Abstract
The establishment of Primary Care Multidisciplinary Teams (PC MDTs) in Northern Ireland represents a pivotal advancement in the ‘Health and Wellbeing 2026: Delivering Together’ initiative by the Department of Health. This program aims to revolutionise primary care service delivery by addressing current demands, facilitating care transitions into community settings, and enhancing early intervention and preventative strategies. This seeks to transform the way in which health and social care services are delivered in Northern Ireland, with a focus on person-centred care, rather than buildings and structures.
The MDT model integrates Physiotherapy, Social Workers, and Senior Mental Health Practitioners, co-located within GP practices. This partnership between Newry & District GP Federation and Southern Health and Social Care Trust has evolved since its inception in 2019, expanding its mental health team to 17 professionals serving a patient population of 150,000 across 29 practices. Focusing on holistic health—addressing physical, mental, and social wellbeing—the MDT emphasises proactive prevention and early intervention to mitigate the need for secondary care referrals. The initiative seeks to foster collaboration with community organisations through joint projects, reflecting a commitment to person-centred care.
Mental Health Practitioners:
- Provide the right care, at the right time at the right place by early intervention and prevention.
- Provide first contact assessments and brief interventions to patients presenting with mental health concerns to GP practices
- Bring additional mental health expertise and experiences to GP practices
- Help to reduce increasing workload on GP practices
- Work alongside the existing practice team to provide enhanced access to health and social care services within a primary care setting.
There is an increased focus on prevention and early intervention initiatives, with the aim of ensuring that patient’s needs are met at the earliest possible opportunity, reducing the need for onward referrals into secondary care services. In light of significant mental health challenges in Northern Ireland, where one in four individuals are affected, the program's community development initiatives—such as the Children’s Mental Health Library, dedicated patient support videos developed for our Youtube channel, and Menopause Support Sessions—aim to address health inequalities, particularly in deprived areas where mental health issues are most acute.
Patient outcomes for 2023-2024:
- 5,120 patients seen across 14,987consulatations.
- 64% of patients seen had no onward referral, with needs addressed withing general practice
- 14% referred to voluntary and community
- 12% referred to Trust primary care team
- 10% referred to Trust outpatients
Patient Feedback:
- You literally saved my life. Thank you.
- I am so lucky to have had this support on my doorstep
- I have really valued this service. It has allowed me to value my life.
Patients are receiving the most appropriate care at the right place and the right time, with 64% of patients not requiring onward referral.
Next Steps:
Continue engagement with patients and the community to expand community development initiatives. Implement the Senior Mental Health Practitioner service across the 3 southern GP Federations/ Southern Trust area to ensure equitable access to this invaluable service.