Thames Medical Hub

The Thames Medical Hub at Walton Community Hospital was opened in Spring 2018 to provide proactive care for older people with frailty and multiple long-term conditions who are registered with GPs in the boroughs of Runnymede and West Elmbridge.

The service is an expansion of the service that was previously known locally as the community matron or virtual ward service. 

The Hub service is provided by a multi-disciplinary, integrated team of health, mental health and social care staff.

Thames Medical Hub is an innovative model that was originally developed in The Bedser Hub in 2015 at Woking Community Hospital. The Bedser Hub has received local and national praise for the benefits it has delivered for patients and the local health system overall.

A similar Hub service is also available at Woking Community Hospital (called The Ashford Hub) for people registered with a Spelthorne borough GP.

The Thames Medical Hub team provides proactive care for medically stable patients. They focus 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 Hub also provides a reactive service, which aims to rule out conditions requiring immediate hospital treatment and to support people to stay at home if this is safe and appropriate.

The Thames Medical 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 Thames Medical 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.

People are encouraged to come to The Thames Medical 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.