Shifting care from hospital to home saves £830k a year in North Kent

HRCG Care Group partnered with Dartford and Gravesham NHS Trust and Kent & Medway ICB to deliver an ambitious integrated community model. With a £4.2m shift of acute funding into community-based care across Dartford, Gravesham and Swanley (DGS), we aimed to support patients to either get home faster or avoid readmission – ultimately reducing the overall need for hospital-based escalation beds.

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An ambitious collaboration that:

1. Releases thousands of patient bed days

2. Is expected to deliver £830k in savings annually

3. Is nominated in HSJ’s 2026 Partnership Awards

Solving the North Kent challenge

Pressures were rising across Dartford, Gravesham and Swanley’s health and care system – from rising hospital admissions and constrained community capacity to a growing number of ‘no longer fit to reside’ patients (NLFTR). To solve this, our partnership delivered a unified community model that supports the national ambition for a ‘left shift’ of care.

HCRG Care Group’s work in DGS has become an exemplar for integration across Kent and Medway. It demonstrates how independent providers can be trusted, equal partners in delivering safe, effective and compassionate care closer to home. What sets this partnership apart is its culture – a genuine commitment to collaboration, transparency and patient-centred innovation. The teams are proactive, solutions-focused and willing to adapt, always asking, ‘What will make this better for the patient?’ The local leadership has also been exemplary – visible, accountable and deeply engaged with system partners.

HCRG’s management team demonstrates clarity of vision, operational grip and a genuine commitment to collaborative working. They listen, respond and act swiftly to emerging challenges, creating a culture where staff feel empowered to innovate and make decisions in the best interests of patients.

The combination of compassionate leadership and operational discipline has been instrumental in sustaining improvements and maintaining confidence across the system – and it ripples up, down and across their organisation and into system partners.

Rebecca Pullen, Associate Director for System Discharge and Flow, NHS Kent and Medway

The model combines three interlinked programmes

It’s designed to deliver seamless coordination between acute, primary, community and social care – providing
more care closer to home, preventing unnecessary admissions and accelerating safe discharge.

1. Virtual ward expansion

Doubling capacity from 20 to 40 ‘beds’ helps to provide safe, multidisciplinary care at home for people who may otherwise require hospital admission. Established virtual ward pathways include heart failure, COPD, frailty and IV antibiotics, where patients are safely managed at home on virtual wards with daily multidisciplinary input, advanced monitoring and rapid access to escalation support.

Patients are also able to avoid hospital-acquired infections, prevent deconditioning and loss of independence – maintaining their quality of life while reducing demand for ongoing, high-cost care.

Patients like Mr K are reporting higher satisfaction, reduced anxiety and better recovery:

I’m 96 years old and have lived with many complicated health conditions for many years – heart failure, angina, COPD, and high blood pressure among them. I live alone, but my family visits often, and I’ve always managed my daily routines independently. I am under the care of the community Heart Failure Nurse Specialist, who upon a review and my presenting symptoms felt my medication needed to be adjusted. I was therefore referred into the community virtual ward, (which I knew nothing about and thought it was a bed somewhere!). My nurse explained that I would receive the extra health care support in my own home and didn’t need to be going to hospital. My nurse managed my access to this fabulous virtual ward and continued to work alongside the Home Ward Nurse – keeping a close overview on how I was responding.

Once my condition settled on the new medication the nurses agreed I could be discharged from the ward and stay back under my specialist nurse care. A kind clinician came to my home with a Docci kit and explained it would be monitoring my heart every 15 minutes and very cleverly sending the results to them to view. My daughter was with me, and together we learned how to use the equipment. I felt confident using it myself. My heart rate improved and I was able to stay at home, continue cooking, looking after myself, and seeing my family, all while knowing my health was being closely watched.

I’m truly grateful for the care I received. My community ward kept me safe and helped me avoid a hospital stay. The Docci kit gave me and my daughter peace of mind, and I felt supported every step of the way. It’s amazing what can be done from home with the right care support.

Mr K

7,300 extra community bed days per year

By doubling virtual ward capacity from 20 to 40 places, we expect to save £830k compared to inpatient bed days.

2. A Community Transfer of Care Hub

We expanded and enhanced the existing discharge model to deliver a seven-day-a-week service – a single point of discharge led by a community-based team that triages patients, sources community or social care packages, and ensures safe discharge. Uniting acute, community, social care and voluntary sectors into one team swaps traditional barriers and handoffs for proactive, multidisciplinary and person-centred discharge – a ‘left shift’ of care that allows people to recover in the right environment, leading to improved long-term outcomes.

Through the hub we’ve delivered measurable, system-wide improvements in discharge performance, which have directly contributed to enhanced hospital flow, reduced bed-occupancy pressures, and better resource utilisation across DGS.

