How East Kent Used System Thinking to Support Frail Patients at Home

Summary

The Challenge: NHS services across East Kent were facing urgent care pressure from a growing older population. Frail patients were moving between ambulance, acute, community, primary and social care pathways, but partners needed a clearer shared view of which patients could be safely supported at home.

The Intervention: Using the Health Insights platform, partners across East Kent identified a proxy frail cohort and built a clearer view of how those patients were moving through urgent care. This helped them strengthen routes into Hospital at Home and urgent community response through a Single Point of Access.

The Result: The wider improvement programme reported around 16 fewer admissions per week for the proxy frail cohort and around 100 fewer bed days per week. This was equivalent to approximately 14 beds, with a non-cash releasing value estimated at around £1.8 million per year.

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A note on East Kent and Health Insights

In this case study, “East Kent” refers to the place-based urgent care partnership working across the region, including NHS Kent and Medway ICB, East Kent Hospitals, Kent Community Health NHS Foundation Trust, South East Coast Ambulance Service, primary care and social care partners.

Health Insights is Kensa Health’s proprietary analytics platform that links data across health and care systems, maps it directly to patient flow over time, and enables users to interrogate system performance in real time. It transforms fragmented data into actionable insight, helping organisations understand what is happening, why it is happening, and where to intervene to improve outcomes.

Urgent care pressure was a system problem

East Kent faced a challenge familiar across the NHS. Namely, a growing population of older people, increasing urgent care demand and continued pressure on hospital capacity.

For frail patients, the problem did not sit neatly inside one service. Their journeys often crossed ambulance services, acute care, community teams, primary care, social care, Hospital at Home and urgent community response.

In urgent care, pressure is often seen at the hospital front door, but the causes sit across the wider system in areas such as how patients are identified, how ambulance crews access alternatives, how community capacity is coordinated and how quickly partners can respond.

Some patients were still being conveyed to hospital despite the availability of more appropriate out-of-hospital pathways. East Kent partners recognised that this could not be solved by one service acting alone. They needed a shared way to identify which patients were most likely to benefit from care closer to home and to understand whether new community-based models were changing patient flow as intended.

The decision was to focus improvement around a defined proxy frail cohort. Partners set a practical target to reduce admissions for this group by 25%, equivalent to around 12 admissions per week, while strengthening safe alternatives to hospital attendance.

Defining the cohort, seeing the pathway

East Kent used Health Insights to connect pseudonymised pathway-level data across urgent care, admitted care, discharge, community and population datasets.

This allowed operational analysts and clinical teams to move beyond headline activity and understand patient flow across organisational boundaries.

A proxy frail cohort was developed using agreed clinical and utilisation criteria, including age, diagnosis and activity patterns. This gave partners a clear group of patients to focus on, monitor and support through alternative pathways.

The work was reviewed through East Kent’s Urgent Care Board, bringing together partners from the ICB, primary care, East Kent Hospitals, Kent Community Health NHS Foundation Trust, South East Coast Ambulance Service and social care.

Health Insights gave those partners a common view of the pathway. Clinical leaders helped interpret what the data meant in practice. The Urgent Care Board provided the governance needed to move from insight to action.

A clearer route into care at home

The improvement work focused on strengthening urgent care outside hospital.

In November 2023, Hospital at Home access was improved through the addition of a Single Point of Access (SPOA). This helped increase referrals into Hospital at Home and created a clearer route for patients whose needs could be met safely outside hospital.

Because many patients in the proxy frail cohort were arriving by ambulance, a new senior paramedic access route into SPOA was introduced. This enabled ambulance clinicians to refer appropriate patients after dispatch, reducing the need for conveyance to hospital where a community pathway was more appropriate.

This created a more proactive and consistent model of care, helping patients receive the right support sooner and closer to home.

Dr Shelagh O’Riordan, consultant geriatrician at Kent Community Health NHS Foundation Trust and President of the UK Hospital at Home Society, described the change:

“Our main intervention was adding SPOA to Hospital at Home. That is where the magic happened and we found more people who were sick enough to go to hospital, but whose needs could be met in the home.”

