Improving local care

Improving Local Care in Dartford, Gravesham and Swanley

We are working closely with GPs, health and social care partners and the voluntary sector to invest in new services and change the way we work to provide the best possible care for you at home or in your local community.  This is called local care.

In this section, we explain why we need to make the changes, the challenges we face and what we are doing to improve local care in your area.

Dr Sarah MacDermott explains the vision for Local Care in north Kent:

Why do things need to change?

Here are some of the challenges we are facing in Dartford, Gravesham and Swanley:


  • Our local population is growing and people are living longer. We are also caring for more people living with long term conditions like diabetes, heart disease and asthma, or who suffer from mental health issues.  People living in our poorest communities are more likely to develop serious illnesses or die at a younger age.


  • GP services are at the heart of local care in Dartford, Gravesham and Swanley, and we have worked hard with our general practices to raise the quality of care provided for patients. Despite this, GP practices are under increasing pressure due to the national shortage of GPs and nurses, along with the need to care for more patients.


  • Many people, and particularly older people who are frail and those with complex needs could be better cared for in their own home (your own bed is the best bed), rather than in hospital. This means that we need to put more services in place to care for people at home.
  • Working as we are now, there aren’t enough nurses, therapy staff and social care workers to fill our vacancies, and like elsewhere in the country, we are facing challenges with recruiting.
  • A lot of our community teams of staff could work better together in a more joined-up way, so that patients do not have to repeat their story many times.
  • There are pressures on budgets and we need to make sure that we get the best value for the money we have available.

If we carry on working the way we are, then we won’t be able to meet the current and future needs of local people within our existing budgets.  That’s why we need to reorganise the way we work to increase the quality of local care in Dartford, Gravesham and Swanley.

How are we tackling these challenges in Dartford, Gravesham and Swanley?

We have been working closely with our partners in the NHS, local government and the voluntary sector on a local care plan to make sure that people in Dartford, Gravesham and Swanley get the care they need in the right place and at the right time.

This is the first time that we have all worked together in this way and all the partners have been involved in shaping the local care plan.  It gives us a real opportunity to bring about positive changes and improvements in the way we deliver health and social care.

The Local Care plan focuses on improving care for older people who are frail and patients with complex health conditions to help them stay well and independent in their own homes. By delivering joined-up care at home this will avoid a number of patients being admitted to hospital unnecessarily and enable them to be discharged from hospital as soon as they are medically fit.

We want to support people more to understand their conditions better and by taking steps to help themselves stay well. We’re also working to help people take better control of their health through life choices like diet and exercise.

Already a number of new services have been introduced and we are investing around £4.2m in Dartford, Gravesham and Swanley over the next two years to improve care delivered in people homes and communities, rather than in hospital.

Our aims

In summary, our aims are to:

  • Offer more support to help people live healthy lives
  • Make sure we are working with our social care and voluntary partners in a more joined-up way to provide more efficient, high quality care and support
  • Design services around the needs of local people
  • Offer you more personalised care that supports your physical, mental and emotional wellbeing
  • Care for you as close as home as possible (your own bedis the best bed)
  • Respond quickly if you become unwell and need extra help
  • Give you improved access to a wider range of services at your local GP practice
  • Support frail older people and those with complex needs to manage their conditions and stay independent in their own homes
  • Attract, retain and grow our workforce
  • Manage our money wisely and make the best use of our resources.

Who will benefit from these changes?

Although the local care plan has been developed for the whole population, to begin with, we will be focusing on improving local care for older people who are frail and those with complex needs.

What’s happening?

A number of new services have been introduced and health and social care professionals are working in a different way to improve the quality of care for our patients.

Here are some of the new services we have introduced:

Multi-disciplinary teams

Local GP practices now meet regularly in ‘multi-disciplinary teams’ with nurses, therapy staff, mental health, social care professionals and community navigators to offer personalised, joined-up care to patients with physical, mental and emotional wellbeing needs.

There are six MDTs in Dartford, Gravesham and Swanley each serving a population between 37,000 and 70,000 registered patients.

The teams meet regularly to review the patients that have been referred to the MDT.  They focus on what matters most to the patient and the support they need to help make their lives better. By doing so, they look at the bigger picture which could include putting a range of services in place to support patients with their medical and emotional needs.

By working together, the MDTs are able to help more patients to be cared for in the comfort of their own home, where possible.

Dr Adekemi Osadiya talks about the Multi-Disciplinary Teams in north Kent:

Community navigation service

People are often not aware of the local services that are available to them or find it difficult to get the help they need.  That is why we have worked with Kent County Council to fund a Community navigation service which is delivered by Imago Community.


