A new team-based approach to supporting residents with frailty and unmet health needs was launched in September 2025.
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.
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.
Team Structure
Where possible, teams will be co-located to support faster, collaborative decision-making.
Core team roles include:
- GP (Medical Lead)
- Case Manager
- Support Worker
- Community Health Care Worker.
Extended team members include:
- Occupational Therapist
- Pharmacist
- Social Worker
- Housing Support Worker
- Community connector.
Neighbourhood teams will:
- Identify residents who could benefit from support
- Carry out home visits to assess health and social care needs
- Develop and implement tailored care plans
- Provide routine and urgent care
- Connect people to local community and voluntary services
- Monitor progress and modify support as needed.
Dr Christopher Hilton, Chief Operating Officer (Local Services) at West London NHS Trust, said:
“Hounslow Care Together reflects the NHS Long Term vision for joined-up, out-of-hospital preventative care in local neighbourhoods.
“It’s about working as one system around the patient, preventing crises, promoting independence, and supporting longer-term wellbeing in communities.”
Martin Waddington, Director of Commissioning/Borough Director Hounslow NWL ICB
“We know too many residents experience fragmented care that doesn’t reflect the complexity of their lives.
“Hounslow Care Together puts people, not processes, at the centre, building strong, consistent relationships with multidisciplinary teams that work together locally.”
How Success Will Be Measured
The test and learn project will evaluate the impact in three main areas:
- Patient experience – access, continuity, and participation in care
- Staff experience – collaboration, job satisfaction, and role clarity
- System outcomes – fewer GP appointments, hospital admissions, A&E attendances, and reduced use of high-cost services.
Hounslow Care Together is funded by all organisations within the Hounslow Borough Based Partnership (BBP) to address the challenge of supporting residents with unmet health and care needs. The integrated health and care model was designed using insights from a 2024 PWC report on care for frail older people in Hounslow, and proving the model’s value will be critical to scaling it borough-wide in the future.