Region’s community NHS teams keeping people safe at home this winter

As the region’s NHS heads into the busiest time of year, it’s not just hospitals that are geared up to help thousands of unwell people this winter.

Community-based teams across the region’s Provider Collaborative are playing a vital role keeping people safe at home and in control of their own health and wellbeing.

All eight NHS Foundation Trusts across the North East and North Cumbria provide a wealth of community-based healthcare services, from district nursing and palliative care, to remote monitoring for long-term conditions and hospital at home services. 

One standout example is the Recovery at Home service at South Tyneside and Sunderland NHS Foundation Trust (STSFT), a service which has been in place for several years and continues to deliver exceptional results. 

The Recovery at Home team provides support during times of illness or if someone experiences an unexpected change in their condition that could develop into a crisis and potential hospital admission. The team responds to patients in their own homes, as well as residential and nursing homes.

In September 2025 alone, 6,600 patients were visited at home across South Tyneside and Sunderland. While the target for preventing hospital admission is 70%, the service achieved an impressive 95% success rate. On average, the team carries out 200 home visits every day, ensuring patients receive timely care in the comfort of their own homes.

Kimberley Huddart is a Nurse Practitioner with Recovery at Home. She commented:

“Recovery at Home means patients can get the care they need without going into hospital. We are there to keep people safe, supported, and comfortable in their own homes and that makes a huge difference for them and their families.”

With the focus often on acute hospital care at this time of year, the NHS in the North East and North Cumbria is already seeing a major shift to provide hospital level care at home. Key initiatives such as ‘Hospital at Home’ services, or ‘virtual wards’ are helping hundreds patients to leave hospital earlier by continuing their treatment at home and preventing admission through remote monitoring.

In South Tyneside and Sunderland, the Hospital at Home service supported 140 referrals in September alone, with patients staying on the ‘virtual ward’ for an average of four days. Similar community NHS teams are making a real difference to people’s lives right across the region with 24/7 access to urgent help and support now widely available at the end of the phone.

Heather Green, Hospital at Home Coordinator in South Tyneside and Sunderland, said:

“By moving care into the community it means we can give patients the chance to receive hospital-level care without leaving their own home. We work closely with our hospital teams to deliver the same high standards of care but in a familiar, comfortable environment, which can make a huge difference to patient recovery.”

The region’s NHS is already leading the way in moving more care from hospital into the community in line with the NHS 10-year plan. Leaders across the Provider Collaborative have praised this work.

Ken Bremner MBE, Chair of the region’s Provider Collaborative and Chief Executive at South Tyneside and Sunderland NHS Foundation Trust, said:

“We have fantastic community NHS teams right across our region and between them they deliver millions of patient contacts every single day.  The amount of care that goes on outside of hospital is quite simply staggering, but all too often the focus is still on hospital-based care.

“Across the Provider Collaborative we want to go further and faster to change this and enhance our community services even further. Although we are at a great starting point, we know there are so many more opportunities to improve and create services that are not only effective, but truly responsive to local needs.

“Our ambition for the future is that only care that really needs to happen in hospital will take place there. We also want to adopt a realistic medicine approach to focus on what really matters to patients by involving them much better in decisions about what can add value to their life.” 

To hear more about the region’s fantastic community NHS teams, tune into the new ‘Frontline Voices’ podcast from the region’s Integrated Care Board in partnership with the North East and North Cumbria Provider Collaborative.

Listen here to community nurses Kimberley and Heather share their insights on how community-led health initiatives are transforming patient care in South Tyneside and Sunderland.