Northdown Surgery in Margate, serving one of the most deprived areas of Kent and Medway, was once in a challenging position. With just two GPs (one preparing to leave), a failed merger, and the risk of handing back its contract, the practice faced an unsustainable future. The challenge was clear: align capacity with patient need, improve experience, and build a sustainable, modern model of general practice.

Inspired by the National Modern General Practice (MGP) framework and refined locally with support from peer ambassador Tim Chan, Northdown embarked on a practice-led transformation. The whole team—GP assistants, partners, managers, and operational leads—were engaged from the outset, with early involvement of the Patient Participation Group (PPG). Outreach sessions at a local church helped explain the changes and build trust with the community.

At the heart of the transformation was the introduction of a Digital Front Door, making online consultations the first point of contact for all patients. This streamlined access, ensured requests were triaged effectively, and reduced unnecessary pressure on GPs. Alongside this, a Care Home Hub was established, now covering more than 670 patients across 27 homes, with 94% having TEP/Respect forms completed. Workforce expansion was also critical: the practice grew from just 2 GPs to 19, supported by a wider multidisciplinary team including ANPs, pharmacists, paramedics, and GP trainees. A new “Roundhouse Model” of care—where a GP consultant is present on the shop floor with an open-door policy—further strengthened trust and efficiency.

The results have been transformative. Once facing closure, Northdown is now recognised as an example of innovation and stability. The launch of the Digital Hub in February 2024 marked a turning point, proving the model could scale and sustain improvement. GP workload from care home patients has reduced by nearly 88%, while 30% of online consultations are resolved at the hub without needing GP input. Patient satisfaction has risen sharply, from 45% to 76% in just one year, with Friends and Family Test results improving from 90% positive in early 2024 to 94% by August 2025. Emergency department attendances and admissions among older patients have also fallen significantly.

The practice has grown from 10,000 patients to nearly 25,000 across two sites, demonstrating both resilience and appeal. Northdown’s journey shows how digital innovation, workforce redesign, and community engagement can turn a struggling practice into a model of sustainable, patient-centred care.

Oxford Health NHS Foundation Trust has a dedicated Menstrual and Menopause Clinic to provide targeted support for patients experiencing complex interactions between hormonal changes and mental health. The clinic is designed specifically for individuals known to Secondary Care Mental Health Services, where symptoms related to the menstrual cycle or menopause may be affecting their emotional wellbeing.

The service primarily offers expert advice to clinicians, helping them recognise and manage the impact of hormonal factors on mental health. In selected cases, patients are offered one-off assessment appointments to explore how their symptoms may be linked to menstrual or menopausal changes. This approach ensures that care is tailored and responsive to individual needs, particularly during vulnerable periods.

In addition to clinical support, the clinic also plays a key role in education. Teaching sessions are available for teams across the Trust, and clinicians with an interest in menstrual and menopausal health are encouraged to shadow appointments. The aim is to raise awareness and build confidence in identifying and managing hormone-related mental health challenges, ultimately improving outcomes for patients and strengthening the support available across mental health services.

A pioneering pilot programme offering flu vaccinations to children aged 2 and 3 has launched across 30 nurseries in the Thames Valley, marking a significant step forward in early years public health delivery. Led by Thames Valley’s School Aged Immunisation Services (SAIS), the initiative spans Berkshire, Oxfordshire, and Buckinghamshire, with 10 nurseries participating in each area. All selected nurseries are attached to schools, allowing vaccination sessions to be coordinated alongside existing school flu programmes for maximum efficiency.

This is the first time SAIS has delivered flu vaccinations directly in nursery settings in the South East region, and it represents the largest trial of its kind. It builds on smaller-scale efforts previously delivered through GP practices and Primary Care Networks in Kent and Medway. The pilot aims to assess the benefits and feasibility of vaccinating toddlers in familiar nursery environments, with a focus on improving access for families and increasing uptake among younger children.

Local nursery leaders and parents have welcomed the convenience and reassurance the pilot provides. Charlotte Taylor, Headteacher of Hardwick Primary School in Banbury, Oxfordshire, said: “Having the flu vaccine offered in our nursery is a fantastic opportunity for our families. It’s convenient, reassuring, and helps keep our children healthy during the winter months.”

