Our priority outcome: connecting services
Our health and care system can be difficult to navigate, which can lead to worse health. Lambeth Together organisations have committed to working together in a more integrated way. This means doing more work in local communities to help improve the health and wellbeing of residents, address health inequalities, and improve access to support. We’ll do this by focusing on three key areas: integrated neighbourhood teams, Hospital @home and Ageing Well.
Context and key challenges
We face challenges as a health and care system in Lambeth. Our population is getting older, and we have more people who are living with one or more long term conditions. This means that, more than ever, we need to have health and care services that work together to support people holistically.
Integrated Neighbourhood Teams
People have told us they want more support in the neighbourhoods they live in. To address this, we’re introducing ‘integrated neighbourhood teams’. These teams will bring together various support services, into the communities they serve, to make it easier for people to find and receive the care they need.
Integrated neighbourhood teams have been highlighted nationally as a key strategy for improving community health and wellbeing. This approach was emphasised in Lord Darzi’s report1, Clare Fuller’s report2 on primary care and the NHS Guidance for 25/263.
Hospital @home
Hospital @home is one of NHS England’s key focus areas in its Recovery Plan for Urgent and Emergency Care4, which will see more patients being supported and cared for in the place they call ‘home’. This will see more patients being supported and cared for in the comfort of their own homes. In doing so, it will help stop people either being admitted into hospital or reduce the length of hospital stays. This frees up beds locally for people who really do need inpatient care. Ultimately, Hospital @home helps people get the right help, at the right time, in the right place, and tailored to their needs.
Ageing Well
The number of older residents in Lambeth is increasing, and it’s important we make sure our services support people as they get older. We’re working together to become an Age Friendly Borough and the council have led on the development of an Age Friendly Borough plan.
As part of this work, we identified frailty* as one of our priorities for 2024 and beyond. We worked with partners to look at where we can have the biggest impact to support those living with, or at risk of, frailty.
*According to Age UK ‘frailty’ is a term that’s used a lot, but is often misunderstood. When used properly, it refers to a person’s mental and physical resilience, or their ability to bounce back and recover from events like illness and injury.5
What we offer
Integrated Neighbourhood Teams
Integrated neighourhood teams are multidisciplinary groups that provide coordinated, localised care to improve community health and wellbeing. Our aims are to work in this way to reduce health inequalities and enhance the wellbeing of residents through a more personalised and preventive approach. We’ve been exploring how our integrated neighbourhood teams will work and how we can better support residents through these teams.
Lambeth has a strong history of working well together. You can see some examples of the ways we plan to take forward the work of integrated neighbourhood teams throughout this report, including our work on MSK Days, cancer awareness and Hospital@home.
Hospital @home
Since 2013, our Hospital @home service has been growing to help more people get health care at home. In the past year, we’ve expanded our community-based care options to all adults and children with no restrictions, provided they can be treated safely at home. Referrals can come from the community to stop hospital admission or from hospitals to facilitate earlier discharge. For clinical safety, and careful management of capacity, a referral from a health or social care professional is required to access Hospital @home.
Since 2013, our Hospital @home service has been growing to help more people get health care at home. In the past year, we’ve expanded our community-based care options to all adults and children with no restrictions, provided they can be treated safely at home. Referrals can come from the community to stop hospital admission or from hospitals to facilitate earlier discharge. For clinical safety, and careful management of capacity, a referral from a health or social care professional is required to access Hospital @home.
Ageing Well
We’ve collated local data and examples of good practice to develop an Ageing Well programme. Throughout 2024 our work has included:
Health assessments in the community
We want to make sure our ageing well services are more joined up and suit the needs of older people and their carers. Starting in the most deprived parts of Lambeth, we’ve begun to identify residents who are at risk of becoming frail, so we can assess their physical and mental health, as well as social needs. We’ve also been running community days to ensure that people who might not be registered or who don’t ordinarily access their GP are provided with support to prevent symptoms of frailty. Supporting care homes
We created a new care home therapy team to help reduce the risk of falls for residents in care homes. The team:
• Assess each individual resident’s fall risk factors
• Develop personalised plans to improve their balance and strength
• Make changes to the care home environment to make it safer
Our impact
The impact of our work through Integrated Neighbourhood Teams is demonstrated throughout this report. All of our projects involve partners from across Lambeth as we aim to work closer together.
Hospital @home
Hospital @home has achieved:
- A 65% increase in hospital @home capacity from 2023/24 baseline
- The joint Lambeth and Southwark target of 40 to 50 beds per 100,000 population set by NHS England.
- 241 people in Hospital @home beds since December 2024.
- 80% of our beds in use by patients against an 80% target set by NHS England.
- greater consistency in service provision, which has made sure people in Lambeth and Southwark receive the same standard of respiratory care and palliative care, regardless of where they live.
Ageing Well
Our health assessments in the community have allowed us to speak to residents who might not ordinarily access health services. We have created a better experience for patients, improved health, and aims to reduce the need for GP appointments, and hospital admissions. So far, we’ve provided assessments at a number of events in the community, including our MSK Days in Fiveways PCN at Flaxman Centre where we did 14 frailty assessments.
Our next steps
Integrated Neighbourhood Teams
Over the next year we’re going to continue to test and learn models of integrated neighbourhood teams. There are three areas we’ll be focusing on:
- Supporting people with long term conditions
- Supporting people with frailty
- Developing a holistic offer in local communities to support the needs of women and girls mental and physical health needs
Hospital @home
To further develop and strengthen the Hospital @home provision in Lambeth and Southwark we plan to:
- Evaluate our use of remote monitoring, taking account of user experiences including patients and staff. We will use this to identify how this is offered consistently, safely and appropriately to patients as an alternative to face to face care where it is safe to do so.
- Continue to review access to Hospital @home services, with a focus on reducing any inequalities in how these services are provided.
- Make sure there are more seamless transitions across healthcare services, from childhood to adulthood, between specialist care areas (such as respiratory, palliative, and end-of-life care), and from hospital care to long-term community support.
Ageing Well
To further develop and consolidate our Ageing Well aims in Lambeth we will:
- Test a community frailty model in the most deprived part of the borough, to test a partnership team between a primary and secondary care
- Develop online falls prevention training for health and care staff across Lambeth to better support older residents
- Understand and create a neighbourhood approach to wound care so residents who need this support can be seen quicker and have improved self management
- Develop our understanding and use of data, digital and AI to better support residents’ health and care
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