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.

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 is working to 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.

Falls service

A new falls service has been launched in Surrey Downs CCG with the aim of easing the pressure on the urgent care system. The Integrated Falls Team commenced in October 2017 and is being delivered by CSH Surrey. The service will provide a triage function and support for non-injured fallers aged 65 and over within their own home or a care home, thereby supporting people to stay safely in their home. The service will also accept referrals from those patients at risk of falls who are under 65 years, in line with NICE guidelines.

The main aims of the service are:

  • Improve patient experience and outcomes by assessing patients, reducing the risk and providing advice, treatment and support.
  • Reduce unplanned hospital admissions due to falls, thereby cutting pressures on emergency and acute unplanned care services.
  • Reduce the number of patients conveyed to hospital in an ambulance who could have been more effectively supported in their own homes.The service can be accessed by GP practices as well as any other health or social care professional in the system. Referrals will be triaged within two hours, subject to an initial assessment to establish if the situation is suitable.After initial triage and work from the MDT (Multi-Disciplinary Hub), patients may then be referred to the urgent or non-urgent falls service depending on their assessed need. The services offered to patients may include 1:1 therapy-led assessment plans with defined goals, equipment aids and adaptations, on-ward referrals for additional patient and carer support, home hazard assessments and balance/exercise classes. CSH Surrey will then provide a falls assessment to identify and address potential causes of avoidable harm.
  • Remember: Always tell your GP and someone close to you if you have had a fall, even if you have not been injured. 
  • This telephone assessment will be carried out by trained registered clinicians employed by CSH Surrey who are capable of making sound judgements through a structured telephone triage process with the patient, their carer or another healthcare professional.
  • The service has been developed as part of the CCG's Falls Care Pathway, initially as a one-year pilot for those who are aged 65 and over and registered with a GP practice in the Surrey Downs catchment area. 

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.

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