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Integrated Care

What does Integrated Care mean?

Integrated care brings together health and adult social care professionals so that they can provide care in a more coordinated way. The aim is to make sure that patients receive the right kind of care in the right place at the right time. Integrated care in Guildford and Waverley is known as My care, my choice.


Why is there a move to integration?

The number of people older than 65 in Guildford and Waverley is expected to grow by 21% in the next ten years. This means that the number of older people living with long term health problems, such as diabetes or heart disease, will increase significantly. Older people, with long term health problems, will need a range of health and adult social care services to meet their needs.

To deliver care in the most effective way possible, services will need to be coordinated so that everyone involved has a clear understanding of the different needs of each patient. For this to happen, professionals will need to work more closely together and so services will need to integrate.


What are the benefits of integration?

The separation of health and social care professionals can limit how services work together. By developing integrated care, health and adult social care will develop new ways of working that will allow them to overcome these obstacles.

Greater coordination will reduce the amount of repetition by professionals in carrying out patient assessments and reduce the delay patients’ face when accessing the care they need. Integration will result in a more seamless transition between different services leading to a better overall experience for the patient.


Which health and social care staff are involved in integrated care?

  • GPs and practice nurses
  • Mental health specialists
  • Community health service staff
  • Social care staff
  • Hospital medical and nursing staff


Which organisations are involved in integrated care?

  • GP practices in Guildford and Waverley
  • Royal Surrey County Hospital NHS Foundation Trust
  • Surrey and Borders Partnership NHS Foundation Trust
  • Surrey County and Borough Councils
  • NHS Guildford and Waverley Clinical Commissioning Group
  • Virgin Care Ltd.
  • Voluntary Sector
  • Care providers and other contributors to health and social care


How does integrated care work in Guildford and Waverley?

Guildford and Waverley CCG has created two locality hubs, Central Guildford based in the Jarvis Centre and Waverley area based at Milford Hospital.

The staff within the hubs, work collaboratively with all of the local GP practices in their area who refer patients with complex needs to provide services within a multi agency model. Trusted Assessments involve Community Matrons, Social Workers and Mental Health teams working alongside the In reach Geriatrician team from RSCH, Clinical Psychology, Rapid Response, SECAmb and Community teams.

Patients are allocated a key worker with the aim of preventing unnecessary hospital admissions and providing services to stabilize the patients at home where possible.

The locality hubs work with patient representatives in a wide scope of work including PACE planning, falls prevention, care homes, advice and support to carers all linking with the acute sector and community hospitals and ongoing development of models of care. 

Download the My Care My Choice Operating Model


Got a question?

If you have a question or would like to find out more about My care, my choice in Guildford and Waverley, please contact us.


Page updated:29 September 2015
Next review due:27 March 2016
Model Publication Scheme:Class 9: The services we commission

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