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.

Access the service

Referrals to the Hub proactive service need to be made via the Single Point of Access (SPA):

The SPA operates between 8am and 6pm Monday to Friday.

The Bedser Hub is located in Woking Community Hospital. The proactive service is available Monday to Friday 9am – 5pm and the reactive service is available Monday to Friday 9am – 6pm.  The service can be contacted on: 01483 545 300.

The criteria are age >65 and Clinical Frailty Scale 4-8. People younger than 65 with more severe frailty may be accepted into the service if it is thought they will benefit from support from an integrated health and care service. 

Proactive service referrals

Referrals for people registered with Woking GP practices are accepted from all health and social care professionals. 

People registered with practices in Spelthorne, Runnymede and West Elmbridge can only be referred to the Bedser Hub by their GP practice. 

Reactive service referrals

Referrals to the reactive service are accepted from North West Surrey practice GPs, SECamb paramedics, Woking Walk-in centre, CSH rapid response, CSH heart failure nurses and the CSH respiratory disease team. Patients must be seen and clinically assessed by the referrer before referral to the service.  

Address

The Bedser Hub, Woking Community Hospital, Heathside Road, Woking GU22 7HS

Opening Hours

  • Proactive service: Monday – Friday, 9am – 5pm
  • Reactive service: Monday – Friday, 9am – 6pm       

Phone numbers

For referrals, please see the information below about our Single Point of Access.

How to get there

Woking Community Hospital is approximately 0.4 miles (10 - 15 minute walk) away from Woking train and bus station. There is (limited) parking for patients and visitors - from 8 January 2024 this will be severely reduced due to construction work on a new community diagnostic centre - find out more on this link. For more information on how to get to Woking community hospital, click here.

Who will I see?

The Bedser Hub team consists of Hub coordinators, Hub matrons, Hub GPs, a Hub pharmacist, a Hub mental health practitioner, Hub social workers and administrative staff.  People on the caseload can be seen by any member of The Bedser Hub team in The Bedser Hub and at home if necessary.

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 on the Hub caseload can access the service, and health and care professionals can refer them for a review, without the need for re-referral. If, following a review by the Hub GP / Hub matron, we feel that a person no longer needs the assistance of the Hub services then they will be discharged, and their family doctor (GP) informed.

People on the Hub 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
  • Dietician clinics
  • IAPT practitioner clinics
  • Dementia navigator clinics

People are encouraged to come to the Bedser Hub for appointments if possible. All sites are fully accessible with good transport links including parking. Please ask a member of our team if you require further information about how to get to the Hub. Outreach visits are provided for people who are unable to come to the Hub.

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.