Our Primary Care Team is embedded across all 21 GP practices in South Tyneside, our ARRS-funded team provides proactive support to people with non-medical complexity impacting their health and wellbeing, or who have multiple long-term conditions and rising risk.

Our Pathways Team works with system partners to redesign and deliver equitable access to services. They work both on and in pathways, using our tested approach to enable proactive, personalised, and fair support for people with complex needs. Our current commissioned pathways include:

Secondary Care

• We support high intensity users of emergency care.
• We one-to-one and group support to people attending the Long COVID / Breathlessness Clinic.
• We support long-term condition rehab, offering ongoing support for people engaged in services such as Cardiac Rehab.
• We enable engagement for those struggling to access or benefit from traditional therapy models .
• We support the Targeted Lung Health Checks community outreach to increase uptake in underserved populations.
• We are working with the Trust to improve DNA rates and equitable access in key services.
• We work alongside community integrated care teams to provide holistic, person-centred support for people with complex needs.

Work Well: We support people at risk of leaving employment due to health and social factors.

Waiting Well: We prepare people awaiting surgery to improve outcomes and recovery.

Healthy Homes: We support residents to improve their physical and emotional wellbeing by addressing issues within the home environment, such as damp, cold, clutter, fuel poverty, or social isolation. We can accept referrals from any professional, including housing officers, social workers, nurses, GPs, VCSE partners and more.

Across all of our pathways we can offer intensive, evidence-based Tobacco Addiction Support, and in-home holistic assessments and personalised support to make environments healthier and safer.

We support individuals with a wide range of needs, including:

• Feeling low, anxious or overwhelmed
• Managing long-term conditions or symptoms
• Coping with chronic pain
• Navigating benefits, housing or debt challenges
• Loneliness or isolation
• Reducing smoking or alcohol use
• Caring for someone else
• Making healthier lifestyle choices

Our team listens, builds trust, and works with each person to identify what matters to them. Together we:

• Set personal wellbeing goals
• Build motivation and confidence
• Connect people to community resources and activities
• Navigate services and coordinate care
• Foster independence and lasting change

We continue to deliver high-quality, personalised support to people with complex needs, and remain committed to our purpose: enabling healthy change in the people and places that need it most. 74% of the people we support each year are from the most deprived areas. We're proud to work closely with the NHS, local authorities, and community partners to build a healthier future, one conversation at a time.

If you are making a referral from an eligible pathway please contact us at:

• 0191 432 9838
• Or email fcc.abu@nhs.net please include Name, DOB, telephone number, GP practice and reason for referral.

Download our Healthy Homes Poster