Why is transformation of community mental health services needed?

There are gaps in the provision of care, which means many people with complex and ongoing mental health needs don’t get the care or support they require. There are often criteria for different services and sometimes people might not meet those criteria, meaning they can fall between services and / or do not know where to go for help.

We also know that there is more we could do to help services work better together, so we can meet people’s different needs, rather than having to refer people between different services and organisations.

Delivering effective mental health support, care and treatment to meet a wide range of mental health needs in the community can only happen if all parts of the health and care system, including voluntary, community and social enterprise (VCSE) organisations work together.

What does transforming community mental health services mean – in simple terms?

Put simply, transforming community mental health services means bringing all the services and agencies that support people with varying mental health needs much closer together to ensure that people get the right care, without having to find their way through lots of service boundaries and without repeatedly telling their story.

What are the benefits of the transformation?

People will be able to:

  • Access community mental health care when and where they need it and be able to move through the system easily so that those who need intensive input receive it in the appropriate place rather than 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 to, and be participants in, the communities that sustain them, to whatever extent feels comfortable to them.
Are children included in the transformation?

The NHS Mental Health Implementation Plan 2019 / 20 – 2023 / 24 and the Community Mental Health Framework for Adults and Older Adults do not include children. However, we will pay attention to how young people access our service when they are ready to move to an adult mental health service.

I keep hearing the phase ‘trauma – informed’. What does it mean?

A trauma – informed approach means our teams aim to understand more about people’s individual care needs. It is less about asking “What is wrong with you” and more about asking “What happened to you, what have been your personal experiences?” Click on the following link to information about the trauma-informed approach to read more about this.

I have heard the word ‘formulation’ used. What does it mean?

A formulation is a way to make sense of a person’s experiences and presenting difficulties. It is made jointly by the mental health worker and the service user to tell the person’s ‘story’ and is usually written or produced in a visual way.

The formulation is a working document so it can change with new information. It will emphasise the service user’s strengths and can inspire hope for change and recovery.

How did you decide to go ahead with the integrated hubs?

There were three main pieces of work which ran concurrently and involved all stakeholders working closely together. They were:

Asset mapping across the pilot local care partnerships (LCPs) to understand existing service provision so we could make best use of community assets, identify gaps to address in the new model and build relationships.

We undertook a ’90 Day Learning Cycle’, which is an Institute of Health approach. This meant we summarised and set out the underpinning principles and components of an integrated community mental health services hub. We followed this with a series of workshops which brought partners together to design how different parts of the new model of care should work.

Finally, groups of our workforces and people with lived experience worked together to describe the key principles and components that were needed to underpin a new model of care for adults and older adults with:

  • complex emotional needs associated with a diagnosis of personality disorder
  • psychosis and bipolar
  • eating disorders / disordered eating

As a result of all this work, a model blueprint was produced for an integrated community mental health services hub and we will start testing the first version this year (2023)

Which services took part in the mapping exercise?

Mapping was done by partners within the three local care partnerships (LCPs):

  • West Leeds, serviced by the West Leeds Primary Care Network (PCN)
  • The Hatch (Burmantofts, Harehills and Richmond Hill PCN and the Chapeltown PCN)
  • Leeds Student Medical Practice (LSMP) and The Light PCN.
How many pilot test sites are there?

Initially there are three local care partnership (PCN) test sites. They are:

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

We will then start to work in other areas during 2023 / 2024

What is a local care partnership?

A local care partnership (LCP) is made up of a range of people working together, regardless of their employing organisation, to deliver joined up collaborative care that meets an identified population’s needs.

There are 15 LCPs in Leeds. Each is tailored to meet local need and the features of that particular community, and membership includes statutory organisations, third sector (community groups) elected members and local people.

By working together, LCP partners can improve access to the right support when their population needs it and thrive using their individual and community assets.

When will we start to see these changes?

We will start testing the new integrated hubs in the pilot areas during 2023. This will be subject to monitoring of staff pressures across Leeds during the winter.

How will integrated hubs work in Leeds?

We recognise the wealth of resources available within local communities that help people to look after their own mental health. Some people do already and will continue to get support, advice and guidance from within their community and never come to the integrated hub.

You can read more by clicking on the following link to information about broad support that will be available.

How will people be referred to the test model hubs?

Depending on the impact of pressures on our workforce during the winter, we aim to start testing the new integrated hubs in the pilot areas during 2023. This means that at those pilot sites:

  • people can be referred to their local hub by anyone, including their GP, self – referral, someone who loves and cares about them or anybody working in any community service in Leeds.
  • referrals will be simple, fast and flexible.
  • all referrals can be made in a number of ways, including by phone or online.
  • we will work with the person to understand their needs and how they can best be met.
  • we will respond quickly to a referral (ideally within a day or two).
  • we will share information about people who use the hub services sensitively and discreetly.
Will everybody who contacts the hub receive a referral?

No, because it may not be necessary or appropriate. Therefore, we also aim to provide a useful resource for people to contact for advice or guidance, for themselves or somebody else, without intending to be seen or contacted by the hub.

It may also be that the hub is not the right place, but we can help people to get the help they need from somewhere else. For example,  if their needs can be met by a GP, they are in need of an urgent crisis response or they have a primary problem with dementia or require a memory assessment.

What happens after a person has been referred to the hub?

