Hounslow serves a diverse population of 262,000 people, with the fifth fastest growing population in the country in the census period 2001 – 2011.

  • West Middlesex University Hospital, Imperial, and Ashford & St Peter’s Hospital are the main providers of hospital services.
  • Hounslow & Richmond Community Healthcare NHS Trust provides community services for adults and children.
  • West London Mental Health NHS Trust provides mental health services

Hounslow CCG 2015/16 annual report.

The chair of Hounslow CCG:

 Dr Nicola Burbidge

Population demographics

  • 262,000*
  • Hounslow is experiencing high population growth; it is due to rise by 12% between 2012 and 2020. There is a projected 18% increase in the older people population (over 65s) over this time period.
  • Heston and Cranford has the highest proportion of non-white residents compared with any other area (63%). The area has the highest proportion of Asian residents (53%), as well as the highest proportion of young people (between 0-19 years) in the borough (28.9%.)

*based on 2013 ONS figures

Health challenges

  • Hounslow has significantly more deaths from heart disease and stroke than the England average.
  • The proportion of Hounslow residents with diabetes is expected to rise significantly in the next 10 years. 
  • There are also high rates of smoking, alcohol and obesity-related hospital admissions, and longer hospital stays for those recovering from a stroke or a fall.
  • Hounslow has a higher proportion of adults in residential and nursing home care than other areas.
  • Due to a growing ageing population and the improved awareness and diagnosis of individuals, diagnosis of dementia is expected to increase between 2012 and 2020 by 23.5%. The volume of younger adults with learning disabilities is also due to increase by 3.6%.

Service improvements

Integrated care

  • Ambulance referrals to Integrated Community Response Service (ICRS): the ICRS team includes GPs, nurses, a mental health nurse, occupational therapists, physiotherapists, a social worker, and a handyman. They work 7am-7pm seven days a week to help people avoid hospital and care home admissions; and help people return home from hospital more quickly.
  • In 2014/15 London Ambulance have been linked to the team so paramedics assessing a patient have the option to call the ICRS team rather than taking them to A&E. 20-25 people a month now get specialist follow up care in their home rather than being taken to hospital by the ambulance crew.
  • Social workers and GPs working together: two of our five localities have been piloting social workers working from GP practices, providing clinics and joining GP teams on case reviews. Their work is picking up social care needs more quickly, preventing them escalating and into healthcare needs. 
  • Seven-day hospital social worker team: working with Hounslow council we have extended the hospital based social worker team from five to seven days a week. This allows home care packages to be set up outside of normal weekday office hours, enabling weekend discharge for patients fit to return home.
  • A housing association is being funded to provide temporary supported housing for homeless people being discharged from West Middlesex Hospital or West London Mental Health NHS Trust.

Community and GP services

  • Musculoskeletal services: a new single point of access service has been introduced and more physiotherapy and pain management services are now available in the community. Only patients needing surgery now need to go to hospital.Community heart failure: community-based outpatient appointments started in Dec 2013 and the use of cardiology treatment plans is helping reduce hospital admissions.
  • Ophthalmology (March 2012), chronic obstructive pulmonary disease (Sept 2012), audiology (Nov 2013) and dermatology (July 2014) all now provided as community services minimising the need for hospital care to when acute admissions are absolutely necessary.
  • Diabetes: a new service launched in May 2015 providing expert advice and support in the community meaning fewer people needing to go to hospital.
  • Supporting children with long term conditions: a pilot started in January 2015 to increase skills in primary care around helping children with conditions such as asthma and diabetes. Hospital consultants work with general practice providing outpatient appointments in GP surgeries and teaching GPs and parents how to better support children; and preventing conditions reaching crisis point and needing hospital admission.
  • Community Recovery service: from April 2015 a new service was established to help people who have lost their independence through illness or accident. The service supports them to build confidence, regain skills and to self-manage their health conditions and medication.
  • New ambulatory emergency care at West Middlesex Hospital: in October 2014 a new dedicated centre at West Middlesex Hospital opened. The centre provides emergency treatment for people with ambulatory conditions (50 specific conditions such as deep vein thrombosis, chronic obstructive pulmonary disease) without the need for overnight stays in hospital. GPs can refer direct to the centre reducing the number of patients sent to A&E.
  • A 24-hour GP-led urgent care centre at West Middlesex Hospital has been in operation since April 2012.
  • Primary Care Plus has been rolled out, offering greater support for mental health conditions from within general practice. GPs are able to offer more holistic support with their knowledge of patient's physical health record. In addition the service provides care from a more relaxing environment; reducing the need for people to visit specialist mental health units for outpatient appointments.
  • Weekend GP appointments are now available across Hounslow with five practices open every weekend for six hours on Saturday and four hours on Sunday, all linked to 111. Patients registered with any of the borough's 54 practices can use these weekend services.
  • We have invested in 44 practices to offer telephone consultations as an alternative to face-to-face appointments, four practices are now offering email consultations and practices have also started to offer online appointment booking and longer appointments to those that need them. 98% of practices offer online booking and repeat prescriptions.
  • We are investing in the primary care buildings needed to deliver more services closer to people’s homes. Three out-of-hospital hubs are already open and two of these will be getting further investment; providing a range of primary and community services for patients including care which was previously only available in hospitals. Two more hubs are planned to ensure coverage across the borough.
  • GPs running weekend clinics in care homes providing more convenient care for residents and helping to reduce unnecessary admissions to hospitals.

