To address the ongoing challenge of supporting residents living with complex needs in Hounslow, all organisations under the Hounslow Borough Based Partnership (BBP) agreed to develop a new model of care based on learning from the 2024 PWC report. The new model will focus on providing integrated, proactive, and holistic care through new multi-disciplinary teams.
The programme will address challenges in the current system by shifting to a model where residents engage with one team rather than many services, where they receive holistic medical care and social support.
The work programme includes testing and iterating the Hounslow Care Together model at selected sites, building a broad understanding of the approach, and preparing to mainstream the model in 2026/27.
This programme was established to develop new ways of working to support improved health and care integration.
BBP partners appointed PricewaterhouseCoopers (PWC) in Autumn 2023 to undertake a review of data, service modelling and process flows between all partner organisations. This helped us to identify new opportunities, and potentially a new model of care.
Over 80 clinical and operational stakeholders engaged with the review over a 16 week period, including:
● Executive Leadership (CEOs, CFOs, COOs and deputies)
● Service Leadership and Clinical Leads
● Front line staff (including consultants, nurses, social care workers, pharmacists, social prescribers, physician associates)
● Data, finance and BI leads.
These findings underpinned the development of the new model of care and the launch of Hounslow Care Together.
Population health data that shaped the new need for the programme highlighted:
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%).
Hounslow Care Together (HCT) brings together generalist multi-disciplinary teams (MDTs) and an extended team of colleagues from West London NHS Trust, Hounslow Council, Primary Care, the voluntary sector, West Middlesex Hospital, and local pharmacists.
It aims to address long-standing issues in the system, including:
- Disconnected services
- Long waiting times
- Lack of preventative and proactive care
- Restrictive referral pathways
- Delayed hospital discharges
The new team-based approach to supporting residents with frailty and unmet health needs launched in September 2025.
Hounslow Care Together (HCT) brings together generalist multi-disciplinary teams (MDTs) and an extended team of colleagues from West London NHS Trust, Hounslow Council, Primary Care, the voluntary sector, West Middlesex Hospital, and local pharmacists.
These teams will work with groups of GP practices to deliver joined-up, whole-person care that is proactive, personalised, and closer to home.
The aim is to reduce hospital reliance, prevent crises, and enable residents to live well at home for longer.
The model is designed for residents who:
- Have multiple, overlapping physical, mental health, or social challenges
- Frequently use services such as GP, A&E, or hospital care
- Are not well-supported by current health and care pathways.
The approach will be tested for 12 months within the Hounslow Heath Primary Care Network, supporting up to 400 patients across six GP practices.
Impact will be assessed across:
- Patient experience — continuity, access, participation
- Staff experience — collaboration, job satisfaction
- System outcomes — fewer A&E attendances, admissions, GP demand, and high-cost use