When we first meet people its important that we understand what’s happening to allow us to get people the right help at the right time. We use a trauma – informed approach. Instead of “What is wrong with you?” we ask “What has happened to you. What have been your personal experiences?” and ”How can we help you?”

We start by having a helpful conversation straight after the initial contact. Sometimes this is all the person needs and we will offer appropriate advice and support. Some people will need a more detailed assessment. Again, support may be put in place at this point and no further assessment needed.

People who remain under the care of the hub will have continuing reviews of their needs.

What care and support will be available at the test model hubs?

Each hub will have a partnership pf people and organisations providing personalised care and support designed for, and with, the person who has been referred. Care and support includes:

  • providing mental and physical care and support
  • providing a range of psychological therapies
  • providing social care
  • third sector agencies providing community support
  • supporting them in their community e.g. housing, benefits, employment etc.
  • sharing information only with people directly involved in the person’s care
  • providing care and support in places and ways that work best for the user of services
  • providing support from a keyworker who the person knows, trusts and can work with.
Who will be in the workforce at the test model hubs?

Although they may not be working in one place, each ‘hub’ of services and support will include the following (in alphabetical order):

  • administrative staff
  • clinical psychologists
  • community well being connectors / social prescribing link workers
  • mental health nurses
  • mental health pharmacists
  • mental health practitioners (experienced, but not ‘professionally’ registered)
  • occupational therapists
  • paid peer support workers / experts by experience
  • primary care staff
  • psychiatrists
  • psychological therapists / psychotherapists
  • social workers
  • support workers – mental health, housing, employment etc.
  • team managers / leaders
Will people be referred out of the hub for treatment?

Depending on their needs, some people may be referred outside the hub for specialist treatment and support. Many people will have a combination of services from inside and outside the hub. If another workforce member of services becomes involved, the person will be offered ‘warm introductions’ rather than simply signposted to the other service.

Information, including assessment and the care plan, will be shared to avoid people having to repeat their story but this will be done with their agreement.

How will people receive support?

There will be a variety of options, including face – to – face, phone or video appointments.

Face – to – face appointments may be in a variety of places, including our office bases, GP surgeries, people’s homes or a carer’s address, or other venues out in the community.

Preferences will be discussed and some people may choose to use a mix of contact methods and places.

How will the multi – disciplinary team work together?

We want to create an environment where all staff feel included and all contributions and challenges are welcomed. Opportunities to come together are key and this can be achieved in a number of different ways.

The hub workforce members will need to be approachable and available to each other and ways that they build relationships, work and collaborate together will be decided within each hub team.

Who will be a keyworker and what will their role be?

Everybody receiving support in the hub should have a named keyworker who will be the ‘go – to’ person for the service users, family member or carer. The keyworker can be anyone within the hub multi – disciplinary team and should be whoever knows the person best or, in the case of someone new to the service, is likely to build the best relationship with someone.

The keyworker does not need to be responsible for every aspect of someone’s support, but they will work with other hub team members or organisations when needed. Their main role is to maintain supportive and therapeutic relationships for, and with, the service user.

What happens if somebody’s needs change? (e.g. their mental health improves or they need to access more specialist support from a different service.)

We will help the person to move on when the time is right, but they will know that they can call on help when they need it.

The personalised care plan includes supporting the person in their community after the hub, including:

  • what keeps them well
  • who is the right person to go to if things don’t go well
  • preparing and agreeing a well being plan / safety plan.

Users of the services can contact Leeds Crisis Services in an emergency if they need to after they leave the hub.

The person can contact the hub at any time after they are discharged (they will have contact details).

We will respond to the person’s needs whether they get better or not.

What is planned after the hubs start?

We will analyse the data and feedback we get from service users, our workforce, stakeholders, carers, people with lived experience, on the pilot hubs when they begin and use this to fine tune the design. We will roll out the remaining LCP integrated hubs during 2023 / 2024.

How will you ensure that people with complex and enduring mental health problems have equal access to housing, particularly in the HATCH are, which has some of the worst housing stock in Leeds?

The Accommodation Gateway service works with people being discharged from acute mental health wards (under 65s, working age adults) or those being cared for and supported by community based mental health teams, to ensure they are moved to accommodation that best suits their needs, in a timely and effective way.

Click on the following links (each link opens a new window) for information about support provided by the Gateway Worker, who:

  • Provides advice on private renting and searches across Leeds.
  • Can make referrals to longer term housing support services, such as Engage Leeds and the Mental Health Homeless Team.
  • Can explore referrals into mental health supported accommodation placements, including prevention (respite referrals).
  • Makes referrals to Community Links residential services, which provides weekly updates, including bed vacancies.
  • Also works closely with city – wide housing service providers, including Housing Options, St George’s Crypt, Beacon Housing, St Anne’s. Together, these organisations help to ensure that people move on to the most appropriate accommodation in the community to meet their needs.
Will asylum seekers be able to access the hubs, even if they are not registered with a GP?

Regardless of their immigration status all asylum seekers can register with a GP and receive free primary care health services in England. This means that they will also be able to access the hubs in the same way as anybody else.

Any asylum seekers who are not registered with a GP, but who need mental health care and support in the community, will be covered by the hub nearest to wherever they are staying.

What will the opening hours be for the hubs?

At this time we are planning that the hubs will be open from 9am – 5pm, Monday to Friday.

Once the pilot sites are open, we will have a clearer picture of demand and pressure points on the services and may need to make adjustments if necessary.