To help prevent unplanned hospital admissions and to support direct access to specialists, there are a number of options available to GPs and community teams:

The South West London NHS 2-hour Urgent Community Response (UCR) service provides fast, home-based medical support for adults experiencing urgent health issues that could lead to a hospital stay if not treated quickly.

What support is available?

  • Catheter care
  • Carer crisis cover (if a carer suddenly becomes unwell, exhausted, or unable to continue providing care)
  • Frailty (suddenly becoming much weaker, more tired or confused)
  • Palliative care or end-of-life crisis (when routine services are not available)
  • Reduced mobility
  • Urgent at-home equipment (for safety and independence)
  • Confusion or delirium (requiring assessment to establish an underlying cause)
  • Falls pick up service when there is no serious injury
  • Urgent diabetes support

Our community healthcare team of nurses and health professionals will respond within 2 hours of a referral.

Who can refer?

  • GPs, community nurses, and other healthcare professionals
  • Care home staff and social care teams
  • Unpaid carers, family members, or the person themselves

How to refer

Kingston (delivered by Your Healthcare):
Call 020 8274 7088 (8am - 8pm)
Last referral via SPA by 6pm (LAS / NHS 111 have alternative pathways through to twilight and night nursing)

Richmond (delivered by Kingston and Richmond NHS Foundation Trust):
8am - 8pm: 020 8714 4060
8pm - 7am: 020 8973 3450

Kingston 2-hour Urgent Community Response Service criteria

Inclusion criteria:

  • Over 18 years old
  • Living in their home or residential / care home setting
  • In a crisis (sudden deterioration in health and wellbeing) and needs community intervention within 2 hours to stay safely at home and avoid hospital admission

Exclusion criteria:

  • Acutely unwell or injured, requiring emergency care intervention and admission to an acute hospital bed 
  • Needs acute / complex diagnosis and clinical intervention in hospital for patient safety
  • Experiencing a mental health crisis and requires referral / assessment by a specialist mental health team
  • Routine home visits for non-urgent conditions or reviews

Further information about the suggested "9 clinical conditions" can be found in the national UCR standard guidance. 

Kingston (delivered by Your Healthcare)

The service offers:

  • Palliative care/end of life care or urgent need and provision of end-of-life medications for symptom control/pain management
  • Advanced Care Planning including support with completing Universal Care Plans
  • Management of residents with complex care needs/exacerbation of a long-term condition
  • Clinical assessment to determine underlying cause of symptoms
  • Patients requiring bladder scan, ECG or diagnostic tests such as POC CRP
  • Urgent/long term catheter care
  • Prescribing medications, all wound products, and catheter supplies
  • Diabetes management support
  • Superficial traumatic wounds
  • Acute confusion/worsening of dementia and frailty
  • Falls without apparent injury (head injury must be excluded prior to referral)
  • Follow up post-admission and ambulance call outs to reduce the likelihood of re-attendance at A&E

Urgent Care and Support Service (daily, 8am - 8pm)
Call 020 8274 7088 (last referral for same-day visit: 6pm)

Night response service (palliative and catheter care)
Call 07436 531237 (available 10pm - 7am)

Referrals accepted via SPA: SPA@yourhealthcare.org

Richmond (delivered by Kingston and Richmond NHS Foundation Trust)

The service offers:

  • Advice and support for residents with complex health needs
  • Assessment, re-assessments and reviews of healthcare for residents
  • Support with initiating programmes of care and developing escalation plans
  • Support in the management of end-of-life care and advance care planning
  • Follow up visits post-admission and ambulance call outs to reduce the likelihood of re-attendance at A&E
  • Reviewing all residents with an indwelling catheter 
  • Prescribing of medication, anticipatory injectable medication, dressings, catheter supplies

Care home support service (Monday to Friday, 8am - 4pm)
Call 07342 085 062

Out of hours support
7 days, 4pm - 8pm: 020 8714 4060

Richmond Night Nursing Service:
7 days, 8pm - 7pm: 020 8973 3450

Virtual wards provide hospital-level care at home safely, using technology and multidisciplinary teams to help speed up recovery whilst freeing up hospital beds for patients that need them most.

The ‘step up’ virtual ward supports patients who suddenly become very ill to help prevent the need for admission. Patients can be admitted from sources such as GPs, 111, the ambulance service or following a 2-hour UCR visit.

Referrals:

Monday to Friday, 8am - 4pm

  • Call Kingston Rapid Response Team: 020 8274 7088
  • Call Richmond Response and Rehabilitation Team (RRRT): 020 8714 4060

Frailty Phone - for urgent queries

For GPs and community teams who need urgent advice and guidance on management of patients over 65 years with a frailty score of 4-5 and frailty syndromes, or frailty score of 6 and above, and with an estimated length of stay of less than 24 hours.

Call 07385 382 814 (Frailty Phone and Frailty SDEC referrals):
Monday to Friday (8.30am - 5pm)

Geriatrician of the Day (GoD) Phone - for non-urgent queries

For patients who are unlikely to require hospital attendance, but GPs and community teams would value specialist advice on non-urgent management of older patients in the community.

Call 07823 402 948
Monday to Friday (9am - 5pm)

Calls should be made by colleagues who are able to discuss the clinical needs of patients.

A specialised service aimed at providing rapid assessment, diagnosis, and treatment for frail older adults (CGA), avoiding unnecessary hospital admissions. 

Our aim is for patients to leave hospital on the same day, sometimes with care or community assessments starting or continuing after discharge. 

The unit is located next to AAU, on level 3 of Kingston Surgical Centre.

Referrals can be made via the Frailty Phone (07385 382 814), Monday to Friday (8am - 8pm)

Note: Frailty SDEC is not a fast track to elderly care admissions or specialist reviews.

PAC aims to identify and support people with escalating health and/or social care needs and keep them healthier at home for longer. 

Following acceptance onto the PAC caseload, a PAC Care Coordinator is assigned to the patient who works with them and the professionals involved in their care (and their family/carer where appropriate) to develop a patient-centred, goal-based care plan.

Referral criteria

Adults (18+) who meet two or more of the below criteria:

  • Multifactorial diagnosis e.g. 2 or more long-term conditions or presence of frailty (based on frailty index scoring) 
  • People where mental health and capacity issues are impacting their ability to cope or their outcomes 
  • Escalating social care concerns (such as deterioration in being able to cope, resistance in accepting help, recent changes in social circumstances)
  • Frequent use of Health and Adult Social Care services 
  • Recent admission/ LAS/ Rapid Response
  • Safeguarding and escalation of risks 
  • Polypharmacy

Other patients may be referred based on professional judgement.

How to refer

Include the following information:

  • Full name
  • Date of birth
  • NHS number
  • Full address
  • Short paragraph of supporting information

To discuss the PAC model or any queries about a potential referral, contact our PAC Managers: