About this action

Focus Patients often face barriers that require broader responses beyond healthcare alone. Formal collaboration between primary care and local social, welfare, and housing providers enables coordinated, responsive MDT working, addressing both clinical needs and social determinants of health. Focus Patients often face multiple social challenges that drive poor health outcomes. Formal collaboration between primary care and social, welfare and community and voluntary organisations creates truly holistic responses. Approaches to implementation: - Map local welfare, housing, and community support organisations relevant to your Focus Patients (see NET_01) - Establish formal partnership agreements outlining roles, referral pathways, and information sharing - Create regular MDT meetings that include external partners, not just health professionals - Develop shared care plans that address both health and social needs - Provide space within the practice for partner organisations to deliver services - Evaluate partnership impact on both health outcomes and social circumstances Key benefits: Addresses root causes of health inequalities through integrated support, reduces the revolving door of crisis presentations, and builds more trusting relationships between statutory and community services.