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
The review is now complete (spring 2024) and organisations are analysing the suggestions through internal governance, and planning next steps.
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%).
We know our Health and Care staff want to do a great job and provide the best possible services for residents and patients, but to respond to the challenges we face, it is more important than ever that we make the most of our expertise and resources so that more people can lead healthy, happy and connected lives. The findings from the review are helping to us to plan our next steps.
The independent review provided analysis and findings that could potentially offer alternative models of health and care delivery, alongside the development of a new model of care for frailty.
Organisations are now planning next steps to support the review outcomes, and identify where further integration of resources could provide better outcomes for service users and patients.
The independent report was presented to Senior leaders in Spring 2024, next steps are now being reviewed by each organisation.