Bedser Hub

The Bedser Hub at Woking Community Hospital was opened in 2015 and provides proactive and reactive care for older people with frailty and multiple long-term conditions who are registered with a Woking GP. The service is provided by an integrated team of health, mental health and social care staff. It is an innovative, multi-disciplinary model that has received local and national praise for the benefits it has delivered for patients and the local health system overall.

In Spring 2018 a similar Hub service (The Ashford Hub)  was opened on the Ashford Hospital site for people registered with a Spelthorne GP. and at Walton Hospital (The Thames Medical Hub) for people registered with a Walton or Weybridge GP.

The Bedser Hub team provides proactive care for stable patients and reactive care for exacerbations and crises. The team focuses on prevention, encouraging self-care, identifying risk factors and managing these early. The service is particularly suitable for people who may benefit from support from both health and care services. 

The Bedser Hub service aims to identify people with frailty or at risk of frailty at an early stage. Patients will receive a multi-disciplinary proactive assessment to identify their needs and be provided with advice and treatment. They will also be signposted to suitable services and have support put in place to help avoid a health or social care crisis. 

The service also provides a reactive service for exacerbations and crises to support people to stay at home if this is safe and appropriate. 

The Bedser Hub is not an alternative to GP or local community services, but works in partnership with these other services to provide a coordinating point for people with frailty.  People remain on the Hub caseload for life and people on the caseload can access the service, and health and care professionals can refer them for a review, without the need for re-referral.  Each person is allocated to a Hub coordinator, who will ring people on the caseload on a regular basis depending on need. 

The patient's care record is shared with health, mental health and social care professionals involved in their care (following patient consent) and the team is notified when people on the caseload attend the Ashford & St Peter's Hospital A&E department or call the ambulance service.  This helps the Hub team identify when people may be going into crisis so they can offer support if necessary.

The following clinics are held in the Bedser Hub for people on the Hub caseload:

  • Care of the elderly, cardiology and respiratory consultant clinics
  • Heart failure nurse clinics
  • Podiatry clinics
  • Dietician clinics
  • IAPT practitioner clinics
  • Dementia navigator clinics
  • Nail cutting service provided by Age UK Surrey (paid)
  • Counselling service provided by Age UK Surrey (paid)

People are encouraged to come to the Bedser Hub for appointments if possible and free community transport is provided if needed. The community transport buses are specially adapted to cater for people with all disabilities, including those using wheelchairs. Outreach visits are provided for people who are unable to come to the Hub.

that provides both proactive care for stable patients and reactive care for exacerbations and crises with a focus on prevention, encouraging self-care, identifying risk factors and managing these early.   An integrated health and care service provided by health, mental health and social care staff; it is particularly suitable for people who may benefit from support from both health and care services.  The Locality Hub service aims to identify people with frailty or at risk of frailty at an early stage in order to carry out a multi-disciplinary proactive assessment to identify their needs and provide advice and treatment, signpost to suitable services and put support in place before people go into crisis.   The service also provides a reactive service for exacerbations and crises to support people to stay at home if this is safe and appropriate. 

The Locality Hub service is not an alternative to the person’s GP practice or local community services but works in partnership with these services to provide a coordinating point for people with frailty.  People remain on the Hub caseload for life and people on the caseload can access the service, and health and care professionals can refer them for a review, without the need for re-referral.  Each person is allocated to a Hub coordinator who will ring people on the caseload on a regular basis depending on need. 

On referral people give explicit consent to a Hub shared care record which includes access to their whole GP record and this remains available as long as they remain on the Hub caseload and can be shared with health, mental health and social care professionals involved in their care.  The Bedser Hub uses EMIS for its clinical record and all team members enter their notes in the Hub EMIS record.  The Hub record can be viewed in the GP practice by opening ‘All Records’ in the EMIS consultation.  The Hub clinical staff have access to the Ashford St Peters Hospital (ASPH) electronic clinical record, the Hub mental health practitioner has access to SABPT electronic clinical record and the Hub social worker has access to the Adult Social Care electronic care record. 

People on the Hub caseload are flagged on the ASPH IT system and the SECamb IBIS system and the Hub is notified when people on the caseload attend the ASPH A&E department or call the ambulance service.  This helps the Hub team identify when people may be going into crisis and offer support if necessary.