Kingston is examining the impact of the merger between Kingston Hospital NHS Foundation Trust and Hounslow and Richmond Community Healthcare NHS Trust (HRCH) on adult community health services, with a focus on standardisation, integration, and preventative care. The council is also building a population health modelling approach in order to understand the needs of the local population so that they are able to plan and deliver appropriate services.

The Health Overview and Scrutiny Panel met on Thursday 10 July 2025 to discuss the review of Kingston's Adult Community Health Services. The panel reviewed a report covering standardising community health services, the role of Your Healthcare (YHC) and district nursing, the impact of the merger between Kingston Hospital NHS Foundation Trust with Hounslow and Richmond Community Healthcare NHS Trust (HRCH), prevention and early intervention in the community, and strengthening community based provision through commissioning and partnership.

Standardising Community Health Services

South West London Integrated Care Board (SWL ICB) is collaborating with local leaders and community providers to standardise community services across the region, including Kingston. The South West London Integrated Care Board (SWL ICB) have been working with place leads and community providers across SWL to review the provision of community services, and service specifications have been reviewed and revised to ensure a consistent set of core service specifications to be used across SWL, including Kingston.

Alongside the specifications the ICB will develop a suite of consistent quality and productivity metrics to be included in all provider contracts. This is consistent with the approach within the national document.

Ed Montgomery, Managing Director of Your Health Care, noted the changeable situation within the NHS and the importance of standardising services across the board.

Impact of the Kingston and Richmond NHS Foundation Trust Merger

The merger of HRCH and Kingston Hospital NHS Foundation Trust, which occurred in November 2024, has led to several clinical projects aimed at improving patient pathways between hospital and community services. The benefits of this merger are being monitored by the Integration Oversight Committee, which uses a scorecard to look at Key Performance Indicators (KPIs). However, the report states that many of the merger case study areas are just starting to be implemented, and benefits are not expected for some months. A number of benefits will increase in impact over the next few years.

Examples of positive impacts include:

  • Urogynae Pathway: A community-based pathway for quicker access to specialist nursing and physiotherapy, avoiding hospital referrals and invasive treatments.
  • Fracture Liaison Service: Identifying patients at risk of fragility fractures and ensuring timely treatment to prevent secondary fractures.
  • Deconditioning Pathway: A program to improve communication and standardise care pathways between hospital and community teams, raising awareness of deconditioning.

Prevention and Early Intervention

Kingston is expanding its Proactive Anticipatory Care (PAC) model, a multi-disciplinary approach for residents with rising complexity, possibly due to frailty. This model aims to shift services from hospital treatment to community-based interventions. As of June 2025, there are 419 clients on the PAC programme in Kingston - where people have been on the programme for 12 months, unplanned care reduced by 49% (SWL Health Insights, June 2025).

According to the report, the council is building a population health modelling approach to understand the needs of the local population and plan appropriate services.

Strengthening Community-Based Provision

The Royal Borough of Kingston (RBK) commissions key services from YHC, including Reablement, Shared Lives, and Handyman services. Key Adult Social Care (ASC) commissioning projects include:

  • Reablement and Equipment Transformation: Reviewing reablement and equipment provision to reduce the need for long-term care.
  • Shared Lives: Exploring ways to expand the Shared Lives offer.
  • Homereadiness: Understanding community-based discharge provision for people returning home after a hospital stay.

YHC also delivers the Health Visiting and School Nursing service for RBK Public Health delivering the healthy child programme. The programme(s) work to support child development, improve child health outcomes and ensure families at risk are identified as early as possible. There have been investments into a number of programmes to ensure care is better co-ordinated and more responsive to people's needs. These programmes include the Maternal Early Childhood Sustained Home-visiting programme (MESCH) which gives additional support to parents and families in the greatest need and the HENRY programme which supports practitioners to give enhanced and holistic approach to children and families, and which has seen improvement in family wellbeing through improved diet, physical activity and emotional wellbeing.

The Better Care Fund (BCF) promotes joint commissioning and delivery across health and care services.

Addressing Inequalities

YHC is committed to promoting equality and diversity, adhering to the Workforce Race Equality Standards (WRES) and the Equality Delivery System (EDS2). The organisation identifies and engages with vulnerable groups, including children in care, those with special educational needs, Gypsy, Roma, Traveller (GRT) families, refugees, and homeless families.