Great West Road and Feltham Localities are involved in an exciting pilot NHS Pathfinder project in Hounslow. We worked to find the best ways for health and social care to work collaboratively to deliver integrated care.

Health and Social Care working together

Here is an outline.

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

 10 members of from the existing Older People and Independent Living Teams for a senior social worker. Additionally, 5 social workers formed a groundbreaking team in Hounslow. The first social work professionals working in a multi-disciplinary locality team.

The NHS Pathfinder team will find new ways to collaborate. Because integration will result in multi-disciplinary working and joined-up services to residents. This will inform the future scope of locality working in Hounslow and inform the Whole Systems work.

The social work staff play an active part in forming and shaping the team and ethos of locality working. We improved outcomes for Hounslow’s residents through new ways of working. All in all, gaining valuable new experience and expertise as social work professional.

About the NHS Pathfinder

The staff will form 2 locality teams, joining colleagues from existing operational health locality teams and meeting structures (e.g. MDG)

The NHS pathfinder project is the first venture into integrated locality work. It will be operational from the 1^st of November 2014 and will run initially for 6 months. The approach will be evaluated to inform the further roll-out of locality working across the remaining GP localities.

A Steering Group supports and overseas the project 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 NHS pathfinder localities. They get involved in meetings at practices 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
• We will find Timely and preventative interventions for those at risk of hospital admission. Also helps to reduce the risk of admission to residential or nursing care.
• 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 NHS Pathfinder 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. Subsequently resulting in a 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.

The 5 GP localities will have collaboration between social care professionals working alongside GPs, care navigators, Nursing, community matrons, mental health workers and other health professionals. Above all the aim; is 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

Another key point of the running of the pathfinder project, we will not be changing the job role of social work professionals; the main purpose of 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 to identify their needs and desired outcomes which place the resident at the centre of all interventions and give them choice and control over the delivery of services.
• As an NHS Pathfinder 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 identify their needs and desired outcomes, helping them to formulate a Care Plan / Support Plan and were 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