The Beacon Multidisciplinary Team (MDT) Test of Change is a neighbourhood-based model designed to identify and support people who may be at risk of being admitted to hospital. The aim is to help people stay well and independent through joined-up, personalised care.
Since it was introduced, the model has supported key NHS priorities around prevention, improving population health, and closer working between local services. Using Brave AI to highlight people who may need extra support, alongside monthly meetings between health, social care and voluntary sector partners, teams can spot concerns earlier and work together to provide timely support before problems escalate.
This model prioritises working ‘with people’ rather than ‘on cases’, enabling practitioners to collectively understand “what matters” and act without unnecessary referral hand‑offs.
Neighbourhood-Based Integrated Care
The MDT brings together health, social care, voluntary sector and community organisations to work together for people living in the local area. By meeting in a community hub, services are based where people live, making them easier to access and helping to build stronger relationships with local communities.
This local approach helps professionals share knowledge, coordinate support and respond more effectively to people’s needs, ensuring care is joined up and centred around the individual.
Prevention and Early Intervention
The MDT helps identify people who may need support before their health or circumstances reach a crisis point. Using Brave AI to highlight those who could be at higher risk, the team can review cases early and offer support sooner.
So far, everyone identified through Brave AI has had an unmet need that would otherwise have gone unnoticed. By stepping in earlier, the MDT can put the right support in place and help prevent issues from worsening, reducing the likelihood of urgent care or hospital admission.
Personalised Care and “What Matters” Conversations
The MDT approach supports personalised care planning, with shared ownership across partners. Interventions focus on what matters to individuals, including connection to community assets, rather than default medical or therapy pathways.
Bottom‑Up System Transformation
Rather than imposing a fixed model, the MDT Test of Change develops and improves through day-to-day practice. Staff from different services work together, learn from real situations, and make practical changes based on what works for local people.
This flexible approach allows teams to adapt as they learn, helping services work more closely together over time. It also gives staff the freedom to use their professional expertise to shape solutions that meet the needs of their community.
Outcomes from the first four months show that the MDT is helping people get the right support earlier and in a way that focuses on their individual needs. Everyone identified through the process has had an unmet need, with support including comprehensive health assessments, care planning, medication reviews, social prescribing, and referrals to community and social care services. Increasingly, decisions and actions are being taken during MDT meetings themselves, helping people access support more quickly and reducing the need for unnecessary referrals.
The model is showing positive results in several areas:
- Early support and crisis prevention, helping reduce the risk of hospital admission.
- Personalised care, with a stronger focus on what matters most to each individual.
- More efficient use of services, with less duplication, fewer inappropriate referrals, and better matching of care to people’s needs.
- Support for people with complex needs, including those living with frailty, multiple long-term conditions, or challenging social circumstances such as caring responsibilities.
- Stronger partnership working, with health, social care, community and voluntary sector organisations working more closely together.
Learning from Spring 2026 shows the model is becoming more established and effective. Teams are making more decisions in real time, coordinating support more effectively across organisations, and responding more quickly to the needs of both patients and carers.
Staff have reported better communication between services, greater confidence in supporting people with complex needs, faster and more effective decision-making, less duplication of effort, and a stronger focus on what matters to the individual.
Overall, the Beacon MDT Test of Change is providing early evidence that local services working closely together can improve outcomes for patients, strengthen teamwork between organisations, and make better use of available resources. The approach has the potential to be expanded and adopted more widely across the system.