep people healthier and out of hospital. More support in the community will mean people who do need to be admitted to hospital will also be able to access more outpatient services closer to home and outside of hospital.

What are we doing? 

Our priorities are:

Virtual community wards

We are building on the success of our ground-breaking ‘virtual wards’, which allow patients who are well enough to be monitored virtually from their own home instead of from a hospital bed. A dedicated team of highly trained clinical specialists use technology to monitor patients on the virtual ward, allowing them to be cared for safely at home. This is better for the patients, as well as freeing up bed space in hospitals.

All South West London acute trusts already have virtual community wards up and running, with the first community virtual wards launched in Wandsworth in 2011.  We are now developing plans to maximise the rollout of virtual community wards to delivery care for more patients who would otherwise need to be treated in hospital by supporting discharge and providing alternatives to admission. These plans are being developed across the system and provider collaboratives, rather than by individual organisations.

In 2022/23 we are:

• Developing detailed plans to maximise the roll out of virtual wards across South West London, making sure that virtual wards are only used for patients who would otherwise be admitted into hospital.
• Making sure that our virtual wards maintain the most efficient safe staffing and caseload models.
• Managing length of stay in virtual wards by establishing clear admission and discharge criteria.
• Developing plans to fully exploit remote monitoring technology and wider digital platforms to deliver effective and efficient care.

Urgent community response

In 2021/22 we launched the two hour community response services across South West London. These services run from 8am to 8pm seven days a week, with services in Croydon and Sutton offering 24 hour care. The services are able to see patients rapidly within their usual place of residence with the aim to prevent hospital admission. A wide range of services is offered, including but not limited to falls pick-up, urgent catheter care and support in case of unpaid carer breakdown. In 2022/23 we will develop these services by:

• Maintaining rollout of 2 hour community response services and continuing to grow these services to reach more people. We will do this by extending operating hours where needed, with minimum opening times of 8am to 8pm, 7 days a week.
• We are building capacity in these services so that by December 2022 at least 70% of 2 hour crisis referrals are responded to within 2 hours.
• Increasing the number of referrals from all key routes, focussing on a focus on urgent and emergency care services, 111 and 999.
• Improving capacity in post urgent community response services to help patients avoid deteriorating into crisis again and to prevent unnecessary hospital admissions.
• Making sure that workforce plans support increasing capacity and developing skills and competences to support the 2 hours urgent community response service
• Improve data quality and completeness in the Community Services Dataset. This will help us to monitor patient outcomes, system performance and capacity growth.

Proactive care

Proactive care services focus on providing proactive care in the community for people with multiple health conditions and for frail individuals who would benefit most from integrated evidence-based care. This can stop patients deteriorating so that they need urgent emergency care services or need to be admitted to hospital.

Read more about proactive care in South West London.

Enhanced health in care homes

We are developing plans to make sure we deliver consistent and comprehensive coverage of Enhanced Health in Care Homes in line with the national framework.

Read more about enhanced health in care homes in South West London.

Reducing community services waiting lists

We are developing a plan to reduce waiting lists for community service waiting lists. This plan includes developing a trajectory for reducing community waiting lists by prioritising patients most in need of care and transforming service pathways and models to improve effectiveness and productivity.

Improving hospital discharge

All partners across South West London are working together to build on processes developed during the pandemic to make maximum use of beds and capacity in virtual community wards, care homes and hospices to reduce the number of delayed hospital discharges. As well as looking to maintain the improvement in hospital discharges across South West London in 2021/22, we are reviewing all processes to identify where further improvements could be made to get people into the most appropriate care setting for them at the right time.

Investing in digital tools

Digital tools and timely, accurate information are key to delivering improved community services. We are developing digital investment plans that support out-of-hospital models of care and making sure that community health services, including independent providers, can access the Local Care Shared Record.

Read more about digital transformation in South West London.