Ambition 2: Person-led care, when and where it is needed

We will work with partners and communities to support the changing needs of people over their whole lives. 

We know that we need to make big, radical changes. We want to transfer power from organisations to individuals. The focus of services is often about managing crisis. We want to shift towards a focus on people keeping themselves well.

Community based care for adults and older people with mental ill-health

We want to remove things that make current services difficult for people to understand. People should be able to reach the support they need when they need it. We are committed to making a radical shift in our approach.

GPs, primary care and community organisations are at the heart of supporting people all through their lives. Each community has its own support and care networks, which we want to work alongside. This will wrap care around the person that needs it. We want to make sure that each person has one story that is understood by all. At any time, people should have access to care and support that is right for their needs. This care and support should be from the organisation that is best placed to meet those needs.

We will work with our partners to create new models of care and support which are simple, easy to access and built on strong, trusted relationships.

Together we will work with people and families to help them to live well in their communities. Together, we will prevent crisis and act early when extra support is needed.

Sometimes people need very specialist support and therapeutic care. We will make sure that we have well trained, skilled people who can respond quickly to provide the right support when it is needed.

We want people get the right care from the right service at the right time. This could be from their GP, social care, community groups, charities, or mental health services.

We will take a radical approach in how we deliver community based care which will:

  • Consist of services and teams working together and rooted in our communities;
  • Move away from a confusing system of referrals, assessments and treatment, to one of constant support and easy access to the right support at the right time;
  • Enable expert advice, support and skilled clinical help is available from our teams when they are needed;
  • Make sure that there is support available for people all day, every day, within their communities, to meet their needs and enable them to keep well;
  • Provide intensive wrap around support for people who need it most;
  • Develop our services with our partners to address the areas of greatest need and health inequality;
  • Develop real alternatives to inpatient care with our partners across our places so that where possible, we can support people in crisis within their own communities.

Inpatient care for adults and older people with mental ill-health

We want to make big changes to inpatient services for adults and older people with mental ill-health.

When people are in hospital, we will protect their human rights every day. We will make sure our inpatient wards are welcoming and support healing. We will make sure staff have the right skills to support effective treatment.

When people are ready to go home or need to move to a different ward, we will make sure this goes smoothly. We will work with social care, housing providers, GPs and primary care so people stay well after their hospital stay. We will also design services that avoid hospital stays.

We will listen to service users, carers and families, to make care personal and improve things for all inpatients.

We will protect rights and be open. We will create safety for people to talk about their concerns. An open culture and rights-based approach will mean that:

  • people will only be admitted to inpatient care if and when they need it;
  • we will always clear on the reason and benefit of admission;
  • people will not need to wait to be admitted;
  • people will not be admitted to hospitals that are very far away from home;
  • inpatient care will be personalised, therapeutic and effective;
  • staff will have the specialist skills needed to provide personalise, therapeutic effective care;
  • inpatient care will be safe;
  • there will be no avoidable long term segregation or seclusion. People will not be kept on their own for a long time;
  • we will support people to return home to their communities as soon as they are able; and
  • people will not stay in hospital longer than they need to.

Children and young people

Children and young people, their families and carers should get the support they need.

Good physical and emotional wellbeing can prevent long-term problems and help people live healthy, happy lives.

We support children and young people:

  • with their emotional wellbeing,
  • with mental ill-health, and
  • after big life events.

Support will be linked across GPs, paediatrics, schools, colleges and community groups to wrap around families. We will improve our services for children and young people who need a stay in hospital.

We will support services to be very different so that children and young people can receive the support that is best for them. We will work with other organisations to: 

  • provide the right help and support to young people and families when it is needed;
  • make sure that there are no long waiting times for help;
  • make sure that the needs, risks and challenges of the child/young person are understood as soon as possible;
  • make sure that help and support is available while waiting for a diagnosis or without a diagnosis;
  • make sure that help is based on the needs of the child/young person and their family;
  • create spaces that children and young people feel safe to go to;
  • safeguard the rights of children and young people at all times;
  • support families in everything we do;
  • work with other organisations to offer better support for children and young people with complex needs, and their families, so they can live well in their own communities; and
  • make sure support doesn’t stop when a young person turns 18 and help them adapt to services for adults.

