Hounslow Council is addressing the issue of patients being repeatedly discharged and readmitted to hospitals, often referred to as the revolving door syndrome.
The Health and Adults Care Scrutiny Panel met on 3 November 2025 to discuss the new model of care and plan future actions, aiming to provide more holistic and integrated support for residents.
The move comes as part of the council's broader New Model of Care, which aims to improve patient experience, support carers, and address systemic fragmentation within the healthcare system. The panel, chaired by Councillor Farah Kamran, has been exploring pressures in adult social care and seeking ways to provide more holistic and integrated support for residents.
During an informal meeting on 9 September 2025, the panel discussed key themes, including the need for a single point of contact for patients, better integration across services, and stronger support for unpaid carers. As noted in the HAC Meeting Notes, Barbara Benedek suggested A single care co-ordinator as a consistent point of contact.
Barbara, who cares for her husband with dementia, highlighted the complexity of navigating multiple services and the need for a simplified system. She also emphasised the importance of patient-centred care and practical assistance for carers, such as council tax relief and transport.
Roger Smith shared insights from volunteering, supporting a holistic approach to care. He also raised issues such as the high incidence of falls linked to faulty chairs and challenges for individuals with multiple conditions. While the meeting information highlights the issue, it does not specify how the council will address the faulty chair issue and reduce falls among vulnerable residents.
He expressed strong support for the New Model of Care as the right direction.
The panel also discussed the importance of building trust through trial results, engaging communities, and reaching vulnerable groups through referrals and word-of-mouth. They emphasised the need for both quantitative measures, such as service uptake and hospital readmission rates, and qualitative, anecdotal evidence to capture the full picture of impact and user experience. The HAC Meeting Notes highlight that patient and carer stories are essential to capture the full picture of impact and user experience. Suggestions included establishing a Citizens' Panel to influence service design. However, the meeting information does not specify how the Citizens' Panel will be structured or what specific authority it will have.
Future actions include continuing engagement with patients and carers to capture lived experience, developing clear metrics to measure the impact of the New Model of Care, exploring mechanisms for community outreach and trust-building, preparing for GP referrals to the voluntary sector from April 2026, and ensuring robust data governance during site visits and evaluations. The HAC Meeting Notes confirm the need to ensure robust data governance during site visits and evaluations.
The meeting information states that from April 2026, GPs will recommend patients to the voluntary sector, but it does not specify which organisations or what services they will provide.
The next meeting is scheduled for 3 March 2026.
For further details, see the Public Reports Pack from the 3 November meeting and the HAC Meeting Notes from 9 September.