Parent Florin Munteanu added: “To have the option of having my child vaccinated at his nursery is great—it’s certainly a helpful option for working parents and my child will be within a familiar setting which will make him more comfortable.”

As winter fast approaches, this pilot is helping to protect children and their families while showcasing a new model for delivering preventative care in early years settings.

Since its launch in June 2022, the Sussex Lung Cancer Screening Programme has made remarkable strides in early detection and treatment, offering targeted lung health checks to people aged 55–74 who currently smoke or have smoked in the past. Supported by the Brighton & Hove GP Federation, the programme proactively invites eligible individuals by letter, followed by a telephone assessment and, where appropriate, a low-dose CT scan at accessible community locations—including mobile units in supermarket car parks.

This approach is transforming outcomes. Of the 62,127 people invited, over 37,000 attended, resulting in 18,627 CT scans and 195 lung cancer diagnoses. Crucially, nearly 78% of these cancers were caught at an early stage, compared to fewer than one in three outside of screening programmes. Early detection means more treatment options and better chances of recovery.

For Ian Needham, 71, a scan revealed a cancerous nodule that was treated successfully with surgery. He’s now back to cycling and enjoying life with his family. Similarly, Ginnie Walker, 59, discovered a stage one tumour during her check and is now cancer-free—and smoke-free.

With continued expansion across Horsham and beyond, the Sussex Lung Cancer Screening Programme is a powerful example of how community-based, intelligence-driven healthcare can save lives and support the NHS’s commitment to early diagnosis and equitable access.

At Maidstone and Tunbridge Wells NHS Trust (MTW), the Phoenix Midwifery Team is transforming maternity care for young parents aged 20 and under. Since its launch in 2021, this dedicated team of specialist midwives, a maternity support worker, and a consultant obstetrician and gynecologist has provided tailored, compassionate care to those navigating pregnancy at a young age—often in the face of complex physical, mental, and social challenges.

Named after the mythical phoenix, a symbol of renewal and resilience, the team recognises that for many young parents, pregnancy can represent a fresh start. Some come from disadvantaged or difficult backgrounds, and the Phoenix Team offers not just clinical care, but emotional support and advocacy to help them build brighter futures.

Central to their approach is the continuity of carer model, which ensures each young parent is supported by a named midwife throughout their journey. This builds trust, reduces anxiety, and improves outcomes. The team provides flexible antenatal appointments, personalised education sessions, and labour care delivered by a familiar face. For those considered high-risk, care planning is done collaboratively with a dedicated consultant to ensure shared decision-making and tailored support.

Postnatal care is equally supportive, with 28 days of at-home visits and access to Phoenix Hubs—community meet-up groups run in partnership with Kent Family Hubs. These spaces offer peer connection, ongoing guidance, and a sense of belonging.

The impact has been significant. Since the team’s launch, pre-term birth rates have nearly halved, and more babies are receiving at least one hour of skin-to-skin contact after birth. The team’s holistic support is helping to break cycles of disadvantage, enabling young mothers to continue their education and access care regardless of language barriers, literacy levels, or neurodiverse needs.

The Phoenix Midwifery Team shows how compassionate, personalised care can change lives—not just for young parents, but for generations to come. Their work is a powerful reminder that age should never define the quality of care someone receives, and that with the right support, every young parent can thrive.

One You Kent, delivered by Kent County Council and Kent Community Health Foundation Trust, provides lifestyle support to help people improve their health and wellbeing. From quitting smoking and managing weight to boosting mental health and increasing physical activity, the service offers tailored advice and practical tools. In East Kent, One You also runs health walks and operates a dedicated shop in Ashford’s Park Mall, featuring consultation rooms, a teaching kitchen, and space for exercise classes.

One person who has benefited from the service is Chris Laing, 46, from Folkestone. After a series of physical and mental health challenges—including a ruptured spleen, bipolar disorder, and heart issues—Chris lost his independence, home, and sense of direction. Support from the Folkestone Job Centre led to referrals to IPS Employment, the Restart Work Programme, and One You Lifestyle Advisor Cas Nech.

