Picking people up before they fall

By focusing on prevention and early intervention, the team aims to stop small health problems escalating into crisis.

“We are trying to pick people up before they fall,” said Sulaimon Ayinde, a senior community nurse who has been seconded to the team from her usual role at KCHFT, “rather than catching them once they are already in hospital.”

The team is supporting a group of patients who are living with frailty or multiple, long-term conditions. For this group, even a minor illness or setback can quickly lead to deterioration.

“Previously, if someone in that group had a fall or an infection and it was not something the GP could manage, they would often go straight to hospital,” Sulaimon explained. “What we are creating now is an alternative, GP-led option.”

The Neighbourhood Health Team brings together a range of skills that would previously have been provided by different services. Working closely with a GP, the team includes therapy, occupational therapy, nursing and care coordination, allowing them to respond flexibly to patient needs.

“This team has amazing skills between them,” said Sulaimon. “Together, that gives us a much broader way of supporting people.”

The seconded team are supporting the existing team, which includes care home, pharmacy, minor illness, health and wellbeing and social care support services.

Together, the 20 collective colleagues has revied processes to better support a neighbourhood model, helping to deliver more coordinated care for patients across primary care and community services.

“If you are living with frailty, you need a specialist but all-round approach,” Sulaimon added. “Not just being told you must go to hospital, but asking whether there is another option that works better for you.”

For occupational therapist Debbie Abbott, the value of the model became clear within the team’s first week.

She described visiting an older woman with advanced dementia, who was being cared for at home by her son.

“She was quite frail, had advanced dementia and a suspected infection,” Debbie said. “When we went in, we had to acknowledge the reality of the situation they were in.”

The team recognised that the patient might be approaching the end of her life and that her son needed support as well.

“We made him more aware that now was the time to get additional support in place for both of them,” Debbie explained. The timing was critical, as she explained:

“This was a Friday afternoon in our first week. If we had not gone in, this would have escalated over the weekend, and the route would almost certainly have been hospital. For both of them, that would have been a really negative experience.”

Instead, the team were able to act early, put support in place and prevent an unnecessary admission to hospital, arranging for end-of-life care at home.

Dr Aravinth Balachandran, Clinical Director for Folkestone, Hythe and Rural PCN, said:

“From a GP perspective, this is exactly the kind of system we need for people with complex needs, frailty and multiple long-term conditions. This is an important step in moving from fragmented, reactive care to a more proactive neighbourhood model.”

Dr Sarah Phillips, Chief Medical Officer for Neighbourhoods, said the work reflects a wider change in how care is delivered:

“Neighbourhood health teams are about putting clinical decision-making closer to people’s homes,” she said. “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.”

For Clare Allon, a therapy assistant, being part of the pilot feels like a meaningful shift:

“It feels exciting to be part of something genuinely different. Instead of reacting at the last minute, we are preventing things from reaching crisis point in the first place.”

As the pilot develops, the team is showing how working together, early and locally, can make care safer and more joined up for patients and their families.