Integrated services for the frail elderly

Integrated services for the frail elderly

The NHS, both nationally and locally, is seeing a rise in the frail elderly population requiring treatment, and those aged 75 and above now account for 30% of national emergency hospitals admissions - a dramatic increase from under 10% just two years ago.

As recognised by the NHS Five Year Forward View, our current “treat and cure” health system, built to react each time a patient becomes unwell, is no longer working for everyone.

The Better Care Fund (BCF) has been introduced to respond to these changes in national demographics.

Surrey Downs are developing a frail elderly strategy, which sets out the CCG’s strategic direction and priorities for 2015/16.

We will improve services for our frail elderly population by working much more intensively with patients with complex, chronic and disabling conditions, aiming to reduce their need for emergency, and often lengthy, bedded care.

Our ambition is to achieve full integration and partnership across commissioning and provider organisations, so we can better support our elderly and frail population to remain independent, confident, and in control of their care, for as long as is possible.

UPDATE: Community Hubs launch and rollout

The new Community Hubs, clinically led by GP specialists, went live from 1st July 2015 within each Surrey Downs CCG locality. The hubs are currently co-located with each community inpatient ward and are providing medical support at NEECH, Dorking and Molesey Hospitals from Monday-Friday.

Additionally the East Elmbridge Hub is now providing the following services: Seven day a week support (including Saturday 8am-4pm and Sunday 9am-1pm) to Molesey Hospital in-patients and home based Hub patients; and urgent and non-urgent home visits to patients referred to the Hub by GPs or Kingston Hospital clinicians.

The Hubs are focused on supporting the frail elderly, who have multiple and complex conditions, and aim to reduce emergency hospital admissions, readmissions, and lengths of stay in hospitals, and to improve patients’ experience of care and support.

The Hubs programme will continue to roll out over the coming hubs, with increased support from partners, further service integration in Epsom and Dorking, and the introduction of a single referral management centre.

Please sign up to our mailing list for updates about this project and to hear about opportunities to have your say.