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Developing our Clinically-led Strategic Plan for South West London – insight from local people and communities around planned specialist care

This report details the insight about planned specialist care from people and communities to inform the NHS South West London Clinically-Led Strategic Plan. This is an opportunity to design a sustainable, effective health and care system that meets the needs of our communities now and in the future. 

NHS South West London are developing a Clinically-Led Strategic Plan.  The plan will be underpinned by high-quality evidence, analysis and insight, and shaped through insight and engagement with patients, the public and partners across the system. This is an opportunity to design a sustainable, effective health and care system that meets the needs of our communities now and in the future.   

This will include looking at:     

  • understanding and predicting the future health needs of our local population in South West London    
  • our clinical outcomes in South West London compared to national best practice    
  • local operational data that shows we are performing for patients    
  • workforce intelligence to support frontline staff to reshape services and work in new ways    
  • insights from the experience of patients, local people and communities who want more control to manage their own health.   

To help inform clinically-led discussions, the South West London ICB community engagement team provided an overview of insights gathered from people and communities on the following areas:   

1. Frailty

2. Maternity and neonatal

3. Mental health

4. Planned specialist care (end-to-end care from outpatients to intervention)

5. Long term conditions

6. End of life care

A series of clinically-led workshops are bringing together partners to discuss each area, between October and early 2026. This insight on what matters most for communities was presented at the beginning of each specialist workshop.   

What we did     

The South West London community engagement team undertook a desk top literature review of insight for each of the specialist clinical areas each workshop is focusing on, pulling out key themes from multiple insight sources to show ‘what matters most to people and communities’.      

We started by mapping sources of local existing insight for each area, drawing on reports from partners locally and relevant regional and national reports.  A nominated member of the team was responsible for coding and theming the insight for each topic – pulling out the consistent and frequent themes.  All the reports we analysed are included in the reference section of ‘Sources of insight’ for each clinical area. 

Insight from people and communities

Insights from people and communities

These are the top themes we have heard from people and communities about planned care.

Long waiting times for referrals, diagnostics tests, results and surgery

  • People highlighted slow referrals to specialist services, delays to or multiple cancellations of planned appointments, with some having to wait over a year for treatment or for a diagnostic test like an MRI.
  • Waiting times are a concern for some groups, including older people, people with long term conditions and those with sight loss or diabetes.
  • People felt that delays negatively impacted both their health and emotional wellbeing. In some cases, people said they wouldn’t seek help until the situation became a crisis, or they would give up completely, even if they know they needed urgent help.
  • While people feel the system performs well in urgent cases such as potential cancer diagnoses, there is less confidence when it comes to non-urgent diagnostic testing.
    • “It can get so much worse while I’m waiting for my next appointment or to be referred.”
    • “They cancelled my appointment 5 minutes before. It was for a test I’d been anxious about for days.”

Recovery, discharge and aftercare

  • Experiences of leaving hospital include rushed discharges and lack of aftercare and follow up.
  • People said they weren’t given opportunities to ask questions or receive clear information about their medication or aftercare, leaving them feeling “vulnerable”.
  • Those with dementia, a disability and people who do not have English as a first language feel especially disadvantaged when the support given isn’t clear or accessible.
  • People, feel like there is disconnect between the hospital and support services in the community which can make the transition from hospital to home more difficult and add pressure to family and carers. One person described feeling “pressured to find someone to be at home with them while not feeling well enough to go home”.
  • There are calls for family members or carers to be more involved in the plans for people leaving hospital to avoid unnecessary strain on those supporting the person leaving hospital. 
    • “I feel they push you out the door and sent home with no follow up”.
    • “After care can be quite sketchy depending on whom you speak with. Not all information is readily accessible”
    • “Need more help to support people leaving hospital- there aren’t enough community rehab services so people get ill and go back into hospital, revolving door”.

