Health and Social Care Integration Programme

The BBP has made significant strides in enabling its partner organisations to better collaborate between themselves, and the local voluntary and community sector to improve health and care services for Hounslow’s communities. However, there remains significant health challenges and inequalities in the borough, alongside increasing service demand and limited budgets.

Against this backdrop, the BBP wants to explore opportunities to develop new integration models between all partner organisations to support more people to live happier, healthier connected lives.

To develop new ways of working, BBP partners have appointed PricewaterhouseCoopers (PWC). The role of PWC is to undertake a review of data, service modelling and process flows between all partner organisations.

We are currently in the review phase (winter 2023),  we hope their independent analysis and findings will potentially offer better models of health and care delivery.

Hounslow is home to about 271,800 residents (2020), the Greater London Authority (GLA) predicts that by 2030 this figure will rise to 288,023 residents. Within this growing population there is an increasing prevalence of patients with long-term health conditions. Some of the challenges we face include:

  • Type 2 Diabetes affects more than 24,000 Hounslow residents and more than 31,000 are at risk of developing it. Also, almost 3000 women in the clinical system have had a record of GDM (Gestational Diabetes Mellitus) in their history, and a previous diagnosis of GDM carries a lifetime risk of progression to type 2 diabetes of up to 60%, particularly within the first 3-5 years.
  • In the 2020 -2021 ‘Public health Outcomes Framework’ (Fingertips) recognised that falls incidents in Hounslow were the highest out of all the London Boroughs for people aged 65-79 years. Between July 2021-June 2022, 3375 people aged over 65 attended the emergency department at West Middlesex after a fall related incident. If a patient aged over 65 requires a hospital admission for a fractured hip – only one in three will return to their former levels of independence and one in three will end up leaving their own home and moving to long-term care.
  • There are over 2300 people living with dementia in Hounslow, and the borough has the second highest emergency hospital admissions rate for people living with dementia in London. This has led to an increased demand on hospitals, and on residential and nursing care.
  • More than 33,500 residents are being supported by their GP for high blood pressure.
  • Hounslow's under 75’s mortality rate from causes considered preventable (2021) is also above the London average for cardiovascular, cancer and liver diseases.
  • Hounslow Council is responsible for funding and organising care for Hounslow’s residents, and they spent £64m on Adult Social Care in the 21/22 reporting year (NHS Digital: Adult Social Care), the primary need for support is physical and social (61%). 

We know our Health and Care staff want to do a great job and provide the best possible services for residents and patients, but to respond to the challenges we face, it is more important than ever that we make the most of our expertise and resources so that more people can lead healthy, happy and connected lives.

This independent review aims to provide analysis and findings that could potentially offer alternative models of health and care delivery – a new model of care for frailty - identify any data gaps and highlight where further integration of resources could provide better outcomes for service users and patients.

The independent report will be reviewed in Spring 2024 by senior leaders, the final report and findings will be shared shortly afterwards. 

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