Community Mental Health Transformation Programme

The Framework (transformation) provides an opportunity to achieve change in the design of community mental health care by moving away from siloed, hard-to-reach services, towards joined-up care and whole population approaches and establish a revitalised purpose and identity for community mental health services.

It supports the development of primary care networks, integrated care systems (ICSs) and personalised care, including how these developments will help to improve care for people with severe mental illness.

Community mental health services are at the heart of the NHS Long Term Plan. One of its key objectives is to develop “new and integrated models of primary and community mental health care [which] will support adults and older adults with severe mental illnesses”. The NHS Mental Health Implementation Plan 2019/20 – 2023/24 describes our overall approach to delivering such models.

We’ve included relevant documents to support the vision of a new integrated community mental health model.

NHS England Roadmap and Long Term Plan

National Institute for Health and Care Excellence guidance

• Rehabilitation for adults with complex psychosis
• Bipolar disorder: assessment and management
• Psychosis and schizophrenia in adults: prevention and management

Mersey Care aims to ensure a leading edge reputation for its work in the sphere of patient, carer and community engagement and participation. To achieve this within the scope of the Community Mental Health Transformation Programme, it’s crucial that we embed patient, carer and community voice through all of the transformation workstreams.

We want to move to a position of meaningful partnership working in all we do - working with rather than doing to! In November 2022, the Lived Experience, Co production, Peer Support Worker and Carer Transformation Workstream formed as a transformation group and began to identify and share initiatives within the Trust.

Following this period of coming together and learning, aims and objectives of the group were agreed:

• To develop a Trust public engagement strategy to support achievement and monitoring of meaningful co-production across all community mental health transformation workstreams
• To develop a standardised model to support with recruitment and retention of peer support workers across community mental health services
• To develop a Trust carer’s strategy which will identify caring priorities for community mental health services 
• To develop a system for ensuring meaningful co-production is embedded within all our transformation workstreams.

Much progress against the aims and objectives has been achieved, with a Trust Public Engagement Strategy developed - within this Strategy, a model and framework. The next steps will be to consider how to implement the priorities within community mental health services. 

Watch our short animation which gives an overview of our ten top tips of co production.

Find out more about co production.

In the Framework, the following guidance for VCFSE was advised.

• Implementing this Framework will break down the current barriers between: (1) mental health and physical health, (2) health, social care, voluntary, community and social enterprise (VCFSE) organisations and local communities, and (3) primary and secondary care, to deliver integrated, personalised, place based and well coordinated care
• Strengthening relationships with local community groups and the VCFSE will support the adoption of more rights-based care based on greater choice and engaging early with communities to address inequalities
• Community connectors/social prescribing link workers, however, will work closely with the whole spectrum of community services and the local VCFSE sector
• Implementing this Framework, which involves triple integration of mental health, physical health and social care, will take time, requiring careful joint working across sustainability and transformation plan/integrated care system geographies by providers, commissioners, local authorities, local VCFSE organisations, service users and carers, and the local community
• The Framework proposed applies the collaborative model to the delivery of community mental health care. In this case, providers include VCFSE organisations, the local authority and other providers of social care, as well as statutory primary and secondary healthcare providers
• Agreed governance structures will be required for the effective operation of all services in this Framework, including the development of systems and processes to support the integration of primary care, secondary care mental health, social care, VCFSE organisations and housing and community services
• Local partners agreeing a multi-year alliance contract with in-built flexibility could also help to focus efforts on the quality of care and help smaller VCFSE organisations to operate on a surer, sustainable basis
• To realise the joined-up approach this Framework sets out, these teams would fully integrate their working with other local services, including primary care networks, employment and housing support staff, key VCFSE organisations in the area and social support services. Care will be planned and delivered across this wider partnership.

The guidance has led our strategy and decision making for our VCFSE workstream.

VCFSE organisations and services

A percentage of transformation funding is allocated to VCFSE organisations to support those with serious mental illness based in our communities. Liverpool and Sefton have funded the below local services to support this population.

Liverpool and Sefton

Age Concern - Liverpool, Sefton and Kirkby

Through Combat Isolation, ACLS intend to launch a bespoke suite of services which will deliver one to one community based social interventions; supporting individuals, building personalised community support programmes designed to supplement existing care plans and delivering activity programmes/volunteer befriending services.

Evolving Mindset - Kirkby and South Liverpool

The service provides an easy entry point for people with mental health needs who are ready to be stepped down into primary care by providing learning-based opportunities to help manage their mental health, reduce isolation and loneliness, develop their skills and live independently in the community. 

Imagine Independence - Liverpool and Sefton

This service aims to enhance the quality of care being provided by the community mental health team (CMHT) to those in scope for the intervention: home (imagineindependence.org.uk)

Sean’s Place - Sefton

This project provides an easy entry point for people with mental health needs by providing learning-based opportunities to help manage their mental health, reduce isolation and loneliness, develop their skills and live independently in the community:

Mens Mental Health Support Sefton | Liverpool - Sean's Place (seansplace.org.uk)

Sefton CVS - Sefton

We have created a dedicated pathway for Sefton adult CMHTs to refer people directly to the service to provide proactive and preventative social interventions:

Sefton CVS | Supporting Local Communities

Warrington, Halton, Knowsley and St Helens

In these places, four care coordinators are employed by the VCA and work connecting patients and community services to be linked in with place-based organisations in the VCFSE sector that can support the patient.