Enhanced visibility and collaboration

In-reach nurses form a vital part of daily ward rounds, MDTs and frailty meetings. This ensures the discharge process begins at admission and that patients are referred promptly to the correct pathway.

Improved system flow and capacity

We’ve reduced ‘no longer fit to reside’ numbers, with daily calls providing live oversight of patient flow and immediate resolution of discharge barriers – often within 24-48 hours of being medically fit. This improves system resilience, especially during peak periods.

Optimised community bed usage

Early identification of patients who are suitable for rehabilitation or assessment beds increases occupancy efficiency while reducing unnecessary hospital stays.

High quality assessment and placement

Comprehensive clinical assessments ensure each patient’s needs are fully understood, improving the appropriateness of placements and reducing readmissions.

95% of care assessments now take place outside acute settings

This is in line with best practice and national policy.

3. MDT Coordinators

To support development and roll out of Complex and Frail Integrated Neighbourhood Teams, MDT Coordinators are now in post, enriching the offer across all PCNs. Using data from the acute trust, coordinators identify patients who’ll benefit most from the INT model, offering support to avoid deterioration and better manage long-term conditions.

I’ve been living with a spinal cord condition since childhood – and also have diabetes. Recently, I was referred to a team of health professionals to help me manage my care better and make decisions that work for me. My team includes my GP, community nurses, a diabetes specialist nurse, physiotherapists, and my care agency – all supported by a team member whose role is to ensure my care is well coordinated.

At first, things were difficult as I wasn’t always following the advice given, and I didn’t want to use a hoist for moving, even though it was recommended for my safety. This put me at risk of pressure sores because I wasn’t moving enough. The team arranged a joint visit to talk things through with me through a multi-disciplinary approach that was explained to me. I met my team MD coordinator and my concerns were listened to. Together we agreed on small daily goals to help me stay mobile. They also supported me in making sure I had the right hygiene items.

Since then, things have improved a lot. I feel more involved in my care and understand why these changes matter. I’m moving more, I’ve started providing my own hygiene supplies, and I feel more positive about working with the team.

I’m grateful for the support and patience shown by everyone. It’s made a big difference to my confidence and independence.

Neighbourhood case study

A model that balances prevention and flow

Together our three interlinked programmes form a reproducible framework for system-wide left-shift, which now informs integrated neighbourhood and virtual care planning across Kent & Medway:

1. Virtual wards prevent admission at the front end

2. The Care Hub ensure timely discharge at the back

3. MDT Coordinators and INTs support patients to stay well and manage their conditions in the community

Recommendations for system-wide transformation

Kent & Medway commissioners are already looking at how the DGS approach could be implemented by other Health and Care Partnerships in the area. NHS England, Medway Council and other regional systems have commended the clarity of our virtual ward and care hub roles, as well as their shared governance and measurable results.

1. Joint investment and leadership

Shared job roles between HCRG, the acute trust and Kent County Council have broken organisational barriers.

2. Standardised operating procedures

Referral process, patient information and escalation protocols are available for replication.

3. Transparent data sharing

Real-time dashboards ensure collective accountability for community capacity and patient flow.

4. A culture of collaboration

Regular multidisciplinary huddles replace siloed communication, which accelerates decision-making.

5. Cross-system learning

Presentations at the Kent Integrated Care Partnership and Integrated Neighbourhood Team Early Implementer events have shared outcomes and best practice.

6. Workforce enablement

Introducing MDT Coordinators across seven PCNs has created a replicable structure for community coordination, linking voluntary, primary and mental health sectors.

7,300 acute bed days saved in 2024-25

With another 4,000 acute bed days so far in 2025-26.

HCRG’s work in shifting care from hospital to home represents true partnership – driven by shared values, mutual respect and a focus on doing what is best for our patients and communities. Their compassionate leadership and collaboration across our system have strengthened neighbourhood-based care and enabled an integrated approach between primary, community, social care and acute services. Through the expansion of the Virtual Ward model, the development of the Community Transfer of Care Hub and their contribution to Integrated Neighbourhood Teams, HCRG has not only improved flow and reduced hospital pressures, but also ensured that more patients receive timely, holistic care in the community. These initiatives have enhanced continuity, empowered primary care teams and delivered tangible improvements in outcomes, patient experience and staff morale. The partnership has fostered a culture of shared responsibility and real-time problem-solving across organisational boundaries, exemplifying the ambition of the NHS Long Term Plan and the integrated neighbourhood model we aspire to deliver across Kent and Medway.

Dr Julie Taylor, Primary Care Medical Director, DGS Health and Care Partnership

Recognised at the HSJ partnership awards

Highly commended: Best provider of community and primary care

Nominated: Most effective contribution to integrated health and care

Nominated: Primary and community care project of the year

Access our community-based care model

Contact HCRG to see how the North Kent blueprint can be adapted for your health and social care system.

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