It’s been very well documented that extended lengths of stay can have a significantly detrimental effect on long term care needs and patient outcomes for frail, elderly people. With an ageing population, our hospital inpatient service sees more and more patients who are frail with complex needs.

With this in mind, the Executive team here at the Royal Surrey County Hospital selected frailty and integrated care as the subject for a quality improvement programme.

Colleagues from the Trust and across the Surrey Heartlands partnership were delighted to have the opportunity to come together to examine how we could improve outcomes for frail elderly patients. We did this by mapping out how to reduce avoidable hospitalisation and support patients to be cared for in their own homes and community.

More than 40 colleagues from across Surrey Heartlands came together for a five-day event – called ‘Value Stream Analysis’ (VSA) – which was held in partnership with NHS Improvement. It was an exciting piece of work and there was great energy in the room during the process.

The VSA is one of many tools used to enable transformation, and forms part of the new Trust tool box for improvement practice. We were delighted to have been chosen as one of seven trusts working with NHS Improvement’s ‘Lean Programme’. The programme is designed to support Trust’s to deliver lean management systems across their organisation, and is helping shape our new approach to transformation work across the Trust.

Surrey and Borders Partnership, SECAmb, Guildford & Waverley Clinical Commissioning Group, Surrey County Council adult social care team, and voluntary organisations including Age UK and patient representatives all joined Royal Surrey doctors, ward sisters, nurses, and other allied healthcare professionals to examine the pathways that a patient with markers of frailty might go through as they journey from their community, through the hospital environment, and back to their community again.


Over the five days we mapped out the entire end-to-end pathway, understanding the issues along the way, and created a map of what, ideally, we would like this to look like in 18 months’ time. The focus was firmly on delivering the results that would most benefit patients.

Along the way we identified some ‘quick wins’ which could be implemented immediately, and could be celebrated with the team to keep up the project momentum. For example, we produced a phone number list to share with Paramedics, enabling them to communicate directly with GPs and thereby reduce unnecessarily conveying of frail patients to hospital. Simple but very effective.

The next step is to start to drive process change so that we can improve each element of the pathway. We’re currently in the early stages of refining how this will be achieved, with regular meetings planned to refine and define each of the areas.  These will include looking at streamlining the discharge process, and also enabling frail patients visiting the Emergency Department to see a geriatrician sooner to determine if they could potentially access more suitable services in the community.

This is the first of many patient-focused quality improvement programmes.

Sarah Scales, Head of the Programme Management Office at the Royal Surrey County Hospital