Community Transformation

What is community transformation?

On 7 January 2019, the NHS published a long-term plan. It set out its healthcare priorities for the next 10 years.

The plan committed to the fastest expansion of NHS mental health services in history.  The key promises were to:

• Transform mental health care so more people can access treatment by increasing funding
• Make it easier and quicker for everyone to get mental health crisis care, including via 111.
• Expand specialist mental health care for mothers during and following pregnancy
• Expand services, including through schools and colleges. This will help children and young people get support when they need it.
• Continue to develop community and hospital services to ensure we can provide the right level of care for people with common or severe mental illness.

In September 2019, the NHS published the community mental health framework for adults and older adults. This framework is intended to transform and modernise the community mental health model. It establishes a purpose and identity for community mental health services and supports the development of Primary Care Networks (PCN), Integrated Care Systems (ICS) and personalised care. The key promises were to enable people to:

• Access mental health care where and when they need it and to be able to move through the system easily, so that people who need intensive support receive it in the appropriate place, rather than face being discharged to no support
• Manage their condition or move towards individualised recovery on their own terms, surrounded by their families, carers and social networks, and supported in their local community
• Contribute and be participants in the communities that sustain them, to whatever extent is comfortable to them

As well as these national drivers of change, the Trust has published its own strategy, ‘With you in mind.’ This strategy includes our plans to deliver safe, high-quality care every day and to improve our inpatient and community services.

Community transformation remains a top priority for future mental health services.

What does it mean for CNTW?

Transformation of community mental health services should lead to more, faster, and better care for all. To do this effectively, services need to be redesigned.

The Trust has two core transformation programmes. They are:

1. Community Transformation Programme and
2. Inpatient Programme.

Both of these programmes consider the needs of children and young people, adults and older adults, and those with learning disabilities and with autism.

The previous Community Transformation Steering Group is now the Community Transformation Programme Board. It is chaired by the directors of the Community Group.

Also, there are four subgroups. They focus on:

1. Community transformation oversight group (implementation)
2. Access oversight group (monitoring access and waiting times, business as usual)
3. Future developments group (new innovations)
4. A special group to oversee the new 24/7 Hub, ‘Hope Haven’, in Whitehaven.

To monitor progress, the Executive Management Group gets updates on these programmes every two months. The Trust Board gets a six-monthly update.

Our new approach was created in partnership with patients and carers, primary care, social care, the voluntary sector and in response to new national guidance.

Understanding you and helping you stay well

This will happen by closely working with:

• Family, friends, carers, peers
• Education
• Voluntary sector
• Social care
• Work and activities
• Housing and benefits
• Primary care, GPs
• Physical Health
• Other partners

Community treatment

Services for people in the community
receiving evidence-based treatment.

Long term complex needs

Services for people in the community with severe mental health needs and other complex needs.

Urgent and crisis care

Services for people in the community with urgent needs.       

Inpatient care

Services for people who require additional treatment within an inpatient setting.

Why is it important?

There is a national directive to improve mental health services and we also have our strategy, ‘With you in mind.’ Everything we do as an organisation must link to and embed this strategy.

Our priorities for community services are therefore linked to the ambitions in our strategy.

When looking at our ambition of quality care every day. Our priorities to fulfil this are:

• Implementing the Patient Safety Incident Response Framework (PSIRF) with clear links to improvement programmes
• Safety improvements
• Triangle of care
• Learning through research
• Embedding a culture of trauma-informed care

For our person-led care ambition we are:

• Developing new crisis models
• Moving away from the Care Programme Approach
• Developing local community-based wellbeing hubs and partnerships
• Using evidence-based treatments
• Improving neurodevelopmental pathways
• Integrating approaches to CYPS pathways
• Improving transitions from CYPS to adult services
• Transforming care of those with learning disabilities and/or autism
• Developing and improving drug and alcohol pathways
• Integrating specialist psychological services in community services
• Progressing key estates projects such as the Campus for Ageing and Vitality in Newcastle

Our priorities to fulfil our sustainable ambition are to:

• Work closely with the voluntary sector, and do this quickly
• Provide seamless care for patients

When considering our priorities for our partnership ambition, we will:

• Undertake system level transformation
• Champion parity of esteem for mental health
• Work to reduce health inequalities

What are we doing across the Trust already?

Seven pioneer adult community treatment teams (CTT’s) were identified across the Trust. There was one in each of the seven places covered by our Integrated Care System (ICS). These were:

• Cumbria East Adult CTT (Carlisle and Eden)
• Gateshead West CTT
• Newcastle West CTT
• North Tyneside CTT
• Northumberland West CTT
• South Tyneside CTT
• Sunderland North CTT

These pioneer teams have been:

• Analysing demand and capacity in their services to make informed decisions on how to proceed.
• They have been identifying opportunities to work collaboratively with partners.
• Testing new patient outcome measures.
• Refining triage, assessment, and treatment planning.
• Reviewing the skills of their clinicians
• Planning how to deliver more evidence-based treatments.

In addition to this work, some Trust-wide work has also been done.

We have reviewed and updated primary care and physical healthcare strategies. We have rolled out the biopsychosocial risk assessment framework across the Trust. We have developed a trauma-informed model of care. We have also made improvements to waiting times, in line with national four week wait targets.

Alternatives to crisis have been developed, such as the Northumberland Safe Haven and Hope Haven in Whitehaven. Access to mental health support is now available via 111.

All adult community treatment teams have now adopted the new processes which were tested by the pioneer teams. Most notably, Dialog+ care planning has been rolled out widely in adult community treatment teams, which we hope will lead to more personalised care.

What difference has it made to patient care so far?

There has been a big focus on getting advice, assessment and help sooner, and this includes improvements in:

• Access points with partners to support people to access the right care at the right time. For example, The Space, a community hub in the west of Newcastle
• Single plan of care using Dialog+
• Better links and services in each community working with primary care, the voluntary sector, social care, and housing to support holistic care
• Primary care mental health workers based in GP practices, to improve support and treatment
• Providing alternatives to admission with crisis and psychiatric liaison models and better integration with existing community services
• Using a trusted assessment approach between clinicians in different services to reduce duplication
• Rolling out patient-rated outcome measures (PROMS) as part of routine care
• Providing reasonable adjustments for people who need additional support to access our services

What next?

The community group is focused on improving waiting times and performance. They are also looking at how to improve access to our services and the assessment locations. The Trust is developing better access and initial assessment processes.

Working groups are developing plans to boost the delivery of trauma-informed evidence-based psychological therapies.

Work is underway to increase the access to Clozapine as a drug treatment for those with treatment-resistant schizophrenia, and systems to support managing this in the community.

A key Trust priority is to reduce reliance on medication for people with learning disabilities and/or autism and provide alternative psychosocial approaches.

We will create better rehabilitation pathways across community, housing, and inpatient settings. This will be in collaboration with social care and our voluntary sector partners.

There is a national directive to move away from the Care Programme Approach. We will develop an integrated approach for this with local authorities and voluntary sector partners. This will allow a shared approach to care planning and risk management in the community.

Enhanced support for those with complex needs and high risks will be developed as part of a new intensive case management strategy, in collaboration with partners.

Individual placement services (IPS) will continue to develop. They will help more people find jobs across the whole organisation.

Hope Haven, in West Cumbria, will open later this year. It is one of six national 24/7 neighbourhood mental health centres and is part of a neighbourhood health service approach. This approach focusses on bringing care closer to people’s homes, making it easier to access. It ensures health and partners in the community work smoothly together.

Future updates

We will use feedback and updates from Community Transformation Programme Board and subgroup meetings to prepare updates and will update these webpages every two months.