How Connect North is improving and streamlining services into one coordinated model: An interview with Claire Ramsey

Summary

Connect North is an innovative, integrated and co-designed social prescribing service operating across the Northern Health and Social Care Trust (NHSCT) area in Northern Ireland.

Finalist in two Picker Experience Network (PEN) Awards categories both in 2024 and 2025, Connect North demonstrates how integrated, person-centred approaches can improve access to care, reduce system complexity and patient safety risks associated with fragmented services and delayed support.

We spoke to Claire Ramsey, Health and Wellbeing Manager at Connect North, to find out more about the service. 

Content

Hi Claire. Can you tell me about Connect North and why was it set up?

Connect North was established in response to system-wide challenges highlighting a fragmented and confusing system. Signposting information was available, but only by referral, and services held varying referral criteria—individuals could be known to multiple services for similar supports while others in need were left unsupported. 

This fragmentation created clear risks to clients, including delays in accessing support, increased likelihood of deterioration while waiting for help and the potential for vulnerable people to fall through gaps between services.

In response, Connect North was created to integrate and streamline services into one coordinated model, reduce duplication, improve access to community-based support and empower individuals to access support earlier through better information and self-service options.

We support adults to address social, practical or emotional issues through a publicly available online directory of services, accessible signposting or via referral to our link worker service for more tailored support. 

How did you involve patients in co-designing Connect North?

Connect North actively engaged with clients and carers at every stage; from review of services to identifying problems, shaping the service model and co-producing resources, to ongoing evaluation. Their needs form the anchoring principles of the Connect North model, service and improvements.

What is social prescribing and what are the benefits to patients?

Social prescribing is a holistic, person-centred and community‑based approach, which recognises that non-medical health-related social needs—for example, work, money, housing problems, the challenges of managing long-term conditions or feeling lonely or isolated—are just as important to our health and wellbeing as our physical health needs. 

Social prescribing connects people to activities, groups and services in their community to meet the practical, social and emotional needs affecting their health and wellbeing. It can lead to better mental wellbeing, stronger social connections, improved self‑management of long‑term conditions, greater empowerment and control, and reduced reliance on traditional healthcare services.

You mention long-term conditions; can you give an example of how Connect North can help a patient with a long-term condition?

I’ll use a diagnosis of dementia as an example here. The impact of this diagnosis on the person and their care circle can be overwhelming, leaving many unsure where to turn for help or feeling alone.  

Without timely and coordinated support, this uncertainty can lead to increased carer stress, social isolation, delayed access to services and a higher risk of crisis situations developing.

Connect North provides personalised, early support to guide people through this difficult time. Clients are offered a one-to-one appointment with a dedicated link worker who takes time to assess and understand their needs, concerns and what matters most to them, before connecting them to services and activities to improve their wellbeing. 

To speed up connection and reduce misconnections between those who need help and support to those who provide it, we set-up our Community Appointment Days (CADs). CADs enable clients with dementia and their carers to connect directly with a wide range of support within a single appointment.  

Can you tell me more about the Community Appointment Day?

The aim of our Community Appointment Day (CAD) is to make things simpler, faster and less stressful, helping people with dementia and their care circle feel informed, supported and more confident about the future.

Immediately following a personalised assessment and care planning appointment with their link worker, clients and their carers are directly introduced to services who can support their needs, within the same appointment. Delays and misconnections to these services are completely eliminated and we use our own service data to ensure relevant statutory, community and voluntary sector organisations are represented for maximum impact. Support services invited typically include those who provide carer support, dementia-specific information, benefits advice, personal and home safety information, and those hosting local groups and activities to improve social connectivity. 

Another important feature of our CADs is that they are hosted in accessible, non-clinical community venues. At each event we create a relaxed and warm environment enabling positive engagements. Every conversation is purposeful and led by the pace of each client and their carer. Clients and carers can attend together or separately as they require, and we encourage regular breaks throughout with refreshments provided. At the end of the appointment, each client/carer is provided with a clear, easy to understand record of their conversations and connections made on the day supporting recall and follow-up.

What were the outcomes and how has it benefited the community?

Our CADs make dementia support for our clients and their carers timelier and more effective while also improving how local services work together as an integrated system. Providing multi-agency care and support via a single appointment reduces referral administration and delays/misconnection to care provision.

Evidence indicates increased uptake of support at an earlier stage, improved coordination between services and reduced duplication of referrals, contributing to a more responsive system.

It also alleviates the burden of responsibility experienced by clients and their carers to navigate complex systems, connect with services and coordinate multiple appointments.

We consistently find that more people are accessing and taking up support earlier. This earlier engagement is critical in preventing deterioration and reducing the likelihood of crisis developing. From a system where people frequently felt on their own with no help and support, to our CADs which offer direct and coordinated care within a single appointment, the client experience is far improved:

“This has completely changed our whole outlook, we are so much more positive about the future.”

“We had no idea so much help and support was available.”

“I can’t believe the tenderness of it all—it’s been wonderful.” 

Co-delivery partners find the CAD and our targeted approach to service delivery around the client to be a more effective use of their time, generating appropriate referrals more efficiently. They also enjoy the opportunity to network, share learning and connect meaningfully with clients and carers to make a positive impact to their health and wellbeing following a diagnosis of dementia.

What advice would you give others wanting to set up something similar in their community or region?

Bring the system to the person, not the person to the system. 

A CAD requires targeted planning based on needs. While strong partnerships and continuous improvement are essential for any event, a CAD specifically requires data-driven planning and effective organisation to deliver a streamlined and personalised appointment with a clear focus on the reality of client and carer needs and experiences. Application of good health literacy principles in practice is essential at all stages and support needs to be timely, coordinated and always centred around the needs of the individual.

What are your next goals and plans for the future?

The future focus for Connect North is on sustaining and refining our CAD model, ensuring it remains efficient, person-centred and adaptable, while extending its benefits to more people and, potentially, other areas of care through sharing learning, resources and good practice. 

In the NHSCT, we are particularly interested in how this model can be adapted to support other population groups and conditions.

We will continue to collect and share our own service data and outcomes with partners and stakeholders to support further improvements, ensuring our service remains targeted, efficient and responsive to need.

Are you doing something similar in your community? We would love to hear about it and share on the hub. Email [email protected] or comment below (you need to be a hub member and signed in).