GWR Pathfinder Locality. Health and Social Care working together.

Great West Road and Feltham Localities are involved in a exciting pilot project in Hounslow. The idea is that health and social care work much more collaboratively.

Here is an outline. More information will be made available shortly.

Locality Working Pathfinder: A quick guide to the project to support GPs

 10 members of the from the existing Older People and Independent Living Teams for a senior social worker and 5 social workers to form a ground breaking team in Hounslow and be the first social work professionals working in a multi-disciplinary locality team.

This team will be a Pathfinder for locality working and there will be learning all the way through the project about integration, multi-disciplinary working and joined up services to residents. This learning will inform the future scope of locality working in Hounslow and inform the Whole Systems work.

The social work staff participating in the Pathfinder are playing an active part in forming and shaping the team and ethos of locality working. The overall aim of the pathfinder is about improving outcomes for Hounslow’s residents through new ways of working whilst gaining valuable new experience and expertise as social work professionals.

About the Pathfinders

The staff will form 2 locality teams; based around Feltham and Great West Road and joining colleagues from existing operational health locality teams and meeting structures (e.g. MDG)

The pathfinder project is the first venture into integrated locality working, it will be operational form the 1st of November 2014 and will run initially for 6 months, during which the approach will be evaluated to inform further roll out of locality working across the remaining GP localities.

The project is supported and overseen by a Steering Group for the duration of the pathfinder. This group is a partnership of the Local Authority and Hounslow CCG as the commissioners of the project and key representatives of the locality MDT.

The social work staff will be making themselves known to all GP practices in the pathfinder localities; involved in meetings at you practice and in wider MDT work across the locality including:

  • To provide professional social work expertise to a locality team; supporting colleagues and managers to ensure an effective joined up response to residents in the community
  • Joined up assessment processes and shared care & support plans
  • Timely and preventative interventions for those at risk of hospital admission; at risk of re-admission; at risk of admission to residential or nursing care; and to support a reduction in the length of stay in hospital following admission.
  • Working in a coordinated way with GP surgeries and health professionals

Acting as a case lead through allocation and case coordination

What do we mean by Locality Team?

The aspiration for Hounslow is that we pursue and roll out our Whole Systems Integrated Care model between the Council and our Health partners within the CCG to drive forward the ‘right support, in the right place at the right time’ for those who need Health and/or Social Care services the most in the future.

Based on the geography of the 5 Area Committees of Hounslow and working across 5 GP localities; locality teams will entail social care professionals working alongside GPs, care navigators, Nursing, community matrons, mental health workers and other health professionals. The aim; to work proactively with people who require earlier interventions to support social and functional stability and person centred life planning that prevents reliance on expensive health and social care. Multi-disciplinary locality team will take a whole person approach to:

  • Prevention
  • Positive risk stratification and risk taking
  • Keeping people safe
  • Active case coordination
  • Coordinated care and support planning
  • Helping people with self-management
  • Supporting parents, carers and families


What is involved in the Social Work Professional’s job role?

During the running of the pathfinder project we will not be changing the job role of social work professionals; the main purpose each role remains as set out below:

Senior Social Worker:

  • To act as the expert practitioner and support direct reports to drive the independence and safety of vulnerable residents.
  • To promote and apply the principles of personalisation and self-directed support to ensure they are able to assess and manage their own needs, risks, uncertainties and capacity and plan the responses to deliver agreed outcomes.

Social Worker:

  • Provide Social Work and Care Management to Hounslow residents and carers and undertake Social Care Assessments and to identify their needs and desired outcomes which places the resident at the centre of all interventions and giving them choice and control over the delivery of services.
  • As a social worker, you will protect the rights and promote the interests of Hounslow residents and their carers to ensure they are kept safe, in line with the Council’s and Pan London Safeguarding Policy including investigations, contributing to strategy meetings and actions.

Social Work Assistant – Independent Living Coordinator

  • Providing Care Management support by assisting Residents and Carers to carry out Social Care Assessments and to identify their needs and desired outcomes, helping them to formulate a Care Plan / Support Plan and where indicated to use their Personal Budget to set up individually tailored services in order to achieve desired outcomes.
  • To work within a multi-disciplinary Community Care Management Team in close partnership with other professionals to ensure a joined up response and to share care co-ordination responsibilities where appropriate