In order to achieve its ambitions of providing the best possible care and outcomes for frail, elderly patients, the Future Hospital team in north-west Surrey are setting up fully integrated locality hubs, starting with the Bedser Hub in Woking Community Hospital.
The north-west Surrey team aims to:
- deliver the best possible outcomes for frail, older patients
- create a coherent health and care system by establishing a fully integrated, person-centred service based around locality hubs.
In order to support the frail and elderly population in north-west Surrey, the Future Hospital project team have set up a locality hub: a physical building which sits alongside a community hospital. Through this hub, the team are able to provide an integrated frailty service for patients and carers. All locality general practices and their services operate in a network supported by diagnostics, pharmacy and transport. By connecting services across the region, the team hopes to expand their project by opening additional hubs across north-west Surrey.
Services are tailored to meet the needs of individual patients, including vulnerable patients
All patients’ needs can be catered for in the Bedser Hub, from initial assessment, preventative and proactive care and illness management. As part of the multidisciplinary team, the Bedser Hub is supported by a group of wellbeing coordinators (WBCs) who:
- are provided by Age UK Surrey to support patients in a holistic way.
- offer patients hour-long appointments which allow the Bedser Hub team to understand the whole person, their support network and their aims and preferences.
- signpost patients to services, both within the hub and externally.
- The number of patients attending the Bedser Hub continues to increase (to approximately 1,500 in 2016).
- The hub is seeing patients from specialist nurses in heart failure and COPD, and some directly from hospital.
- In July, the team hosted an event for colleagues in phase 2 at the Bedser Hub.
- A delegation of colleagues from Singapore visited the hub as part of a study visit to London. They were impressed by the patient-centredness of the service and the focus on supporting people to remain healthy and independent in the community for as long as possible.