What's happening in Folkestone, Hythe and Romney Marsh?
Andy Cruickshank
In Folkestone, Hythe and Romney Marsh, the NHS is testing a new approach to neighbourhood health, bringing services together around local communities to deliver more proactive, joined-up care.
Working with primary care networks (PCNs) and led by local GP representatives, the area is acting as a pioneer site, helping to show what neighbourhood health looks like in practice and what it will take to do the same thing successfully across the rest of Kent and Medway.
The work is already shaping the wider development of single neighbourhoods across the system, bringing together community health, primary care, mental health, social care and voluntary sector services to better support local populations.
Chief Nursing Officer for the Integrated Neighbourhood Health programme, Andy Cruickshank said: “What we are building in Folkestone, Hythe and Rural is helping shape the future of neighbourhood health across Kent and Medway.
“This is about health and social care organisations and the voluntary and community sector, working differently together for patients, intervening earlier and making care feel more connected and meaningful.”
Dr Sarah Philips
Kent and Medway's Chief Medical Officer for Neighbourhoods, Sarah Phillips said: “For colleagues we are saying: you are one team. You’re not separate services — you are working together for all our patients. We are redesigning how this works in practice, through pioneering three models of care.”
Organisations involved in the Folkestone, Hythe and Romney Marsh pioneer
There are three primary care networks (PCNs) involved in this work, along with Kent Community Health NHS Foundation Trust, Kent and Medway Mental Health NHS Trust, East Kent Hospitals NHS Foundation Trust and local groups and services.
Primary care networks (PCNs) are groups of surgeries working with community, mental health, social care, pharmacy, hospital and voluntary services, to offer more personalised, coordinated health and social care to people in their area.
Each PCN is involved in testing a specific new model of care.
Read more about the three models of care
Read more about the three models of care, how they are being delivered and how they are transforming care for patients in Folkestone, Hythe and Romney Marsh. We will be adding learning and case studies to each of these as we progress the programme.
Reactive care: Rapid support closer to home
In Folkestone, Hythe and Rural PCN, a new Neighbourhood Health Team is piloting a more joined-up approach for people living with frailty and complex needs.
The neighbourhood health team
The team provides urgent, hospital-level care at home for frail and housebound patients, helping avoid unnecessary admissions.
The multidisciplinary team includes dedicated GP input five days a week, alongside nursing, occupational therapy, therapy support and care coordination - enabling a rapid and coordinated response around patient needs.
Patients identified within the highest-risk groups can be referred for same-day urgent support, as their need is flagged on their GP record.
The model began with one GP practice and is now expanding, covering a significant proportion of the PCN population.
Referrals are also starting to come via the clinical navigation hub, shared with the ambulance service, which reviews 999 calls to assess whether patients can be safely treated at home, rather than being taken by ambulance to hospital.
For Occupational Therapist Debbie Abbot, the impact of the model became clear during the team’s first week, when colleagues supported a patient with advanced dementia and a suspected infection at home.
“If we had not gone in, this would have escalated over the weekend, and the route would almost certainly have been hospital,” Debbie said.
Instead, the team intervened early, coordinated support for the patient and her family and prevented an unnecessary admission.
“What we hope is that a patient tells their story once,” Debbie added, “rather than being passed between services and starting again each time, we coordinate around them.”
What are we learning?
- multidisciplinary teams improve responsiveness and coordination
- dedicated GP input is particularly important for frailty
- earlier intervention can help prevent avoidable hospital admissions.
Read about how the team kept Margaret at home:
Proactive care: Helping people to stay well
In Folkestone and Hythe, teams are taking a targeted, proactive approach to care, starting with the patients who need it most. By identifying and supporting the 100 people at highest risk of their health deteriorating, services are stepping in earlier to prevent crisis and avoid hospital admissions.
This work is supported by a nationally recognised risk stratification approach, which uses data and clinical insights to group patients by level of need. This helps teams quickly identify those most at risk and prioritise coordinated, preventative support.
For the Total Health Excellence West (THEW) primary care network, this way of working is already well established. Multidisciplinary teams meet fortnightly to review patients at highest risk, bringing together GPs, community health, pharmacy and social prescribing to agree joined-up care plans.
Janet (left) and Sally Simkiss
One example is Janet from Folkestone. Before being supported, she was living with multiple long-term conditions, experiencing isolation and struggling to manage day-to-day life. Care coordinator Sally Simkiss recognised early on that without intervention Janet’s health was likely to deteriorate.
“When I reviewed her records, I could see straight away that if we did not act, she would probably end up in hospital,” Sally said.
Working alongside GPs, KCHFT’s Integrated Pharmacy Team, community nursing and social prescribing colleagues, Sally coordinated practical and clinical support tailored to Janet’s needs.
Today, Janet is living independently and has rebuilt her confidence and social connections.
“She was like sunshine walking through the door,” Janet said of Sally’s first visit. “The difference with Sally is that she does not come once and disappear. She rings. She pops in. She notices things.”
Building on this success, teams across Folkestone and Hythe have systematically reviewed their 100 highest-need patients - checking records, putting advance care plans and ReSPECT forms in place, and proactively contacting each individual to offer support.
The first cohort has now been completed, with the next 100 patients already underway.
Alongside this, a new directory of services is being developed through the Joy app, helping professionals connect patients to local voluntary and community support more easily. Work is also underway to integrate this into GP clinical systems.
THEW also hosts a social care Multidisciplinary Team (MDT), which unites GPs, dedicated care coordinators, clinical pharmacists and mental health professionals into a single, cohesive unit.
The MDT collaborates in joint clinical meetings to build singular, personalised care packages. By directly linking frontline NHS medicine with community social services and voluntary sectors, this proactive service supports individuals to manage long-term conditions safely at home. It also provides vital relief to unpaid family carers.
What are we learning?
- earlier intervention helps prevent deterioration
- joined-up teams improve patient confidence and independence
- relationships between services are critical to prevention.
Read more in our online articles:
Outpatient care: bringing care closer to home
On the Romney Marsh, the pioneer programme is testing how outpatient and preventative care can be delivered closer to home.
This work recognises the challenges some residents face travelling to hospital appointments, particularly in rural and coastal communities.
More than 600 patients have helped to identify the barriers to accessing care by answering questions about what it’s like to attend hospital appointments – from the good to the bad.
The model is focused on:
- improving early diagnosis
- strengthening end-of-life care
- increasing community-based outpatient appointments
- improving coordination between services
- expanding advice and guidance between clinicians.
The aim is to reduce unnecessary travel while making care feel more connected and accessible for patients.
So, what are we learning?
The pioneer site has highlighted that different communities need different approaches, so flexibility is important, while local organisations, support groups and community networks all have a vital role to play in helping people stay well and independent.
Key learning also shows that involving teams in designing services helps drive new ideas and stronger engagement. We are also seeing how important strong relationships and shared responsibility are in making neighbourhood working successful.
Sarah Phillips, Chief Medical Officer for Neighbourhoods, said: “Neighbourhood health teams are about putting clinical decision making closer to people’s homes. By bringing professionals together around patients with the most complex needs, we can intervene earlier, prevent deterioration and offer care that feels more personal, coordinated and humane.”