Scaling Integrated Multi-Disciplinary Teams in Primary Care: Lessons from the South Eastern Trust’s Cross-Sector Model in Northern Ireland

Background: Amid rising service demand, GP workforce pressures, and persistent health inequalities, the South Eastern Health & Social Care Trust, in partnership with the GP Federations and Voluntary and Community Sector (VCS) , launched the South Eastern Primary Care Multi-Disciplinary Team (South Eastern MDT) Programme in 2018. The initiative aimed to embed integrated, preventative care directly within general practice, in alignment with Health and Wellbeing 2026: Delivering Together.

 

Approach: Implementation was supported through best practice project and change management across six domains:

• Strategic Alignment – Co-designed outcomes aligned to regional transformation goals.
• Scalability – Flexible, adaptive infrastructure responsive to local needs and capacity.
• Community Integration – Investment in VCS partnerships and community asset-building.
• Governance and Accountability – Shared structures complementing organisational diversity.
• Workforce and Culture – Integrated induction, cross-sector supervision, shared training and values.
• Professional Standards – Discipline-specific clinical leadership to uphold quality and regulation.

Service user involvement and co-production were key — including project board representation, participatory planning workshops to agree priorities and lived experience.

 

Results: The South Eastern MDT model positions First Contact Physiotherapists, Mental Health Practitioners, Social Workers, Social Work Assistants, Health Visitors, and District Nurses within GP practices, enabling direct patient access without GP referral. Operating across 37 practices in Ards, North Down and Down areas, the model currently serves circa. 248,000 patients, spanning urban and rural populations with varying deprivation.

 

A distinctive feature is the embedded partnership with the VCS, with seed funding supporting co-produced wellbeing initiatives targeting social determinants such as loneliness, housing instability, and social isolation.

• >97% user satisfaction, as captured in the 10,000 More Voices project.
• 32% increase in referrals to VCS-led wellbeing programmes.
• Earlier intervention in physical, mental, and social care, with reported improvements in care navigation and patient outcomes.
• Improved workforce stability and retention within primary care.
• Improved cross-sector collaboration and trust, reflected in sustained joint governance and data-sharing arrangements.
• Workforce resilience bolstered through shared learning environments and integrated supervision models.

 

Implications: The South Eastern MDT programme offers actionable insights for health systems aiming to scale integrated, community-rooted primary care. Key enablers of success include:

• Development of a flexible model and culture to manage complexity, build consensus, and track readiness.
• Shared leadership and mutual accountability across statutory and non-statutory sectors, breaking down traditional siloes.
• Deep and continuous co-production with service users, carers, and community partners to ensure relevance, equity, and legitimacy.
• Prioritisation of local adaptability over rigid standardisation, supporting responsiveness to demographic, geographic, and workforce variation.
• Sustained focus on health equity, preventative care, and workforce sustainability as core system goals, not secondary considerations.

 

The South Eastern MDT model demonstrates that integrated, community-based primary care can be effectively scaled when underpinned by structured collaboration, diversity, adaptive delivery framework, and meaningful community engagement. Key enablers include shared leadership, sustained co-production, along with a deliberate focus on equity, prevention, and workforce sustainability. This model offers a replicable blueprint for health systems—across Northern Ireland, the UK, and internationally—seeking to transform primary care around the principles of person-centredness, local adaptability, and population health equity.