With Cas’s guidance, Chris set realistic goals and joined Fit Together, a local initiative tackling isolation through exercise. Gym sessions and dietetic support helped him rebuild confidence and improve his wellbeing. He later completed mental health training and secured a paid role as a peer support worker at Ashford Safe Haven. Now, with a pacemaker fitted, Chris is driving again and thriving—proof of how joined-up, personalised support can transform lives.

Growing Health Together in Horley is a collaborative initiative that brings together primary care, community organisations, and local residents to improve health and wellbeing at neighbourhood level. Recognising that GP services alone cannot address the wider determinants of health, the programme supports a more holistic, place-based approach—anchored by at least one GP surgery in each neighbourhood.

In Horley, the Health Hub has become a vibrant centre for community-led wellbeing. Activities such as walking groups, coffee mornings, and community gardening offer accessible ways to stay active and connected. One standout initiative is the Men’s Shed, a volunteer-led group where people meet to share practical skills, enjoy making and mending, and build new friendships. Located beside the Hub’s community garden, the Shed has grown rapidly and now includes both men and women.

Another key feature is Chatterbox Birchwood, run by Volunteer Health Champions who offer a welcoming space for advice, emotional support, and signposting. The team helps residents access online health information and provides tailored guidance for carers, ensuring no one feels alone in navigating their health journey.

Together, these initiatives demonstrate how aligned partnerships and community assets can create the conditions for better health—right where people live.

West Sussex has one of the largest populations eligible for NHS Health Checks in England, prompting a multi-strand approach to ensure broad and equitable access. The county delivers checks through GP practices, community pharmacies, Prevention and Assessment Teams (PATs), and the West Sussex Wellbeing programme. With over 50 GP practices signed up and a network of larger pharmacies offering clinics—particularly in areas with limited GP coverage—the system is designed to maximise reach and convenience.

Outreach provision plays a vital role in engaging harder-to-reach communities. PATs, made up of multidisciplinary teams including community nurses, offer NHS Health Checks in trusted, non-clinical settings such as libraries and community centres. These checks are often delivered alongside broader preventative services for vulnerable adults and older people. In parallel, West Sussex Wellbeing teams operate across districts and boroughs, using local insight to target areas with high health inequalities. From permanent hubs in shopping centres to mobile units and pop-up clinics in leisure centres, the programme meets residents where they are.

A key strength of this model is its integrated approach. Wellbeing teams not only conduct NHS Health Checks but also offer immediate access to health improvement services like smoking cessation, weight management, and alcohol advice—often delivered by the same staff in the same location. This continuity reduces barriers to engagement and ensures timely support. Where urgent medical concerns arise, staff are trained to refer individuals directly to appropriate healthcare services, with results shared with GP practices when consent is given.

Looking ahead, West Sussex continues to refine its provision to ensure coverage across rural and urban areas. Providers coordinate closely to avoid duplication and maximise impact.

An innovative partnership between Surrey and Borders Partnership NHS Foundation Trust and Epsom and Ewell High School is helping students thrive while significantly reducing referrals to specialist mental health services. Through the Trust’s School Based Needs team, part of the Mindworks Surrey service, students are receiving early, targeted support for their emotional and mental wellbeing – where they need it most.

Clinicians from the team work closely with school staff to embed inclusive practices, tackle stigma, and offer tailored advice on how best to support individual students. For those with more complex needs, the team provides direct consultations with the child or young person and their family, helping them access appropriate specialist care when needed.

At a recent showcase event attended by local health and education leaders, students shared powerful stories of how the support they received had transformed their lives. The impact is clear: in the last quarter the team delivered 2,158 consultations—nearly double the number from the same period last year—while only 2% of young people required referral to specialist or community mental health services.

This partnership shows how early intervention, collaboration, and compassionate care can make a lasting difference in young people’s lives, ensuring they feel supported, understood, and empowered to succeed both in and beyond the classroom.

For over a decade, the Surrey and Borders Partnership NHS Foundation Trust has been working to transform lives through its Recovery College—a self-enrolment service offering free courses to help residents manage their mental health. Described by former service user Kate Monfort as the “best kept secret” of the NHS, the college provides psychoeducational support that builds confidence, self-esteem, and a sense of control.

