Vulnerable Adults Service

The Norwich Vulnerable Adult (VA) model is a tiered, step up, step down integrated model of care for adults with complex needs and severe multiple disadvantages. The patients supported are often homeless, living in temporary accommodation or accommodation which may be at risk. Individuals are supported in the most appropriate tier, based on their acuity and complexity. The Inclusion Health Hub is for individuals experiencing acute chaos, extreme complexity and multiple co-morbidities. It is intended that individuals will only spend a short time (ideally less than 6 months) being supported by the Inclusion Health Hub before being ‘stepped down’ to the less intensive service.


The service commenced in April 2020 at the midst of a global pandemic, and despite the impact and challenges this posed the service continued to grow. Key recruitment enabled the service to become robust and resilient and able to create a structured focus to strive to achieve the requirements of the new model and improve both the health outcomes for patients and address inequalities. The new service successfully transitioned from the old service model provider to Norwich Practices Ltd (NPL) as the new service provider


The core team of a service lead, clinical lead, ICC and support workers adopted a collaborative working approach which created processes to follow by holding weekly Multi- Disciplinary Team (MDT) meetings with partners and stakeholders. Communication networks with Inclusion Health Practices (IHPs) were established and regular meetings and discussions implemented to improve patient care. A partnership approach was adopted to ensure that contributions from professionals within the IHPs and linking with their own ICCs was established to strive to continually improve the service and patient experience.

The service was subject to the Health Overview Scrutiny Committee in October to ensure it was deemed as safe and beneficial. The outcome from the HOSC was wholly supportive, and the aim being that services of this type will be rolled out across the county, which is fantastic.

The service offers a holistic approach to patients care, and we now look to use the input from the integrated care coordinator (ICC) to discuss potential onward referrals to other non-clinical services and interventions that will give patients greater support networks within the community. This social prescribing approach enhances the ease of the transition through each tier of the model for patients and addresses the wider determinants of health.   In addition to this, it also supports new working relationships across sectors with an MDT approach that really does put the patients at the centre and ensures that complex vulnerable patients are kept safe and are supported.


You will find more information here.

Safe Surgery

Our Vulnerable Adults Service (VAS) based at Under One Roof in Norwich has committed to becoming a ‘Safe Surgery’ (28 April 2022). The ‘Safe Surgery’ programme is an initiative which has been launched by Doctors of the World to tackle the barriers faced by many migrants and other inclusion health communities in accessing healthcare.
As a minimum, this means declaring that the practice is a ‘Safe Surgery’ for everyone. This includes migrants and other underserved communities such as Gypsy Roma, Travellers and those with no fixed address, it ensures that a lack of ID, proof of address, immigration status or language are not barriers to patient registration at a surgery and that staff are equipped with the skills to be inclusive and welcoming.  More info