Community Mental Health Services Transformation
1. National Policy Context
The national policy context for transforming community mental health services is set largely by ‘The Community Mental Health Framework for Adults and Older Adults’ published by Government in September 2019, and this builds on contributions from other organisations such as the Kings Fund and also senior leaders of NHS Trusts and Local Government. As such there is a high level of consensus about what the transformation of community mental health services should aim to achieve, as well as on many of the key building blocks and principles that should inform how they should be organised and operate.
In summary, recent years have seen a focus on developing specialist community mental health services, which have aimed to address the very significant health inequalities of people with Serious Mental Illness (SMI). Specialist teams are multi-disciplinary with Consultant Psychiatrists and Nurses, Occupational Therapists, Psychologists and other Allied Health Professionals within their establishment. They offer care, treatment and support through regular out-patient appointments, home visits, psychology interventions and pharmacological support to help control symptoms.
In East Sussex the Community Mental Health Services currently provided by Sussex Partnership NHS Foundation Trust are:
· Assessment and Treatment Teams (Community Mental Health Teams) in Hastings, Eastbourne and High Weald Lewes Havens, providing multi-disciplinary secondary community mental health services for adults and older adults.
· Memory Assessment Services in High Weald Lewes Havens.
· Memory Assessment Services in Eastbourne and Hastings are provided by primary care providers.
· Community Rehabilitation Team, rehabilitation for adults with SMI within community settings
· Thinking Well, day service for adults with a diagnosis of Personality Disorder delivered in partnership with the community and voluntary sector.
· Health in Mind, primary mental health care: Improving Access for Psychological Therapies and Mental Health Practitioners.
· Urgent Care Services which include Crisis Resolution Home Treatment Teams, Street Triage, Crisis House, Havens and Sussex Mental Health Line.
The intention now is to move to a wider range of more proactive community-based services, with the aim of helping people with Serious Mental Illness maintain the stability most enjoy most of the time (by addressing social determinants of mental health), and to expand the availability of treatments such as psychological therapies, to intervene earlier and prevent people developing serious mental health problems in the first place.
This approach also recognises the centrality of primary care, not only in currently managing the majority of mental health care in the community, but also in having established Primary Care Networks (PCNs), providing an important vehicle on which to build more integrated services at place-based / neighbourhood levels.
Alongside primary care, these should bring together and better harness the full range of community resources from voluntary organisations and services commissioned from third-sector providers, with in-reach and support from specialist and statutory organisations, whose resources would become increasingly aligned operationally, to these place-based / PCN level structures.
In parallel, there is national recognition that specialist services must increase their capacity to meet increased need in general for mental health care, and also to diversify and enhance their focus on people with specific needs such eating disorders and personality disorders, and those whose recovery requires specialist rehabilitation.
Many of these national ambitions are accompanied by targets and milestones set out within the NHS Long Term Plan (LTP), although this also allows flexibility particularly in relation to community services’ transformation, for the phasing in of new services, depending on local circumstances.
2. Local Policy
The local response to this national policy context was developed following stakeholder events, which involved multiple stakeholders and partner organisations. It proposes that the foundation for community mental health services be integrated teams organised around and serving the needs of populations defined by PCNs, and that eventually everyone with mental health needs should have these met and co-ordinated from within the resources available from these new teams, or Emotional Wellbeing Services (EWS) as it is proposed they be known.
Specialist services would then be freed-up to focus on those with severe or deteriorating mental health problems, by providing specific care and treatments not available within EWS. The aim is that transition to specialist services would be seamless as they would be organised as a resource belonging to and available for EWS to call upon, rather than being subject to separate eligibility criteria.
This vision for transformation is well established and widely supported by stakeholders across Sussex. The approach to implementation is collaborative and incremental to ensure learning is taken at each step of the way.
3. Sussex-wide Investment Programme 2021/22
A range of different funding streams are associated with various aspects of national policy and the LTP for mental health, meaning some are earmarked and restricted to specific purposes whilst others can be used more flexibly to meet local priorities. These different funding streams include:
· Mental Health Investment Standard (MHIS) funds - these require CCGs to uplift investment in mental health each year by at least as much as its annual uplift;
· Community Services Transformation Funds – these must be bid for and are allocated nationally. They may also require match-funded investment;
· Spending Review monies – nationally allocated to key priorities.
The Sussex wide programme has therefore used these funding streams to optimise investment available locally for achieving the transformation of community services, based on needs assessment and in the context of wider prioritisation of resource for mental health services and achievement of NHS Long Term Plan targets.
