Designing the model

The NHS in Leeds, city council, third sector, service users, carers and people with lived experience have been working together since 2021 to design a model to improve health services and care for adults and older people who have serious mental health illness.

Although children are not included in this work, we are looking closely at how they move into adult services, to ensure it happens as smoothly as possible.

There are three transformation pilot sites in Leeds, which are the following local care partnerships (LCPs):

  • West Leeds, served by the West Leeds Primary Care Network (PCN)
  • The Hatch (Burmantofts, Harehills and Richmond Hill Primary PCN and the Chapeltown PCN)
  • Leeds Student Medical Practice (LSMP) and The Light PC

A major task was mapping current service provision in each of the pilot LCP areas and building an understanding of how these services work together. At the same time we used the Institute of Health Improvement’s 90 Day Learning Cycle to scan, summarise and convey underpinning principles and components of an integrated community mental health hub. The group undertaking this work specifically looked at personalised care planning, a key worker role and the multi – disciplinary team.

Unfortunately, this work took longer than 90 days as it had to be paused between January and March 2021 due to a COVID surge.

Design workshops

During summer 2022, workshops brought together partners from across the NHS, third sector and Leeds City Council to design key parts of the new model of care. The workshops looked at:

  • access and assessment of people referred to the services treatments (interventions) and support
  • individual key workers appointed for each service user
  • clinical outcomes and how these would be measured
  • pathways out of the hub once the person was able to move on
  • personalised care planning processes for service users and how to ensure these were jointly made by the professional and the service user.

The programme is now looking at how the hubs can be set up for each of the three pilot sites and what their format should be.

Physical premises and the IT services needed to ensure information can be shared in complete confidence are among the things being considered.

In the meantime, details of the hub vision are being shared with statutory, non-statutory and voluntary organisations across Leeds, with the aim that they should be available from March 2023 at the latest.