Posted on: 26 January 2026
In a time of intense operational pressure across the NHS, Hillingdon Health and Care Partners (HHCP) – the place-based collaborative between The Hillingdon Hospital NHS Foundation Trust, Central and North West London NHS Foundation Trust (as the Integrator Organisation), the London Borough of Hillingdon, the Hillingdon Primary Care Confederation, and 3ST (our voluntary sector partnership) – is showing what happens when transformation is local, integrated and focused on people, not just services.
Over the last six months, HHCP’s place-based model - bringing together hospital, community, primary care, mental health, voluntary sector and adult social care around neighbourhoods - has started delivering measurable, system-wide impact. This progress has been driven not by structural change alone, but by shared leadership, aligned incentives and a common, evidence-led understanding of population need and system pressure.
The data shows it’s working
Amid rising complexity and winter pressures, the system in Hillingdon is holding up better than expected. Why? Because care is moving upstream, informed by shared data and proactive intervention:
- A&E attendances dropped by 4.9% (June–Nov 2025 vs. June–Nov 2024), despite demographic and demand growth.
- “No Criteria to Reside” (NC2R) delays - a key system flow metric - fell by 34%, from a daily average of 50 to 33. By December 2025, fewer than 4% of Hillingdon Hospital beds were occupied by patients without a clinical need to remain, compared with a NW London average of 14% and a London-wide average of 12%.
- Emergency admissions among 5,000 patients with severe frailty reduced by 36%, reflecting proactive case management and integrated community and primary care support.
- Hypertension prevalence rose from 10% to 14%, on track for a 16% year-end target, with 80% of patients achieving blood pressure control - the highest rate in NW London.
These results demonstrate a system that is preventing crisis as well as resolving it - shifting from reactive to preventative care, and from organisational silos to integrated, place-led delivery. Crucially, partners are working from a shared, place-level view of performance, using a small number of agreed metrics to understand pressure, track impact and act early.
Place-based working: built around neighbourhoods and shared outcomes
At the heart of HHCP’s progress is place-based integration. Hillingdon’s three Integrated Neighbourhood Teams (INTs) are now fully operational, bringing together:
- Community and primary care professionals
- Mental health clinicians
- Adult social care teams
- Specialist acute care practitioners
- Voluntary sector partners
This is not just structural alignment - it is relational collaboration supported by shared insight. Teams are increasingly co-located, working with shared caseloads and a common understanding of neighbourhood-level population health needs. This has improved continuity, confidence and consistency of care for residents at greatest risk of crisis.
Population health analytics are increasingly used to identify people at risk earlier - particularly those living with frailty, multiple long-term conditions and unmet preventative need - enabling multidisciplinary teams to intervene upstream rather than reacting at the hospital front door.
Key enablers such as Pharmacy First, mobile community diagnostics, same-day urgent primary care, mental health at the front door of ED and urgent community response have made same-day access to care more reliable and more local. Digital has acted as a practical enabler of this integration, through shared dashboards, virtual MDT working and proportionate information-sharing arrangements that reduce duplication without requiring wholesale system replacement.
Adult Social Care has played a critical role throughout - particularly in shaping and enabling discharge, rehabilitation and reablement - reinforcing shared accountability for flow and outcomes.
The hospital’s role: shared insight, shared action
The improvement in hospital discharge performance in Hillingdon has not come from new services alone. It has come from a genuinely shared understanding of the root causes of delay, aligned solutions and a system-wide commitment to act on evidence rather than assumption.
What has changed is not just what is delivered - but how it is delivered, and by whom:
- The Hillingdon Hospital, CNWL, Adult Social Care and other partners undertook joint diagnostic reviews of discharge blockages, examining variation in practice, multidisciplinary coordination and process clarity.
- Daily reviews and new Place Gold Command oversight created a single, agreed view of discharge performance and actions, with partners aligned on what “good” looks like.
- These efforts enabled a step-change in NC2R performance, falling from 50 to 33 per day - and to 25 per day by December 2025.
- Hospital teams are no longer managing discharge in isolation, but as part of a joined-up, place-led model with shared ownership of flow and outcomes.
This shift - from siloed working to system collaboration informed by shared data - has been one of the most impactful enablers of improved system flow.
CNWL’s Integrator Team: The engine behind system working
Behind the scenes, a small but influential Integrator Team hosted by CNWL has quietly powered this transformation. More than programme management, the team acts as the connective tissue across partners, translating strategy into delivery and ensuring alignment at pace.
Key functions include:
- Coordinating the roll-out and scaling of neighbourhood and reactive care transformation
- Leading the development of shared data dashboards, including NC2R and neighbourhood-level performance
- Supporting governance, unlocking delivery blockages, and maintaining system alignment
This capability enables Hillingdon to operate as a true place-based system, not a collection of services - combining relational leadership with shared insight and disciplined execution.
Conclusion: a system that works because it works together
The Hillingdon system has not been transformed by top-down mandates or isolated pilots. Its progress reflects local leadership, shared accountability and a commitment to evidence-led, community-driven care. It has been built neighbourhood by neighbourhood, relationship by relationship - and informed throughout by a clear understanding of population need and system performance. HHCP is here to work with and for our patients and service users. We are partners in their care with a shared passion for better outcomes for the people of Hillingdon.
As winter pressures continue, the HHCP model shows that when services are aligned around people and place, supported by shared data and pragmatic digital enablement, flow improves, outcomes get better, and the system becomes more resilient, more equitable and more human.
For more information: Hillingdon Health and Care Partners :: Central and North West London NHS Foundation Trust