Kate first joined the college as a student in 2016, later becoming a volunteer and eventually a member of staff. “I found it incredibly helpful for my own mental health and recovery journey, and it just works,” she said. The college’s approach centres on psychoeducation—teaching individuals about mental health conditions and emotional wellbeing in a way that empowers them to take charge of their recovery. “Doing these courses, finding my tribe… it was just so helpful,” she added.

Courses cover a wide range of topics including OCD, anxiety, and depression, and are delivered in safe and supportive learning spaces or virtually. Activities such as arts and crafts are also offered, creating a welcoming environment for creative expression and connection. For Linda Parfitt, another former student turned volunteer, the first course on self-compassion was life-changing. “It was a revelation,” she said. “It’s helped me feel that I’m not alone in the world.”

Service Manager Nina Clayton-Broom explained that the college began as a pilot for people with personality disorders but quickly expanded due to its success. What makes the service truly accessible is its open-door policy—no GP referral or formal diagnosis is required. “You don’t need to prove how difficult things are for you,” she said. “And sometimes mental health services can feel a bit like that.”

The Recovery College stands as a powerful example of how education, empathy, and community can come together to support mental health recovery.

In a bold step toward tackling health inequalities, NHS Hampshire and Isle of Wight has partnered with Dentaid The Dental Charity to launch a mobile dental service that brings free, high-quality care directly to those who need it most. Designed to alleviate pressure on overstretched dental services and improve access for underserved communities, the initiative is transforming how dental care is delivered across the region.

The mobile dental units travel to community centres, public buildings, and sports facilities, offering appointments to families experiencing poverty, people at risk of homelessness, children, and new or expectant mothers in areas with the highest risk of poor oral health. Patients receive check-ups, oral cancer screenings, emergency treatments such as extractions and fillings, and tailored oral health advice—all free of charge. Emergency appointments are also available for those suffering acute dental pain with no other access to care.

The service is supported by a wide network of local agencies, including GP practices, foodbanks, community groups, and NHS 111, who help identify and signpost eligible patients.

In its first year alone, the mobile units treated 5,169 residents, delivering over 20,000 dental procedures. Hundreds of children and young people have also benefited, and through Dentaid’s BrightBites programme, 3,744 schoolchildren learned essential skills in toothbrushing, nutrition, and the importance of regular dental care.

Th partnership is not only improving oral health outcomes but also restoring dignity and confidence to individuals who have long struggled to access basic care.

In Portsmouth, around 17% of the city’s 55,000 children and young people require support beyond universal services. Many are neurodiverse, yet the traditional diagnosis-led system has struggled to meet their needs. Long wait times, fragmented services, and limited post-diagnosis support prompted Portsmouth’s Integrated Children’s Commissioning Team to rethink the approach. In 2019, they launched a major co-production initiative with the then named-Solent NHS Trust, local authorities, schools, voluntary organisations, and over 80 parents and young people to develop a more inclusive, needs-led model.

Central to this transformation is the Portsmouth Neurodiversity Profiling Tool—a framework that helps professionals and families understand a child’s neurodivergence across areas such as emotional regulation, sensory levels, and attention skills. This tool, paired with a handbook and resource bank, enables early support without relying solely on clinical diagnosis. A dedicated multi-disciplinary team was also established to provide a “one stop shop” for families, bringing together experts from health, education, and social care.

The Portsmouth Neurodiversity Team (0–19) plays a key role in delivering this pathway. The team includes family support workers, child and adolescent clinicians, an educational psychologist, speech and language therapists, occupational therapists, and a service lead. Their mission is to improve early identification of neurodiversity and offer consistent, universal support for families and professionals—reducing the need for lengthy assessments. The team provides a single point of access for advice, training, and extended support for more complex cases.

Since its launch in 2022, the strategy has led to an 89% reduction in requests for formal diagnosis, bucking national trends. Over 500 professionals have been trained to use the profiling tool, 15 schools have begun adapting environments to better support neurodiverse pupils, and a competencies framework is helping build a more informed, inclusive workforce. Portsmouth’s approach is now recognised as a pioneering model—shifting from diagnosis to diversity, and from services to system-wide transformation.

