Developing a model of team-based, integrated primary and community care and social support for a neighbourhood

Since Autumn 2024, partners in Hounslow have been developing an integrated model of primary and community care for people with frailty and others with multiple health and social needs.

Reviews of our system had revealed a number of weakness in our current services: a lack of good generalist, ongoing care for people with complex needs, meaning that the system fails to intervene proactively to keep people well and avoid hospital care; a fragmented landscape of small services; and increasing costs.

 

From Autumn 2024, we brought together staff from across our system to address these challenges. Patients, carers and the voluntary sector played a key role in helping us understand the problems and think creatively about solutions. We agreed to test a model of small, full-time integrated teams sitting in primary care centres.

Our ambition was to restore relationships and continuity, reduce the loss of information and transaction costs that come with transferring people between services, and make better use of staff than possible when staff work in separate silos. We also wanted to restore accountability, through small teams delivering holistic care for defined panels of patients.

 

We argued that this could also lay the foundations for longer term restructuring. If we build a coherent model of team-based primary and community care, this should provide a basis for simplifying services and moving more staff out of hospitals and service silos into neighbourhoods.

In mid 2025, we brought together staff and patient representatives to co-design the model. We learned from high performing systems in England and other countries. Over three months, we developed our service specification and operating procedures, as well as clarifying our philosophy of care, model of team working and desired culture.

 

 

In September, the partnership launched its first two prototype Hounslow Care Together teams. Each team sits together full time at a health centre and serves patients registered at three GP practices. The teams include GPs from the practices, a nurse case manager, social support worker, community health worker and care coordinator. A social worker, housing officer, occupational therapist and pharmacist spend a day a week in each team supporting patients or upskilling staff. Hospital consultants will participate in monthly multi-disciplinary discussions.

In their first month, the teams assessed their first forty patients. In a workshop after the first month, one team member asked :“Shouldn’t we have done this years ago?” Others described being liberated from paperwork, now that they could turn to a social worker or housing officer for help rather than writing a referral letter. The teams received their first thank you letter from the family of a frail couple.

 

 

By April 2026, we will be able to share evidence on patient reported health outcomes, staff feedback on working in the new team structure, and evidence of the impact on use of GP services, A&E and hospital services. We will also be able to share learning on the co-design process, mobilisation of the teams, refinement of the team model and plans for applying this model at scale.