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A new model for integrated health and care frailty services - North West Surrey’s locality hubs

North West Surrey has been selected as one of the four projects in the second phase of the Royal College of Physicians ‘Future Hospital Programme’. Here, Dr Radcliffe Lisk and Dr Nicola Kirby describe the integrated GP-led community service designed to promote independence, physical and mental well-being.

Of the 31,000 people in North West Surrey who are over the age of 75, approximately 15,000 are either frail or at significant short-term risk of becoming frail. With one of the lowest levels of premature mortality in England, we have a higher proportion of our population living longer into old age.

Our mission was to find a way to manage the challenges we face from a growing older population within an integrated GP-led community service and in a manner that promotes independence, physical and mental well-being, prevents patient deterioration and carer breakdown, and safely delivers appropriate acute care in community settings.


“Our ambition is that no one should become frail if they can be helped to remain healthy, safe and independent and no one should be in an acute bed just because they are frail.”

To achieve this North West Surrey is establishing a fully integrated, patient-centric frailty service based around Locality Hubs, a physical location which will house a multi-disciplinary team to provide all assessment and planning, preventive, proactive and reactive care and rehabilitation for an identified cohort of patients; supported by diagnostics, pharmacy and transport services. 

Working from identification of the reasons why people decompensate allowed us to produce a systematic focused design that will provide value now and in the long-term. The model is structured and standardised; measurable and auditable; scalable and transferable to multiple patient cohorts. 

Common pathway construction and consensus methodology showed up important gaps and inefficient overlaps in care that could be addressed, resulting in a simpler, more coherent and ultimately more efficient patient-centred experience, and utilising fewer resources that are better aligned. 

This model of care, in many ways unique, has been designed from the bottom up, using a strong fact and evidence-base and robust consensus building methodologies. It partners primary care leadership with secondary care medical support, and although the model is GP-led, it is not a medical one. Instead, it weaves together multidisciplinary care in a common and aligned pathway. It also brings together key elements of socialisation and engagement activities at the group and community level, including provision of exercise classes and social activities. 

The model delivers standardised, high value multidisciplinary care to patients focused on evidence-based tasks and activities that maximise health and help maintain independence and functioning, based on individual need. These interventions are delivered in a co-located setting by a single integrated team including carers and volunteers, and we have provided for transport to enable attendance at the hub for those people who would otherwise struggle to attend. In addition, patient contact frequency and intensity is optimised for meaningful engagement. 

Quality assurance and patient safety is engineered into operational processes through evidence-based, peer reviewed standard operating procedures.  Effective on-going assessment, care coordination and care planning makes use of a shared support plan, encompassing all disciplines, which is pre-populated with essential care elements across seven core service lines (the seven elements care plan). Support plans are completed by patients with the support of a wellbeing co-ordinator; ensuring services are individually designed and integrated around the individual. This means that we can reserve MDT assessment for those who most need it. 

It provides both proactive (for stable) and reactive care (for exacerbations) with a focus on prevention, encouraging self-care, identifying risk factors and managing these early. There is also technology that enables new means of remote communication for staff and patients as well as remote monitoring through appropriate tele-health interventions. 

This is supported by an integrated care record and with methodologies and approaches that are readily transferable to other patient groups and systems.

The development of the locality hubs project has involved extensive stakeholder engagement and commitment from primary and secondary care, community services, social services, mental health, districts and boroughs, the voluntary sector and most importantly patients themselves.

Our first locality hub opened in Woking last December, and two further hubs will be opening later this year. 

We are proud to have been selected as one of four projects in the second phase of the Royal College of Physicians ‘Future Hospitals Programme’. We look forward to working with them to help us to deliver on our commitment to improving the service provision for this frail older population. 

For more information about North West Surrey’s locality hubs, please contact Dr Nicola Kirby on or Dr Radcliffe Lisk on or visit the North West Surrey CCG website. 

Nicola Kirby

Radcliffe Lisk

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