70 Years of the NHS NHS Kingston

Long term conditions

Diabetes clinic

Older people and people with long-term conditions (LTCs) 

Kingston CCG has developed an out-of-hospital strategy which has the following broad objectives:

  • Improve choice and outcomes for vulnerable adults, people with long term conditions and frail elderly

  • Care closer to home and in the home

  • Avoiding admissions into hospital

  • Early supported discharge from hospital

  • Integrating care across care settings and providers


Kingston at Home

Much of our effort to deliver these objectives is included within the Kingston at Home programme. The major emphases for Kingston at Home during 2014/15 are:

  • Further integration of health and social care community services through the consolidation of Kingston at Home service model and pathway
  • Single point of access to community health services – multidisciplinary team triage and assessment
  • Admission avoidance
  • Early supported discharge
  • End of life care
  • The above particularly relates to reablement, rehabilitation and intermediate care
  • Care homes
  • Rapid response
  • Community therapies
  • Support Your Healthcare CIC (the community health services provider) in the redesign of the medical components of Kingston at Home to enable more people to receive care at home
  • Review and redesign of community (district) nursing and community matrons service model and care pathways in light of the caseload profiling project
  • Explore the requirement for step-up and step-down community beds (Cedars Unit)
  • Explore the requirement and service model for assessment bays at Surbiton Health Centre
  • Embed consistent use of risk stratification and multidisciplinary team (MDT) care planning and case management, particularly for people at risk of unplanned used of health and social care services. This to be based on GP practice populations, with primary and community staff centrally involved along with social care and mental health services colleagues
  • Work with patients with long-term conditions to increase levels of patient self-management
  • In partnership with RBK (Adult Social Care and Public Health) commission integrated adult prevention services with specific focus on the health funded Age Concern Kingston “Stay Well at Home” Service
  • Subject to evaluation extend telehealth deployment, aligned with Adult Social Care commissioned telecare services

The CCG is committed in all of its work for adults and older people in championing and applying best safeguarding principles and practice.


Personal health budgets

The NHS Mandate makes a commitment to offer the option of a personal health budget to people with long-term physical and mental health conditions who could benefit, from April 2015.

The CCG is progressing development work for personal health budgets for people with continuing healthcare needs, and this will take the potential future extension to long-term conditions into account.

Development work to extend the continuing healthcare arrangements from April 2014 to those with long-term conditions by April 2015 will progress throughout 2014/15.

Kingston Clinical Commissioning Group, 2nd floor, Thames House,
180 High Street, Teddington, TW11 8HU
Tel: 020 39419900
Email: kingstonccg.communications@swlondon.nhs.uk

NHS 111 NHS Choices