Community-led care praised as Causeway MDT delivers joined-up services across 17 GP practices

L-R Suzanne Kennedy, Elizabeth Craig and Mandy Corr

Members of the Causeway Hospital Partnership Board have praised the success of a community-based model of care that is delivering joined-up, neighbourhood services for people across the Causeway Coast and Glens area.

At its latest meeting, the Board received an update on the work of the Causeway multidisciplinary team (MDT), a partnership initiative jointly run by the Northern Health and Social Care Trust and the Causeway GP Federation.

Established in January 2020, the MDT now operates across 17 general practices, bringing together professionals from health, social care and community sectors to improve access to timely support.

The MDT model enables Trust staff to work closely alongside GPs to streamline access to services such as physiotherapy, mental health support and social work, with a strong emphasis on early intervention and prevention.

Elizabeth Craig, social work lead with the Causeway MDT, explained that the approach is about far more than traditional healthcare delivery.

She said:

“The main objective of multidisciplinary teams is to improve the interface between primary and secondary care, and the community and voluntary sectors.

“There is a very strong emphasis on prevention and intervention and meeting a person’s needs at the earliest possible opportunity. We know that healthcare alone has a relatively small part in a person’s overall health and wellbeing; other factors such as employment, income, housing, education and lifestyle all play an important part.

“The model is also very much aimed at keeping people well in the community, and putting in those supports in a timely way so that we can help people, particularly those who are elderly or frail, to avoid hospital visits or stays.”

Over the past five years, the impact of the MDT has been significant. The team has carried out more than 112,000 consultations and supported over 32,000 patients, with 75 per cent of consultations delivered face to face. Notably, only four per cent of patients required referral into secondary care, highlighting the effectiveness of community-based interventions.

Gillian Traub, Director of Operations with the Northern Trust

Gillian Traub, Director of Operations with the Northern Trust, said multidisciplinary teams were central to reshaping how services are delivered at a local level.

She said:

“A key focus of the Department of Health’s Reset Plan is on neighbourhood care and this is what Causeway MDT is doing so well already.

“Strengthening our links with the local community and delivering our services closer to home for people, is a big focus of our vision for Causeway, and our Causeway MDT plays a really vital role in that.

“Providing interventions and support at the right time means people are less likely to reach crisis point or have their health deteriorate to the extent where a secondary care pathway is the only option.”

Beyond direct healthcare provision, the MDT model also supports wider community wellbeing. Seed funding has been provided to 20 local groups working on key health priorities, including Age Concern Causeway.

Manager Mandy Corr highlighted the value of partnership working, particularly in supporting people living with dementia.

She said:

“We are often so focussed on the buildings – the hospitals - but so much care sits outside of that. We all know that we need to reduce the reliance on acute care and the work we are doing is hugely supportive of that.

“There are real opportunities for us to work together and strengthen community-led care and Causeway MDT allows us to do that.”

The Causeway Hospital Partnership Board itself was established in November 2024 to help drive forward the Trust’s Vision for Causeway. The Board brings together Trust staff alongside representatives from community and voluntary organisations, service users, community transport providers and local council partners.

Co-chair and Northern Trust Non-Executive Director Kathy Mackenzie said the success of the MDT was clear and could serve as a blueprint for other areas.

She said:

“It has been really wonderful to hear first-hand about this fantastic model of care that is operating in the Causeway area. This approach is proving to be a huge success; so much so, that the Trust is going to be rolling out another MDT in the East Antrim area and we hope to replicate the success there.

“Rethinking how we deliver our services, with a strong emphasis on community care, is a real driver for change and I’m pleased that the Northern Trust is at the forefront of that reform.”