One neighbourhood at a time

The Dover INT partnered with housing services and mental health teams to support people at risk of homelessness. Wraparound care – including medication reviews and benefit support – led to fewer crises and stronger community resilience.

Thanet’s INT is supporting patients with multiple long-term conditions, including mental health needs. For patients with multiple long-term conditions who are frequently attending A&E, the Thanet team coordinate care planning, home visits and voluntary sector support. The result? Fewer hospital visits, better health, and a more stable life.

In Canterbury, health and care teams are focusing on housebound patients aged 50 to 70 who have needed at least two home visits in the past year. These patients receive a full assessment from health and social care coordinators, looking at both medical and personal needs.

Care is then planned and coordinated through regular team meetings involving different professionals. This joined-up approach helps patients manage long-term conditions, improves housing and social support and reduces feelings of isolation – making it easier for people to stay well at home.

Late-stage cancer diagnoses were common in Romney Marsh. The INT introduced the ‘Think, Talk, Act’ approach, encouraging early conversations about care preferences. Community nurses, hospices and GPs worked together to ensure dignified, personalised end-of-life care – often at home. Targeted lung health checks identified 43 cancers and stop smoking support reached 595 patients – one of the highest uptakes nationally.

Tonbridge INT created daily huddles with GPs, paramedics, and nurses to plan who should visit each patient. It supports 664 housebound patients, with more than 50 home visits per week. The new way of doing this sees a frailty coordinator triage and allocate visits, this reduces duplication, improves care quality, and ensures patients are seen by the right person at the right time.

Primary care networks have identified patients who are most at risk and worked with care coordinators in the GP practice to proactively manage their care. This has resulted in A&E visits dropping from 223 to 33 in six months for this group of patients, with unplanned GP appointments falling from 671 to 126. That’s empowering the patient, giving you the tools to manage your conditions, supporting you to stay healthier.

GP practices are working closely with local councils and voluntary groups to connect patients with wider support services. They’ve set up a Health and Wellbeing Hub that helps people with everyday needs – like cleaning, shopping, quitting smoking, finding a job, or making friends.

Non-clinical staff help resolve issues quickly, so patients get the support they need alongside their medical care. Feedback has been very positive and this may be expanded to support other teams.

A special home-visiting team is helping frail, housebound patients get the care they need quickly and easily. The team includes GPs, community nurses, paramedics, complex care staff, and a frailty coordinator. They offer one point of contact and clear support pathways.

In one year, the team received more than 1,000 referrals. More than half of these patients didn’t need to be referred elsewhere and 99 per cent of patients, carers, and staff said care was delivered faster than before.

A team of professionals is helping children and young people who are struggling with their mental health. The team includes a GP with extra training, a social prescriber, a mental health expert and staff who support frequent attenders at hospital.

They work with families to reduce stress caused by things like money worries, poor relationships, or lack of access to healthy food. They also help children manage early signs of anxiety and depression through therapy and support.

This service has brought different organisations together and made a real impact – 82 per cent of young people said they felt less anxious and 35 per cent felt less lonely. GP visits dropped by 39 per cent, and emergency department visits by more than 60 per cent.

In Maidstone and the Weald, health and care teams are joining forces to support adults whose mental health hasn’t been improving, even after regular GP visits. These patients are now being discussed in special team meetings that include GPs, community nurses, social workers, and voluntary organisations. Together, they create a care plan with the patient and their family to tackle not just health issues, but also personal challenges like housing problems or loneliness.

This joined-up approach has made a big difference. Patients say their quality of life has improved and they feel healthier. They also need fewer GP and hospital visits –appointments dropped by 54 per cent, and hospital visits by 61 per cent.

In Medway and Swale, INTs are supporting patients with COPD, heart failure, and cardiovascular disease to avoid emergency admissions through proactive care, while others are focused on addressing self-harm in 10 to 24-year olds through tailored community-based support.