Mental health and wellbeing

  • A psychiatric liaison service is in place providing mental health support to people already being treated at West Middlesex Hospital for physical health conditions. It provides patients with a single point of access and support with mental health services when discharged.
  • Primary care mental health workers are now working with GP practices to manage more complex mental health patients.
  • The IAPT programme (improving access to psychological therapies) increased capacity in 2014/15 from 10% to 15%.
  • North West London was the second area nationally to have its action plan approved for the ground-breaking Mental Health Crisis Care Concordat, ensuring better, joined up, care for people experiencing mental health crisis.

Our future plans

Whilst we have made significant improvements, there is still more we want to do to improve care in Hounslow.

Integrated care

  • Care Navigator Service: piloted in 2014/15, the service supported around 350 people with face-to-face help. GPs refer to the service which then helps people ensure they can be directed to all the health and social care support they may need. The service is helping prevent pressure on hospital/emergency services by directing people to alternatives services and catching issues early before they need acute care. In 2015/16 we plan to make the service more accessible through a mix of both telephone and face-to-face appointments, increasing the number of people supported to 5,000 per year.
  • Putting social workers in Emergency Departments is an integral part of Hounslow’s plans to support the acute sector. Additional hospital social work capacity will ensure that more people who are detained in hospital for a mental health assessment are seen within 48 hours, which will significantly reduce the number of delayed transfers of care.
  • Social workers in general practice – building on work from 2014/15, we plan to extend the presence of social workers in general practice to all five localities in 15/16 and make the service available seven days a week through our weekend GP services.

Mental health and wellbeing

  • Integrated dementia services: strong clinical leadership and the joint development of a provider 2015/16 business case will lead to investment in earlier diagnosis and more resources to treat patients in a timely and appropriate manner.
  • Develop a strategic plan to transform mental health and wellbeing services across North West London. This will involve partnership working across health and social care and other partners. 
  • ntegrating Mental Health to ensure people receive the most appropriate care, closer to home.
    • 50% of Community Mental Health shifts to Primary Care (excluding children's services, Mother & Baby community, Specialist teams and Memory services).
    • 20% of mental health appointments will be picked up by GP practices

Community and GP services

  • Extending services in primary care: through 2015/16 we will be moving a further 18 services out from hospital settings to be provided by general practice, including for people on blood thinning medication requiring monitoring, diabetes care and complex wound care. Working in localities, GPs will be able to offer these extended services to residents across the borough. If your GP does not offer a service they will be able to refer to a nearby practice that does. Weekend opening in each of the five localities will make these extended services available seven days a week.
  • Care Plans for over 75s and people with long-term conditions: integrating IT systems across services has also enabled more effective use of care plans in the future. In 2015/16, we are aiming to offer care plans to 7,000 local patients, supporting people more effectively and treating problems earlier to avoid hospital admissions
  • Integrated community paediatric services: extending the services established as a pilot in January 2015.
  • Social workers in general practice: the 2014/15 pilot in two localities will be rolled out across all five localities.
  • Improved personal care services: The Council and CCG have jointly procured an integrated recovery-focused personal care service offering people effective, quality and appropriate health and social personal care at home. The new service will be delivered by a range of providers; with the contract mandating the payment of the London Living Wage to all staff (including travel time to and from people's homes). Higher quality personal care for social and health needs will help reduce hospital admissions.
  • Additional district nursing support for General Practice: from 2015/16, we're investing an extra £400k in district nursing, providing people with more care from GP surgeries and as home visits.
  • Improved buildings: Hounslow is investing in the primary care estate needed to deliver more services in an out-of-hospital setting. Seven practices will receive a share of £1.4m to improve their buildings.  In addition, five out-of-hospital hubs are planned to deliver further services in the community
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