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Our plans

Delivering better care out of hospital

The next major challenge facing the system is the number of people who are in hospital who don't need to be there because there is currently no alternative.

Currently, too many older people are admitted to hospital when, with appropriate out of hospital care, they could be treated in the community and looked after in their own home. Around 25% of patients could be looked after in their homes or supported in the community.

A move to more out of hospital care would improve quality of care and save money. For every £1 spent in hospitals, alternative community care can be provided for 70p.

Over the next five years, we will be investing £190m more a year across North West London on out of hospital services, including integrated care and more access to general practice. These investments will result in more staff and better facilities to deliver it.

How we are delivering this in Hounslow

Our plans to deliver better care out of hospital are outlined in our out of hospital strategy

Hounslow CCG has already made considerable progress in delivering this: 

  • We have established five networks of GP practices to work with their local community health and social care teams, supported by a lead consultant to identify and review patients at risk of becoming ill. Initially the focus has been on diabetic patients and the over 75s. Plans are in place to extend it to patients with lung disease and patients with heart disease.  All the health professionals will meet together to discuss and co-coordinate a patient’s care, improving the quality of care that patients receive.

  • GPs are starting to identify patients at highest risk of unscheduled admission to hospital.  Practice nurses will co-develop a care plan with the patient and carer (where appropriate), ensuring that all the services the patient needs are working together helping to prevent the patient attending hospital when they do not need to.  They are supported by a Care Navigator who will work with the GP, the community matron and the social worker to support the highest risk patients to ensure they can access all the services they need, self-manage their conditions and proactively ask for help, and that their family carer is supported.

  • We are targeting care of patients with diabetes as an area of improvement. We have increased the number of educational training slots for patients to learn how to manage their diabetes. We have been steadily increasing our diabetic consultant capacity from half a day a week since early 2011, to one day per week in early 2012 and to two days per week in 2013. The consultant plays a crucial role in leading and developing the intermediate service. By autumn 2014, the CCG will have procured a new diabetes intermediate care service to deliver a much more integrated service including treatment, education and foot health.
  • We have introduced a new consultant led community pulmonary rehabilitation and home oxygen service. The main aim of the service is to enable people with lung disease and respiratory problems to increase lung capacity by a series of exercises and provide education about self-management.

Our priorities for 2014/15

  • Diabetes is consistently identified as one of the most important issues of concern for Hounslow CCG.  As part of our overall strategy for tackling this disease and reducing avoidable admission into hospital we intend to train primary care clinicians to improve management of diabetes. We will also increase access to diabetes education for both Type 1 and Type 2 patients, supporting the promotion of diabetes education in hard-to-reach local communities and where there are language barriers. At the same time we will encourage multi-disciplinary working across localities to ensure the delivery of coordinated, planned care for patients with diabetes.

  • The development of a new primary care centre in Heston (HPCC) is a top priority for the local health economy and in 2014/15 we will be looking to move this exciting project forward. The development of the HPCC will transform local primary care services and facilities serving almost 25,000 local people in one of Hounslow’s areas of highest deprivation and health need.  HPCC will allow five local GP practices to deliver their core service to the high standards expected in Hounslow and deliver the radical new model of out of hospital care where extended primary care GP services play a major role reducing the use of local acute hospital services.

  • With our partners in CWHHE we intend to commission a musculoskeletal service that will seek to reduce the number of referrals to acute orthopaedic services by making practical best practice improvements to existing services (central booking service, GP direct access physiotherapy, CATs, pain management service) to achieve the reduction in referrals.

Find out more 

You can find out more about our priorities for 2014/15 in our commissioning intentions.