This collaborative working project between Boehringer Ingelheim Limited (BIL) and NHS Hampshire and Isle of Wight aims to make it easier for everyone to access the treatment that they need and receive better, more effective care. It particularly aims to support people from communities with a higher risk of chronic kidney disease (CKD) and communities where accessing the right care can be more challenging. The project focuses on reducing health inequalities by improving early diagnosis and providing proactive care to slow the progression of CKD.

CKD affects approximately 10% of adults in the UK, yet many cases remain undiagnosed until the condition has significantly progressed. The new initiative will enhance early detection by increasing access to screening in communities where accessing the right care can be more challenging, providing targeted outreach, and ensuring that those most at risk receive timely intervention and support.

Oxfordshire’s innovative Whole Systems Approach to Physical Activity is a coordinated and collaborative effort led by Active Oxfordshire and supported by a range of regional partners, including the Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board, Oxfordshire County Council Public Health, and local district councils. Jointly funded and community-driven, this strategy aims to combat physical inactivity through a diverse suite of interventions tailored to local needs.

Key initiatives include training 500 healthcare professionals to initiate meaningful physical activity conversations with patients and expanding successful programmes like YouMove and Move Together to cover maternity and Early Years services.

The project also delivers targeted support in priority neighbourhoods through Active Travel outreach, subsidised swimming lessons for over 4,000 children, and campaigns like falls prevention to protect vulnerable groups. New working groups have been formed to integrate volunteers into health pathways, amplifying support networks across the county.

This approach is already showing significant outcomes. Participants saw a 36% drop in GP appointments and a 28% reduction in demand for urgent care services within 12 weeks of engagement—translating to improved wellbeing and reduced pressure on the healthcare system. Additionally, recorded falls decreased by 12%, demonstrating the tangible health benefits of increased physical activity and community investment.

The Kent and Medway Social Care Partnership Trust Rough Sleeper Team is making a tangible impact by reaching and engaging individuals who are either currently experiencing homelessness or are at risk of becoming homeless. With an estimated 40% to 80% of people sleeping rough also facing mental health challenges, the path to securing stable housing becomes increasingly complex. To address this, the team partners with local authorities to provide person-centered support services tailored to help individuals build safer, more secure lives away from the streets.

At the heart of this initiative is a multidisciplinary team—psychiatrists, social workers, and nurses—working in collaboration with Mental Health Together and other secondary mental health care providers. Rather than waiting for individuals to seek out services, the team meets people where they are—on the streets—offering direct assessments and compassionate care in real time. This flexible and innovative approach is vital to breaking down barriers and delivering the right support at the right moment.

Thanks to consistent, empathetic engagement, the Rough Sleeper Team has earned a strong reputation within vulnerable communities.

Much of their success stems from word-of-mouth recommendations from those they’ve helped, making it easier to connect with others in need. Since its introduction, the team has driven meaningful improvements—bringing stability, hope, and dignity to those who need it most.

Recently featured on the front page of The Times and celebrated by their local MP, the NHS Hampshire and Isle of Wight Foundation Trust’s pioneering partnership with Citizens Advice is demonstrating the power of joined-up care.

On a mental health ward, caseworkers have been providing one-to-one guidance on social challenges such as debt, housing, and employment—common triggers for mental health crises. This joined-up approach helped people leave hospital sooner and reduced the risk of them needing to return, by tackling the root causes of their mental health problems.

An economic review found that every £1 the Trust invested in the programme generated £14 in savings, thanks to shorter hospital stays and reduced demand for other services. Staff have also reported lower stress levels and greater job satisfaction, as they can focus on providing clinical care while Citizens Advice tackles the broader social challenges affecting recovery.

Committed to moving from treatment to prevention, the Brookside GP practice in Earley has a dedicated team of health and wellbeing advisors who work with patients who might need support in a whole range of areas such as diet and exercise, emotional health, loneliness, financial issues and social anxiety. By taking a holistic approach to patient wellbeing means the practice can tackle the root causes of many patients’ issues, as well as supporting them medically.

Preventing patients from needing further medical by supporting them with proactive preventative initiatives – easing strain on services and improving outcomes for local residents.