Great West Road – Integrated Care NHS


This was a meeting that we held at Great West Road Locality, now called a Primary Care Network, following the main Whole Systems Integrated Care WSIC meeting. This is a summary of our Great West Road locality (Hounslow) integrated care meeting discussed on the 9th of December 2014. It was a short but productive meeting.

Recap of WSIC event and discuss outcomes of the Simulation event.

Discussed ways in which we can access advice from the providers for individual patients when we need it.  In addition, we discuss the use of social media to deliver integrated care was discussed. A quick summary of what happens elsewhere, we are ahead of the game (although it often does not feel like it!). 

Update on locality pathfinder

Following a presentation from Phil Howell from the London Borough of Hounslow, We identified ways to work collaboratively with Hounslow CCG and the London Borough of Hounslow to identify ways in which we can work collaboratively. This pilot is running in Great West Road and Feltham localities in the first instance. 

Great West Road – Workforce & training

Natalie Oswald, NHS NW London gave a verbal presentation. She discussed CEPN (Community Education Provider Networks). Undeniably the biggest rate-limiting step for implementing WSIC. Therefore,we will work on identifying learning needs as providers (primary, secondary and social services) and see if we can collaborate with joint external training, develop internal training teaching, mentoring/coaching within our locality etc. Dementia is an obvious one to start with. 

Great West Road – Locality patient forum

Presently, we plan to set up a locality patient forum, increasing patient engagement and education. Once this is set up, we’ll develop patients’ educational needs and help them to own and improve their health outcomes. Explore the community and self-directed learning rather than the traditional didactic approach taken with patient education. Combination of online and meetings.

Great West Road Locality (Primary Care Network) themes

  • Develop a single care record
  • Reconciling accountability with the nominated care coordinator. Having clear points of contact.
  • Building up trust between providers and patients. Understanding each others roles eg sitting in on each others clinics.
  • Improving communication between providers, developing a contact list, physical meetings, phone calls, conference calls (video & telephone), including contact with patients. Social workers have already started ‘drop-in clinics, at Hiyos practice which have had positive initial feedback. These will be extended and offered to other practices.
  • Streamlining referral process between providers
  • Getting feedback on referrals made. A clear summary of what has been done and what the person who has received the letter needs to action. Social workers will start trialling this now.
  • Finally, a review of existing resources of all providers and identify ways in which we can streamline them to improve service we provide for patients and avoid duplication.


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