Outcomes and impact

The data showed a reduction in hospital admissions for the proxy frail cohort, alongside a corresponding increase in referrals seen by community teams. This gave clinicians greater confidence that patients were being supported through alternative pathways.

Partners compared actual activity after the enhanced model was introduced with the level of activity that would have been expected if previous trends had continued. This enabled partners to estimate the difference between expected and observed activity following the introduction of the enhanced model.

Activity impact

• around 16 fewer admissions per week for the proxy frail cohort
• around 100 fewer bed days per week
• increased referrals into community services

Capacity and value

• equivalent to approximately 14 beds
• estimated non-cash releasing value of around £1.8 million per year, based on £350 per bed day

Just as importantly, the data gave partners greater confidence that community pathways were reaching the right patients and that the observed shift in activity was meaningful.

Over the same period, the wider South East trend excluding East Kent PCNs increased. This strengthened confidence that the change observed in East Kent reflected a meaningful local improvement.

The analysis does not claim that one change alone caused the reduction. Instead, it gave partners a credible shared view of what changed over time and helped them understand whether the enhanced pathway was associated with fewer admissions, fewer bed days and more patients being supported through community alternatives.

The patient impact

The impact was not only operational. It was also felt by the patients themselves.

Patrick, aged 84, was assessed at home with stroke-like symptoms and diagnosed with heart failure. He was treated at home with IV diuretics, avoiding admission. His family described the experience as being:

“Like a little hospital had come to our house.”

Ann, aged 99, was found unwell at home. After ambulance attendance, the frailty team stabilised her and arranged monitoring so she could remain at home, in line with her wishes recorded in her RESPECT form.

Her daughter Jean said:

“More people should be aware there are options that don’t involve hospitals.”

These stories show the purpose behind the data: helping people receive safe, appropriate care in the place that best meets their needs.

Why the approach worked

The work succeeded because it combined linked data, clinical leadership and system governance.

Health Insights gave partners a common evidence base. Clinical leaders helped define the cohort and interpret what the data meant. The Urgent Care Board created a forum where partners could review the evidence, align around the same patient group and make decisions across organisational boundaries.

The pathway redesign was clinically led, with Dr Shelagh O’Riordan and colleagues using the data to test whether urgent care outside hospital was making a measurable difference. Ronan Chansou, Senior Health Data Analyst provided the analytical support and methodology, while Alexandra Baxter, Head of Urgent Care helped drive the data-led approach across urgent care.

The system was not simply asking:

“How do we reduce hospital activity?”

It was asking:

“Which patients could receive better care through a different pathway?”

That distinction shifted the conversation from isolated performance pressure to patient-centred system redesign.

What others can learn from East Kent

East Kent’s approach is scalable because it is not a single dashboard or isolated service change. It is a repeatable method for improving complex pathways.

The method is straightforward:

• define the patient cohort
• understand the pathway across organisational boundaries
• redesign the response around patient need
• monitor whether activity changes over time

As Claire Thomas, Deputy Chief Executive, said:

“The data is fundamental to our understanding of current patient flows, what we want to do about patient flows, and whether or not we are achieving our goal.”

The approach is already informing future planning across Kent and Medway. It is supporting business cases for shifting investment from acute to community services and shaping future urgent care resource allocation.

The model is continuing to develop. SPOA began with two bases and has moved to one East Kent base to make better use of resources. It currently operates five days a week, with plans to move to seven. Further work is also underway to link data with RIO community data, strengthening the ability to identify and track frailty cohorts over time.

Conclusion

East Kent shows what system thinking looks like in practice.

By defining the cohort, understanding the pathway, redesigning the response and tracking whether activity changed, partners were able to move beyond fragmented reporting and make more confident decisions about urgent care outside hospital.

For frail patients in East Kent, that meant strengthening alternatives to hospital attendance, supporting more care at home and reducing avoidable pressure on acute services.

The work with East Kent shows how Health Insights can help partners understand complex pathways, work from a shared view of demand and make more confident decisions about where action will have the greatest effect.