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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.  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).

The new NHS online hospital launches in 2027, but what is it and how will it work? Join the Patients Association's free online event on 11th May at 2pm to learn more. NHS Online will give patients with certain conditions the option of having their hospital appointment online. Together we’ll look at what an online NHS hospital means to people, and will discuss the benefits, opportunities, risks, and concerns. Join us if you are a patient, healthcare professional, policy-maker, carer, charity worker, or simply anyone who wants to learn more about this new initiative. Speakers Chair: Rachel Power - Chief Executive, the Patients Association Jonny Brown - Programme Director, NHS England Jacob Lant - Chief Executive, National Voices Patient representative Register

There are many reasons why missed appointments happen, and some of the causes can be complex. ‘Missingness’ can have poor outcomes for patients and research shows that those who experience the greatest health inequalities are at highest risk. Join this Patients Association webinar looking at missed appointments, or ‘missingness’. Together, we’ll explore the reasons why patients might miss their health appointments, from practical barriers to emotional and systemic factors that can make healthcare feel out of reach. We’ll also discuss what can be done to ensure patients feel more confident in attending those appointments, and how services can make it easier for people to communicate when they can’t. This webinar will highlight perspectives that patients, and healthcare professionals, may not have considered, helping us all to think creatively about how to make visiting healthcare services as accessible as possible. Speakers: The session will be chaired be Sarah Tilsed, Head of Partnerships and Involvement, who will be joined by: Dr Susan Langridge, Deep End GP Andrea Williamson, GP and Professor of General Practice, lead for the missingness in healthcare project Caroline Norman, HARP (health access for refugees) Project Manager at Refugee Council. Register

We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Patients and their families and carers not knowing who to contact to chase up a referral, having to travel miles for appointments, missing appointments because the letter didn’t arrive on time, or having to repeat the patient’s history and medications to every new healthcare professional they see because the notes haven’t been shared or clinicians "don’t have time to read them all". These issues are widespread and urgently need to be addressed if we are to prevent people falling through the gaps and suffering worse health outcomes. In this blog, Sue* shares her and her husband's experiences of trying to coordinate the healthcare system and highlights the challenges and frustrations they continuously face. Difficulties getting a diagnosis My husband Neil* has a very rare chronic condition that means unfortunately he is not managed in the area we live at as it’s a regional centre some miles away. We live in North Yorkshire, one of the largest geographical areas in the country, and we feed into various health economies. It took over 4 years and three different healthcare organisations before Neil got his diagnosis. Every time we see someone new we have to go through all of Neil’s medical history again, and then they often say that it’s not their area of expertise because they only deal directly with one area or speciality; they don't think of the patient as a whole. Whilst waiting to get the diagnosis, Neil had a heart attack so he was initially treated more locally to us but it was still over 40 miles away from where we live. When we called an ambulance for a second time he was taken to a different hospital from the first one he was treated in. So he was taken to two different geographical areas not even under the same trust. To add to this, Neil is also under lots of different specialities, i.e. rheumatology, general surgery, dermatology, respiratory and lipids. So he is being treated and has appointments in numerous places. Coordinating appointments and results With all these different specialties, even if they are within the same regional centre, none of the information is joined up or accessible, including blood results from the GP. We find that things are incorrect all the time and we spend a lot of time trying to coordinate Neil’s care and following up on test results, appointments, etc. Neil receives appointments in various ways—emails, phone calls, texts, letters, messages left on his answer phone. You might get a phone call followed by a letter, or you could get a message to say ignore the letter. You may miss a call but you don’t know which department to ring back because it usually comes up as an unknown number. Recently, Neil received a text message which said he was on a waiting list, but it didn’t say what it was for or what specialist department it was from. It said in the text that if you no longer wanted the appointment and wanted to cancel it, to follow a link, but we had no idea what the appointment was referring to or where it came from! As a patient you want to have some control over your health and be able to see all blood test results, scan results and letters from the hospitals. For example, it would be so much easier to look at Neil’s medications and patient letters if they were all in one place but you can't look at the medical records to see what's been said. The only way we can get it is waiting for the letter to be seen by the GP and then, eventually, added on to their system, but it's not always quick because again it's a different geographical area and systems that are disconnected. As a patient with a new disorder, you’re not familiar with the system. Neil was referred to other specialities from rheumatology. Unfortunately, the treatment plan. including tests or length of wait for appointments, isn’t shared directly with us. We rely on my note taking to ensure everything is completed and followed up. Often we end up going to an appointment without the tests Neil needs to have done due to the length of wait for the test, or the test being triaged and cancelled but this not communicated either to us or the referring doctor. The waiting for test results at the moment are long for some of these tests but if it was in your capacity to be able to seek or understand when you might possibly get them, you wouldn't then end up wasting an appointment. You would wait until you've had the results back or know when it might be. It could take us over two hours travelling time for a wasted appointment. We don’t want to waste our time and the time of others. Lack of communication Neil has radiotherapy coming up shortly and we've had no communications regarding it. I ended up making a phone call to inquire and was given a date. But we’ve still not received a phone call, no email, no letter or anything about it, even though they've got the date and time in their books. You can’t make plans, for example if you are trying to go away for the summer. If you’re waiting for a treatment, which on the NHS may take a while, you want to know when to expect the appointment. It’s a lot easier to manage your condition or diagnosis if you have the knowledge of when something's going to happen and you can manage your own expectations. Navigating the various healthcare apps To try and help with all of this we’ve been really keen to try and find a way to get all of Neil’s medical information, from many different organisations, together in one place and to rationalise appointments. We signed up to the NHS app which then put us on to System Online and then Neil was directed to AirMid UK. We've also found the Patients Know Best app which has been set up and says that you can access all your records but it seems to be only if an organisation has signed up to it. So we’ve got four apps to supposedly access the information but not one of them has all of Neil's information. We are actively looking for an online place which has all the information but none of it ties up. None of the apps give you the same information. We’ve asked our GP but he couldn’t help and hadn’t heard of some of the apps we’d found. A system that isn't working These are just a few examples of what we’re dealing with. I’m lucky as I have some medical knowledge so I know when we're missing something or waiting for something and I will chase up, but not everyone will have this knowledge. If it’s an older patient, or someone who hasn’t got family to support them, then they are on their own to navigate a very complex system. A system that isn't working. *The names in this blog have been changed to ensure anonymity. Are you a patient, relative or carer frustrated with navigating the healthcare system? Or is your GP practice or Trust doing something innovative to make it easier for patients? We would love to hear your stories. Please add to our community forum (you will need to register with the hub, it's free and easy to sign up) or email us at [email protected]. Related reading The challenges of navigating the healthcare system: David's story The challenges of navigating the healthcare system: Margaret's story Navigating the healthcare system as a university student: My personal experience Lost in the system? NHS referrals "I love the NHS, BUT..." Preventing needless harms caused by poor communication in the NHS (DEMOS, November 2023) Robust collaborative practice must become the bedrock of modern healthcare Robbie: A homeless patient’s struggles with the system Digital-only prescription requests: An elderly woman sent round the houses Lost in the system: the need for better admin Digital-only prescription requests: An elderly woman sent round the houses