Clear and confident communication between services and patients

  • It can feel for some patients that coordination between hospital teams, diagnostic services, community care and GPs is not always joined up. They describe feeling as though they are being “passed from pillar to post” without NHS staff being able to provide clear answers. It can leave people feeling like they need to manage their own admin themselves, and chase referrals and results.
    • “Communication is key around diagnostics, and it is often very poor. People are often left unsure of who will receive their results and when.”
  • People want to be kept informed about what’s happening with their care, especially after past experiences of referrals or results not being shared or not being told what happens next.
    • “There is no real effort made to explain rather we are rushed off with pamphlets”.
  • People would like to choose their preferred mode of communication; for example, if they receive texts, emails, or letters.
    • “Some centres will text you – which is great, and others will just send a letter”

Common barriers – transport, digital, and affordability 

  • It can be harder for people to organise transport to planned care appointments. People described difficulty getting to appointments because of limited public transports options, inaccessible routes and stress around hospital parking. Changes to eligibility for NHS transport are causing issues for people. These issues particularly affect older people, disabled people, carers, low-income households and those who live in less well-connected areas like New Addington and East Merton.
    • “People get very anxious about transport to get to and from hospital appointments and worry about being late and getting lost.”
    • “Blindness is no longer a criteria for NHS transport and he struggles to get there.”
  • Booking planned care appointments online can be challenging, particularly for older people and those with limited English.
  • Financial pressures make it harder for people to access services. The rising cost of living and travel expenses mean that some people are having to choose between paying for appointments or other essentials such as food.
    • “A resident reported having to go with eating for a day after having to taxi to hospital.”

Involving and supporting carers

  • Carers often reported they are not equipped with the information needed to provide support for the person they care for when they return home from hospital. In some cases, they are not involved in the discharge planning, and feel their views are dismissed.
    • “Carers are either not being involved in discharge planning until the last minute, or feeling their views are being dismissed”.
  • Some carers said they felt emotionally pressured by health and social care professionals when they explained they couldn’t continue providing care. In some cases, people described being told they didn’t care about the person if they left them in hospital or being accused of being selfish.
  • Carers said they value the times GPs have checked in with how they are doing, following the discharge of the person they care from hospital.
  • Carers and families want more support and access to respite to help prevent burnout.

Continuity and coordination between services

  • People want to see the same health and care professional so they don’t have to repeat their story at every appointment. This was especially important for those with long-term conditions, neurodiversity, learning difficulties and physical disabilities, who really valued continuity of care.
    • “No-one really knew her at the service as every time she goes, she sees someone else.”

Tackling inequalities and making care more inclusive

  • People want care that recognises their communication needs and background and beliefs.
  • For those who do not have English as a first language, the communication issues between services and patients are more prevalent and in general people expressed frustration with trying to navigate the NHS. People would like more interpreting and translation services.
  • It makes a difference to patients when staff understand their lived experiences and they welcome more culturally relevant health information.
    • “We need to see more experts with lived experiences getting involved, especially Black and Brown Voluntary Groups.”

Joined up community care and considerations

  • People welcomed the idea of more services being provided in the community rather than in hospitals however, for this to work well, people feel communication and integration between hospital and community services needs to improve.
    • “Put measures in place for self-management prior to discharging home from hospital. Have more communication between the hospitals and community teams to enable safer discharges home.”
  • People felt concerned that a shift from hospital to community might mean that families and carers would need to take on more responsibility of care.  People were concerned that this might place significant burden on families and potentially impact on their work, personal life and wellbeing.

Virtual wards

  • People appreciate being able to get better in a familiar setting, such as their home, surrounded by their friends and family. Virtual wards are seen as a positive step that could support recovery and saw the benefits of also freeing up hospital beds. 
  • Some people have concerns about the effectiveness of remote monitoring and if it could be as reliable as physical observation.
    • “Sometimes it needs a person to lay eyes on you to see other vital signs”.
  • Some are worried that digital barriers may lead to older people or people from low-income households not being able to be monitored virtually if they do not have the right equipment or what the cost of energy bills would be.

Diagnostics services closer to home

  • The convenience of Community Diagnostic Centres (CDCs) closer to home is appealing. People said they are more likely to attend an appointment if it was closer to home.
  • They like that they will be able to avoid longer travel time and parking issues by attending an appointment at a Community Diagnostic Centre, especially those with mobility issues. 
  • Care provided in a familiar environment is a positive, as people would like less hospital visits which can be overwhelming.
    • “Would be fab to have non-hospital based, pure diagnostic centres to speed process”.
  • However, some people are concerned that alongside the development of Community Diagnostic Centres there would also need to be improvements in communication and better joining up between services – “just bring some of these issues closer to their doorstep”.

Sources of insight

These are the reports we have used in this summary of insights around planned care. We have used reports from our South West London insight bank drawn together from engagement work across South West London including from our Healthwatch and VCSE partners:

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