Pathfinder Pilot. Collaboration between health and social services in Hounslow

Hounslow Clinical Commissioning Group, who are responsible for health are working together with London Borough of Hounslow in order to provide more collaborative services for our local population.

  • social workers in teams to reflect the 5 areas in Hounslow.
  • Roll out Whole Systems Integrated Care model Click her for more information. 
  • Extended hospital social work team


Pathfinder - Intended Benefits


 Patients and residents

We want a well coordinated and collaborative approach to people with complex and urgent health and social care needs

We want people to maximise their independence, self manage their physical and mental health and avoid inappropriate admissions


Reduce congestion in the Health and Social Care ‘whole system’ particularly in the acute sector

Avoid unnecessary future costs – with significant pressures on all organisations, we want to capitalise on achieving positive outcomes by working together


Enable and empower the workforce to work together, learn from each other and be satisfied in their role.

Create a more integrated workforce for the future, underpinned by the legislation of the Care Act and the support of initiatives such as the Better Care Fund

Bring together provider organisations to maximise outcomes for individuals and establish practice that is built on trust and mutual understanding of roles


Recruitment to the Pathfinder team – August 2014

The systems, tools for practice and resources to function well as a pathfinder team – July – End Sept 2014

A functioning locality pathfinder team of social work capacity (as described previously – 1st November 2014

A full evaluation and report on the pathfinder period to inform further implementation of localities across 5 areas. – February 2015 – March 2015

LBH social work teams Locality working roll out – April 2015


  • A functional Multi-Disciplinary Team with a targeted populations approach and ‘Care Coordinator’ allocations process
  • Single electronic referral and case management processes, the eradication of multiple & paper based referral pathways and move to better sharing of systems & information
  • Joined up assessment processes and a ‘Shared Care and Support Plan’
  • Information sharing and governance agreements
  • A joint system protocol
  • Overall governance arrangements including management of the team.
  • Co-location, assets, facilities and pooled resources
  • Budget sharing, pooling and integration


  • There have been a series of Multi-disciplinary meetings, drop in ‘social work surgeries’ and other meetings between Health and Social Care professionals. The key behaviours and cultures that need to emerge from locality working are:
  • Joint and shared care planning; putting the person at the centre and creating an efficient and effective process for getting different professional input to an individual.
  • A better shared understanding of the various professional roles in a locality
  • Smart referral and joint working – reduce waiting times between the traditional organisational boundaries
  • Trust and respect of each other
  • Commitment to reducing the collective workload of all involved
  • A clear and shared understanding of the terms ‘Care Coordinator’ and ‘Care Navigator’ and clear understanding of what each role involves.

 How do we collectively work towards these aims??