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 Ashford Hospital (called The Ashford Hub) for people registered with a Spelthorne borough GP.

Access the service

Referrals to the Hub proactive service need to be made via the Single Point of Access, which Monday to Friday:

Patients are given appointments. They can contact the service for advice and information by phone on 01932 414 222 or 01932 414 209 or via email on CSH.ThamesMedicalHub@nhs.net

The Thames Medical Hub is located at Walton Community Hospital. The service is available Monday to Friday 9am – 5pm.

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. 

Address

Thames Medical Hub, Walton Community Hospital, Rodney Road, Walton-on-Thames KT12 3LD

Opening Hours

Monday – Friday, 9am – 5pm 

Phone

01932 414 222 or 01932 414 209 

Email 

CSH.ThamesMedicalHub@nhs.net

How to get there

With good access to Hersham Station, Walton  Community Hospital has free parking available to patients and visitors

Who will I see?

The Thames Medical 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 Thames Medical Hub team in the Hub and at home if necessary.

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 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. 

he 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. 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.