Since launching in September 2025, Hounslow Care Together (HCT) has supported more than 100 residents with complex health and care needs, focusing on those most at risk of crisis or hospital admission.
One recent case highlights the difference coordinated neighbourhood working can make. An elderly resident with Parkinson’s disease and multiple co-morbidities was already receiving input from reablement and community services. However, despite significant involvement, coordination gaps and rising carer strain were increasing the risk of deterioration and hospital admission.
The team provided a single point of contact, strengthened oversight through a Universal Care Plan, supported a carer assessment and proactively monitored risk. The result was improved coordination, increased carer confidence and reduced likelihood of crisis escalation, helping the resident remain safely at home.
This type of impact reflects the purpose of HCT: restoring continuity and shared accountability around residents with complex needs.
HCT colleagues report that the new model is also improving how professionals work together.
“Shouldn’t this have happened years ago?”
A support worker described the practical shift in day-to-day working:
“I’m skipping lots of the emails I used to send to housing or OTs. I don’t have to do the admin because I just ask a team member to jump in.”
HCT was developed following a 2024 review of local frailty services, which highlighted fragmentation, duplication and limited proactive support. The model aligns with the wider NHS ambition to strengthen integrated, neighbourhood-based care.
HCT seeks to establish strong relationships, and continuity based care for patients, minimising the need for people to be passed between different services.
Evaluation is ongoing as the test-and-learn programme continues to develop across the Borough Based Partnership. System leaders will decide later in 2026 whether to spread the model across the Borough. Further project aims can be found at https://