Northern Trust plans neighbourhood care teams to help older people avoid hospital stays
Monday 28 September 2026
The Northern Health and Social Care Trust is developing four integrated neighbourhood teams in a major shift towards providing more care in people’s homes and reducing avoidable hospital admissions.
The new Neighbourhood Model of Care will bring together primary care, community and social care services and the community and voluntary sector, with an initial focus on supporting older people as winter approaches.
Trust leaders say earlier intervention could help people remain independent at home, while easing pressure on Emergency Departments and other acute hospital services.
Four areas of work for winter
Members of the Causeway Hospital Partnership Board heard about the plans at a meeting last week, where Trust staff outlined four workstreams being developed through the neighbourhood approach.
These include establishing a care home support team to help manage falls within care settings and avoid unnecessary transfers to Emergency Departments, alongside strengthening the Trust’s Hospital at Home service.
Work is also planned to develop education and clinical pathways for diabetes management in the community, while the Trust is exploring how its Causeway multidisciplinary team can work alongside GP colleagues to provide enhanced support for people at home.
Keeping people well at home
Diane Spence, Director of Adult Community and Older People’s Services, said the aim was to move towards a more proactive and integrated system of care.
“We want to develop a proactive and integrated approach to keeping people well in their own homes so we can help people avoid a hospital stay and reduce reliance on our acute services.
“We know that a hospital stay does not always produce the best outcome, particularly for our older population, so we want to strengthen care pathways in our community settings and create multidisciplinary teams that can support service realignment and the shift towards a Neighbourhood Model.”
The approach represents a move towards intervening earlier and delivering more services outside hospital, rather than waiting until a person’s condition deteriorates to the point where acute care is required.
Radical rethink of integrated care
Kathy Mackenzie, a Non-Executive Director at the Northern Trust and co-chair of the Causeway Hospital Partnership Board
Kathy Mackenzie, a Non-Executive Director at the Northern Trust and co-chair of the Causeway Hospital Partnership Board, described the plans as a significant departure from the traditional approach.
“Every year we do what we always do, but this is a radical rethink and approach to integrated care, and it will hopefully make a huge difference.”
Thelma Dillon, Chair of the Trust’s Engagement Advisory Board, described the move on behalf of service users as “an excellent development”.
“This is about bringing the right expertise to people in their own homes and building relationships and trust with our community. There are real opportunities here to have an integrated, joined up approach,” she added.
Causeway partnership established in 2024
The Causeway Hospital Partnership Board was established in September 2024 to drive progress on the Northern Trust’s Vision for Causeway.
It is co-chaired by Ms Mackenzie and the Trust’s Director of Operations, Gillian Traub. Ms Mackenzie is now preparing to retire and step down from her roles as a Non-Executive Director and co-chair of the Partnership Board.
Paying tribute to her contribution, Ms Traub said:
“We are all very grateful for the work Kathy has done across so many areas. As a local resident and member of the Causeway community, she stepped forward and led us through change and challenge, showing great leadership.”
The development of the four neighbourhood teams will now be particularly significant as the Trust enters the winter period, with the effectiveness of measures designed to prevent unnecessary hospital admissions likely to be closely watched as pressure increases across health and social care services.