The team of Community Navigators work with people to identify what will make the greatest improvement to their health, wellbeing and confidence; providing information, advice and guidance to help them access a range of community, health and social care services.  These include carers’ support, housing options, benefits, aids and adaptations and activities within their local community.


People can be referred to the service via their GP practice, Multi-disciplinary team or other health and social care professionals.  They can also make a self-referral.


Rapid response teams

The Rapid response service is a team of specialist nurses and therapists who provide urgent specialist care for people at home, 24 hours a day, seven days a week, responding to a call usually within two hours.


The team is being expanded to support more patients from the community or being discharged from hospital to ensure they receive the care they need in their own home.


This will reduce the number of patients having to be admitted to hospital unnecessarily and help those who have been discharged from hospital to regain their independence as quickly as possible at home.

Primary care home visiting service

A new paramedic-led home visiting service is available for housebound patients who can now be seen earlier in the day and receive the care they need, rather than waiting until the afternoon for a visit from their GP.

There is also a higher chance that if patients need to go to hospital, they will be seen and can return home the same day, where they will recover more quickly, rather than ending up staying overnight if they are admitted later in the day.

This service is already making a difference to patients and GPs, whose workload is being freed up to see more patients in their surgeries.

John McAllister – Paramedic, Primary care Home Visiting Team:

After 10 years working as a paramedic for South East Ambulance Service, John McAllister decided it was time for a change.

“Being a paramedic is a tough job both mentally and physically, and working nights and weekends with a young family was beginning to take its toll,” explained John.  I was also interested in a new career path in the pre-hospital and primary care setting. So, I went to work for Medway Community Care, where I learned a lot about community care services.”

When John discovered in late 2018 that DGS Health, the local GP Federation, was setting up a new Home Visiting Service and was looking for paramedics to join the team – he knew that he had found his dream job.

Launched in January 2019, the paramedic led Primary Care Home Visiting Service is available to all 30 GP practices serving the population of Dartford, Gravesham, and Swanley.  The aim of the service is to provide home visits earlier in the day for patients who are too unwell to get to their GP surgery.  Patients can then be seen more quickly and get the care and treatment they need, instead of having to wait until the afternoon for a home visit from their GP.  It also frees up GP time to focus on other areas.

John works within a team of five paramedics and a healthcare assistant who have been heavily involved in setting up the 18-month pilot scheme.

“It’s been fantastic to be here right at the beginning. When I first arrived, there was a lot of work to do to set up the service.  I worked with the team to create the GP referral pathways and to develop new policies.  It has been a challenge, but it’s great to be at the forefront of everything that’s going on.”

Based at Gateway Medical Centre in Northfleet, the team is ready to take calls from the GP surgeries from 8.30am. Any referrals are quickly followed up with a home visit by one of the paramedics.  Most of the patients they see are elderly or frail with a range of conditions from urine infections, skin conditions, UTIs and chest infections.

“As paramedics, we are used to treating people at home and signposting them to other services.  If a patient needs to go to the hospital then we will send them in, but ideally our aim is to treat  people at home and avoid hospital admissions. Since the service started, we have only admitted 10% of our patients into hospital,” explains John.

The team is available to carry out visits throughout the day, with the last visits usually scheduled between 3.30pm and 4pm. If patients need antibiotics or other medications, they will contact their GP surgery straightaway for a prescription.

“Our Healthcare Assistant is also able to support patients with other aspects of their care, such as obtaining prescriptions or doing other errands to support a patient’s overall health and wellbeing.  She may also follow up with a home visit two or three days later to check up on the patient.”

When the team carries out a home visit they will make an assessment of the patients’ condition and conduct a holistic assessment of their health and wellbeing.  If required, they may make referrals to other services such as social support, housing, community or the voluntary sector.

“Sometimes it’s about making a cup of tea for a patient, as they might not have seen anybody for a while and they have called you because they’re anxious. By having a cup of tea and spending a bit of time, they can explain to you what’s going on, so you can get a better picture and that makes a massive difference.”

In a recent survey, 95% of GPs rated the home visiting service as excellent or very good, with many commenting on the difference it is making to their workload. There are now plans in place to expand the team to include eight paramedics and two healthcare assistants, so they are able to take more referrals from the GP practices.

This animation explains how the NHS, local government and the voluntary sector are working together to provide better care closer to home.

Get Involved

Your views are important to us.  Sign up to our Health Network to keep up to date with local NHS news and details of events and workshops you can get involved in to help us improve NHS services.