People with a learning disability

People with a learning disability should be treated with humanity, dignity and respect.

People with a learning disability should receive healthcare just like everyone else. If they need extra support to stay well and have a good life, they should receive it. Sometimes support will be provided by a service that is only for people with a learning disability. Services that help everyone will make changes so that their support is suitable for someone with a learning disability.

People with a learning disability should only go to hospital when they really need to. This should be close to where they live. When someone with a learning disability is in hospital, we will always protect their rights. We will work with other organisations so that people in hospital can go home as soon as it is right for them.

We will work with other organisations so people with a learning disability stay healthy and live well in their communities. We will:

  • support people in their own homes;
  • think about how we use medicines, so we don’t give people medicine they don’t need;
  • meet people’s physical and mental health needs at the same time;
  • make sure staff understand the needs of people with a learning disability, and
  • communicate in a way that works so we understand each other.

People with neurodevelopmental conditions

Neurodevelopmental conditions include:

  • Autism;
  • Attention Deficit Hyperactivity Disorder (ADHD);
  • Dyslexia;
  • Dyspraxia;
  • Dyscalculia; and
  • Tourette Syndrome.

People with these conditions are sometimes described as ‘neurodivergent.’

Neurodivergent people are entitled to the same healthcare as everyone else. Making services suitable for neurodivergent people makes them better for everyone. This includes services that are not specifically for autistic people, for example, mental health wards. We will work with other organisations to make sure people only stay in hospital if they really need to.

We will improve our understanding of neurodiversity, neurodivergence and the increased risk of suicide in autistic people.

We will make sure staff have the training to support people effectively. We will make sure there is early support to diagnose and identify the needs of autistic people, people with ADHD and their families.

We will review how we use medicine with people because of their neurodivergence or behaviours of concern. We will make sure that we don’t give people medicine they don’t need.

We will make things easier for people to understand and we will respect their communication preferences.

People who need support from secure services

Secure services provide safety and real change for a better life.

Secure services provide treatment for people with complex mental disorders linked to offending or seriously harmful behaviour. Some will be involved with the criminal justice system (CJS), courts and prison. Secure services help people gain a deep understanding of themselves and their history.

The Secure Care Provider Collaborative is a partnership with Tees, Esk and Wear Valley NHS Foundation Trust and other organisations.

We will help service users gain new skills, understanding and ways of responding to things they find difficult. This will help people move on from secure settings and have more freedom, choice, and control in their lives. We will do this by focusing on:

  • mental health;
  • dealing with strong feelings;
  • addictive behaviours;
  • risk to others;
  • physical health;
  • social skills;
  • relationships;
  • meaningful activities; and
  • trust and hope.

People with neurodisabilities

We help people with brain diseases or injuries to be as independent as they can in their everyday activities.

We will work with GPs, other hospitals, social services and other organisations to:

  • tackle issues that stop people from being admitted to inpatient care;
  • tackle issues that stop people from being discharged when they are ready;
  • make sure therapy services are available every day (including weekends);
  • shorten the time that people wait for outpatient care or community care, and
  • make it easier for people to come to appointments.

People with problematic substance use or addictive behaviours

People can recover from their problems with substance use or addictive behaviours.

We will help people get well and stay well by working with them, their families or carers and charities.

We will make sure that services are joined-up and that there are services available for everyone.

If people have mental health problems alongside their problematic substance use or addictive behaviours, we will help them with both.

We will improve services based on changing needs, for example problematic gaming and gambling behaviours.

We will work to the principles of:

  • ‘everyone’s job’ (services will work together to meet the needs of people), and
  • ‘no wrong door’ (however people come into contact with services, they will be offered care and support that is personalised to meet their needs)