Investment in 2021/22 of over £7m has been confirmed in relation to this community programme across Sussex, and includes investment in the following areas:
Specialist Services
· Expansion in core community team capacity
· Personality Disorders
· Community Rehabilitation
Emotional Wellbeing Services
· (New) Mental Health Practitioners
· VCSE Engagement and Transformation Change leads
· Third-sector Support Co-ordinators
· Access Facilitators – SMI Physical Health Checks
Programme investment planning is now underway for 2022/23 in advance of national guidance being issued. A phased approach is planned to ensure sustainable workforce expansion and build on learning.
4. Community Mental Health Services Transformation in East Sussex
In order to oversee the transformation of community mental health services in East Sussex, a Mental Health Oversight Board was established in July 2020. This reports to the Sussex Health and Care Mental Health Collaborative as well as to its constituent member organisations. This has a primary focus should be on improving mental health services for its local population and enables place-based ownership and leadership of the elements of the Sussex Integrated Care System Mental Health Collaborative Programme, that need to be defined and delivered at place level to reflect local need, circumstances and nuances. These elements form part of the single mental health plan and programme for East Sussex focussing on adults of working age and older people.
It was subsequently agreed that in relation to the transformation of community mental health services, having a local place-based perspective would be most valuable. This was where the key relationships necessary to achieve envisaged change either already exist, such as between the CCG and Local Authority, third-sector partners and Housing Authorities, or had the best chance to be most easily developed, such as with the 12 Primary Care Networks (PCNs) established within the boundaries of East Sussex.
We have established three Working Groups to develop local plans for East Sussex, as well as to link with system-level groups to help ensure work is properly co-ordinated. Each has multi-agency representation and Experts by Experience in their membership. The resultant structure is set our below:
4.1 Specialist Services
In relation to some of the key national priorities for the development of specialist services, East Sussex is already well served by having established for example, an innovative partnership model for supporting people with Personality Disorders (PD), involving day care facilities commissioned from the third sector (Southdown), and in-reach / treatment interventions provided by SPFT. There is also a well-established community rehabilitation service in East Sussex.
The focus of local work on these services is therefore to improve their effectiveness, through enhancing integrated working between the Trust and Adult Social Care for example, where there are common interests in delivering rehabilitation, and in better co-ordinating consistent service responses such as from primary care / A&E departments, to people using our PD services.
Local services for adults with eating disorders in East Sussex have benefited from investment being allocated from the Sussex-wide programme and support for the development of a detailed Business Case to sustain and potentially expand this in 2022/23.
4.2 Emotional Wellbeing Services
Whilst the development of specialist services is largely about extending existing service models and providing consistent services and core capacity across Sussex, the establishment of Emotional Wellbeing Services (EWS) to serve PCN defined populations, represents the more transformational change element in the Programme. For this reason, it has been given a primary focus within place-based initiatives, where good progress has been made.
In part this is due to East Sussex having the benefit of already well-established primary care based mental health services known as Health in Mind (HiM), which incorporate not only IAPT psychological therapies but critically for the development of EWS a number of qualified Mental Health Practitioners (MHPs) aligned with specific GP Practices.
These deliver most of the functions which national policy (referred to earlier), suggests need to be significantly expanded to achieve the transformational change required at PCN level. In summary these roles include delivering:
· a consultation, advice, triage and liaison function
· support for shared decision-making about self-management
· brief evidence-based treatment interventions
· facilitated onward access to treatment services.
The plan for East Sussex is that additional resources will be used to recruit more MH Practitioners into the existing HiM infrastructure and will have a key focus on aligning to the PCNs. These services will help address PCN population health needs and work is informed by public health data and intelligence on service utilisation, equity of access and clinical outcomes.
4.3 Housing and Supported Accommodation
Secure housing of a sufficient quality is a critical factor in anybody’s mental health, and yet is too often it is an issue for people with serious mental health problems in particular. For these reasons, it is being given a specific focus within the mental health programme, following an ICS level Mental Health Accommodation Report which made recommendations for a more strategic approach to be taken both Sussex-wide and within each area.
In pursuit of this aim, SPFT has appointed an associate Director of Housing, and a place-based Working Group has been established to improve access to and flow within the full range of housing and support accommodation options available in East Sussex, for people who might otherwise be in sometimes inappropriate settings, including inpatient beds.
The progress made by this group to date, includes appointing a dedicated Mental Health and Housing Project Manager who will lead on producing a place-based plan, and mapping work to describe supply and demand across the East Sussex accommodation pathway as well as an Equality and Health Impact Assessment of current provision, both of which will help to identify priorities for action.
5. Conclusions
Delivering the transformation of community mental health services is a very significant and important programme and requires integrated working and a shared focus as well as additional resources. We have a shared vision for change and are working together with all partners and stakeholders, including most importantly, the involvement of people who use these services in order to continue to deliver more integrated community-based services.