Community Transformation Programme

The Community Transformation Programme brings together partners from across health, social care and the voluntary, community, faith and social enterprise (VCFSE) sector to improve how and where people receive care.

Rooted in the Joined Up Care Derbyshire (JUCD) Integrated Care Strategy, the programme focuses on changes that help people live independently for longer with the right care, in the right place, at the right time.

Our aims:

Help more people stay at home, rather than in hospital
Improve hospital discharge for people with complex needs
Expand services that support recovery and independence

How we’re working:

All JUCD partners are involved in the programme’s governance and oversight. The programme is structured around three key workstreams, supported by:

NHS, social care and VCFSE partners
Clinical and frontline staff
Newton Impact, our delivery partner

What’s next:

We’re engaging colleagues from across the system through a series of workshops to explore how we can:

Prevent unnecessary admissions
Improve discharge processes
Support people to recover and stay well at home

These conversations will shape practical solutions based on frontline experience.

We are committed to:

Improving real outcomes and experiences
Using data and insight to guide change
Designing solutions with the people who deliver care

We expect some early changes will be in place ahead of winter, with more to follow.

Updates and resources

Latest progress across Derbyshire

The Community Transformation Programme is helping more people in Derbyshire to be supported at home, avoid unnecessary hospital admissions and leave hospital sooner when they are ready.

Fewer unnecessary hospital admissions

A new approach using clinical navigators in emergency departments at Royal Derby Hospital and Chesterfield Royal Hospital has now been tested. Early results suggest it could help the local health and care system avoid more than 1,400 hospital admissions each year by supporting more people to return home with the right community care. Work is now underway to decide how this model will be funded and run in the long term. At the same time, same‑day emergency care for medical patients at Chesterfield Royal Hospital has continued to perform well, helping more people be treated and discharged on the same day.

Helping people leave hospital sooner

Reducing delays for patients who are medically fit to leave hospital is now a key focus. Changes at Royal Derby Hospital have already cut the time it takes to refer people for ongoing care and support. The Derbyshire Care Transfer Hub, working with hospitals, local authorities and care providers, is helping to coordinate discharges, resolve complex cases and make sure people can go home or to the right care setting as soon as it is safe to do so.

More care and support at home

Across Derbyshire County, eight “Our Best Weeks” initiatives have been completed with local reablement teams (known as START). These focused weeks have helped increase the number of people receiving short‑term reablement support at home and have shaped the next stage of improvement work. The focus now is on building on this progress, making the support even more effective and enabling more residents to recover and live independently at home. In Derby City, the Community First reablement service has also improved, with its effectiveness now above target.

This progress has been made possible by the hard work of many teams across the system, including the Care Transfer Hub, Community First, START reablement teams and colleagues involved in arranging care packages and scheduling visits. Their work is helping to create a more joined‑up system that keeps people well, independent and supported in the place that is right for them.

Contact:

Kirsty McMillan: kirsty.mcmillan3@nhs.net

Community Transformation Programme monthly update – September 2025
The Programme is progressing from design to testing, having engaged over 150 partners to improve care pathways. Key workstreams include reducing hospital admissions through trialling different ways of working using the Central Navigation Hub, enhancing complex discharge processes, and boosting home-based enablement services. Efforts continue to address capacity challenges and improve coordination across health and social care. More detail is below.

For more information on any of the below or to get involved contact: Kirsty.mcmillan3@nhs.net

The Community Transformation Programme (CTP) is progressing in designing changes across its three main workstreams, involving over 150 colleagues from NHS organizations, local authorities, and the voluntary sector through workshops and design groups.

Incoming Bed Demand Workstream:

Establishing new working methods that include community colleagues in hospital front doors at both acute trusts.

Purpose is to prevent admissions and direct patients to appropriate community services.

Patients will be referred via the Central Navigation Hub.

Rollout planned from October at Chesterfield Royal Hospital (CRH) and Royal Derby Hospital (RDH).

Complex Discharge Workstream:

Aims to reduce the time patients requiring ongoing community support remain in hospital after being medically fit.

Focus on reducing delays on wards and streamlining sourcing processes.

The Care Transfer Hub is being trialled at CRH and expanding to RDH.

Initial referrals have been made into the hub with triaging and case management moving to be more centralized.

Home-Based Enablement Workstream:

Seeks to maximize independence by delivering enablement services effectively.

Workshops have identified opportunities to improve service capacity and team availability.

Implementation plans include better visibility of team capacity to manage demand.

Coordination work with County Council, City Council, Derbyshire Community Health Services (DCHS), private care and voluntary sector partners.

Over 60 individuals have engaged in shaping solutions.
Community Transformation Programme monthly update - October 2025

Community transformation programme – improving care through collaboration

The community transformation programme continues to build momentum, with live testing of new ways of working now shaping real improvements for patients and staff across Derbyshire.

Incoming bed demand
Following the successful launch of community navigators at Chesterfield Royal and Royal Derby Hospitals, work is now taking place that will consider where to continue identifying more opportunities to avoid unnecessary admissions. Early results remain encouraging, with several examples of patients being safely supported at home through virtual wards and community teams. The collaboration between acute and community colleagues continues to strengthen, helping ensure people receive the right care, in the right place.

Complex discharge
The new care transfer hub is now supporting Chesterfield Royal Hospital receiving all referrals and improving the flow of patients out of hospital. Early signs show fewer delays and shorter stays once patients are medically fit, while at Royal Derby Hospital the model is being extended across more wards. Work also continues to strengthen digital visibility, daily huddles and escalation processes so that every patient has a clear plan and progress can be tracked in real time.

Home-based enablement
Across both city and county teams, in depth analysis continues so we can better match staffing and capacity to demand and improve the consistency of reablement support. In the county, teams are continuing to use the new rota forecasting tool to balance workloads and maintain service continuity. In the city, design workshops have concluded with new operational dashboards now in development to help measure and sustain improvement.

Together, these developments show how the transformation programme is testing ideas, refining processes and embedding new ways of working that make a real difference for local people. Thank you to everyone involved for your continued commitment and collaboration.
Community Transformation update - January 2026

Incoming Bed Demand

The ED Turnaround trial has been running for seven weeks across Royal Derby Hospital (RDH) and Chesterfield Royal Hospital (CRH), successfully avoiding 23 admissions in the week commencing 12 January alone. Community navigators continue to play a vital role in supporting discharge planning and preventing unnecessary hospital stays. Task and finish groups are now focusing on high-potential pathways to expand this impact further, with CRH launching a new Medical SDEC booking process and RDH extending navigator activity.

Complex Discharge

The Care Transfer Hub has now been fully rolled out across all wards at RDH and CRH following successful trials and refinements. It aims to reduce discharge delays by using accurate data to identify bottlenecks and target interventions. The Derbyshire hub now accepts referrals from all wards, streamlining transitions from hospital to home and enabling more responsive, coordinated care.

Home-Based Enablement: Rotas, MDTs, and SMART Goals

County teams have completed engagement and submitted new rotas to balance capacity across a full 7-day week, with the new model launching on 9 February. City teams have been running new multidisciplinary team (MDT) and caseload touchpoint sessions for nine weeks, focusing on supporting independent living. SMART goals are being used to guide care planning and improve outcomes, while efforts continue to increase START team capacity and reduce reliance on private providers.

System Collaboration: Progress Through Partnership

This update reflects a strong collaborative push across Derbyshire’s health and care system. From acute hospitals to community teams and councils, partners are aligning around shared goals – reducing admissions, improving discharge processes, and enabling people to live well at home. The emphasis on accurate data, coordinated design, and frontline engagement continues to drive meaningful transformation.