In Surrey, the integrated care system (ICS) worked with provider organisations in Guildford and Waverley to identify almost 3,000 patients who were aged over 65 and on four or more elective waiting or follow-up lists.
The cost of care for these individuals is estimated to be around £19 million per year, with multiple teams and providers caring for these individuals in a fragmented way.
Working together, partners in the system, including GPs and the hospital, wanted to restore services post-COVID in a joined-up manner for patients needing long-term speciality care and mental health services.
The people they identified also had wider health and social needs and this work showed how uncoordinated their care had been until now. However, after joining together, local GPs in Guildford and Waverley are working with geriatricians at the hospital and a multi-disciplinary team across the partnership to roll out a proactive integrated care hub for these people. This will mean people can be seen by multiple specialists at one time, often virtually, improving their patient experience, increasing the number of professionals they can access across health and care, reducing the need for multiple visits to hospital, reducing their risk of picking up infections and reducing NHS workload.
Patients can easily access help from the wide-ranging team catering to their personal needs, including a social prescriber and special interest GP or geriatrician. They are also using new technology to help patients recognise when their condition is getting worse and setting up follow-ups to make sure this happens as little as possible.