A new vision for community mental health services
Surrey and Borders Partnership NHS Foundation Trust (SABP) is leading the way in introducing an innovative transformation of community mental health care for adults and older adults with severe mental illnesses.
What is the Adult Community Mental Health Transformation?
The Transformation aims to create a care model that provides holistic, person-centred care for people with significant mental health difficulties - one which involves the integration of physical and mental health, the integration of primary and secondary care, and the integration of healthcare and social care services so that people with long term needs, or specific mental health concerns will receive faster access to higher quality care.
GPimhs & MHICS
Our Trust is rolling out new multi-professional services to GPs’ surgeries where it is called the:
- GP Integrated Mental Health Service (GPimhs) "GEE-pimms" across Surrey
- Mental Health Integrated Community Services (MHICS) "mix" in Surrey Heath and Farnham, Hampshire
The services operate from nearly 80 GP practices, covering a population of more than one million people. The services are a partnership, designed and delivered with local GPs, people who use our services and carers, as well as social services at Surrey County Council and third sector providers Community Connections Surrey and Andover Mind.
A key aim of the service is to ensure people who fall in the gaps between GPs and specialist care, or are ‘bounced’ between them with multiple rejected referrals, can be seen quickly and easily. The service’s ‘No Wrong Door’ policy means any patient referred by their GP will be seen, breaking down barriers to care. The intention is to provide evidence-based treatments and access to community support, help people before they reach crisis point and reduce waiting lists.
These new teams in primary care are just one part of a bigger puzzle of transforming community mental health services. They will be combined with redesigned secondary care services for adults, so together they work as ‘one team’ serving groups of GP surgeries, called primary care networks. Routine patients will be seen in primary care. When in crisis they will be referred to specialist teams, returning to primary care when stable – ‘easy in, easy out’.
New services
AEDimhs offers support for adults facing eating problems that impact their daily lives but are low in medical risk. Accessible through local GPs, the service helps individuals achieve their recovery goals using evidence-based therapies in line with NICE guidelines.
After a referral, individuals will receive an assessment pack with appointment details and pre-assessment questionnaires. Assessments are conducted online and typically last about an hour, with family members or friends welcome to join for support.
For young adults aged 18-25, the FREED pathway provides rapid access to specialised treatment for those with eating disorders lasting three years or less.
Additionally, AEDimhs offers an online course for families and carers, developed in collaboration with Beat, the UK eating disorder charity, equipping them with strategies to support their loved ones while prioritising their own well-being.
SUN is a community-based service designed for adults facing challenges with complex emotions, often associated with personality disorders. This welcoming and accessible network offers peer support groups where individuals can share their experiences and provide mutual support without needing a formal diagnosis.
SUN is ideal for anyone diagnosed with a personality disorder or those who identify as having complex emotional needs. Participants can discuss a range of issues, including low self-esteem, emotional instability, and difficulties in relationships. Each group is facilitated by a clinician and a peer support worker, creating a safe environment for open dialogue and shared learning.
SUN emphasises confidentiality and mutual respect, bringing a sense of community among its members. With opportunities for involvement beyond group meetings, such as community meetings, focus groups, and social events, SUN encourages active participation and collaboration in shaping the service.
Psychologically Informed Consultation and Training (PICT) empowers GPs and professionals working across Primary care, social care and third sector organisations to work effectively with people who use their services who have complex emotional needs or personality disorder.
The aim of the PICT model is to enable people with difficulties associated with personality disorder to have a more positive and meaningful life by increasing knowledge and understanding of their symptoms and the challenges they face, among professionals who are providing support.
PICT achieves this by upskilling professionals through consultation and training to help them work with confidence and compassion when engaging with people in this group.
The Advice & Guidance 18 Years + service allows GPs to send clinical queries directly to senior mental health practitioners. This system is designed to support GPs in managing mental health issues effectively without needing a formal referral to secondary care. GPs can submit inquiries related to mental health conditions and medication directly through an e-referral system, with responses typically provided within three working days.
More information
What we’ve done so far
SABPT’s Community Mental Health Transformation programme is delivering this transformation as part of the early implementation sites in Frimley and Heartlands ICSs. It started out as a pilot with three GPimhs teams in Surrey Heartlands in Spring 2019 and expended to Primary Care Networks (groups of local GP practices) across the two ICSs. Nearly 80 practices were providing the service by August 2021.
In Autumn 2023, GPimhs/MHICS, Lived Experience Practitioners, ARRS Primary Care Mental Health Practitioners, GP Advice and Guidance, SUN, MEP, PICT and AEDimhs fully rolled out across 31 PCNs, receiving more than 40,000 referrals and offering more than 100,500 appointments since launching in 2019, including seeing patients in GP practices.
The next phase in 2024/25 is to move closer towards fully achieving the NHS Long-Term Plan vision, by bringing together the new and traditional core community mental health teams into “One Team”, and aligning the One Team with newly forming Place-based integrated neighbourhood teams that are bringing health, care, voluntary sector and local authority colleagues together serve the needs of the local population better.
The benefits for patients
The benefits are:
- Easy access to specialist mental health care without needing to meet secondary care thresholds and face long waiting lists
- Timely access to evidence-based treatments, such as psychological therapies, better care for co-existing physical health problems and advice about medicines
- Support is offered from the first appointment, so patients don’t have to wait a long time for secondary care assessments while their mental health worsens
- Support for wider life issues that can trigger mental ill-health such as unemployment, housing and financial worries
- Help to manage their own condition and improve their quality of life, supported by families and carers and linked into community activities promoting social connectedness and wellbeing
Why do we need to change community mental health services?
Patients often complain they have to repeat their stories at repeated assessments. This improvement is designed to prevent this.
Another frequent complaint is that patients fall between the gaps, they are considered not ill enough for secondary care but too severe for Talking Therapies.
Some patients currently face a ‘cliff-edge of being discharged with no support. The improvement will provide more flexible support for ongoing needs.
They will also address the social roots of people’s mental ill-health, taking a “What’s happened to you?” instead of a “What’s wrong with you?” approach.
How is the service performing?
The service saw more than 7,000 patients with significant mental health issues in its first two years.
Patient satisfaction with the service is extremely high. Patients say they can access the service quickly, feel heard and can manage life challenges better.
Only a small proportion (1% to 5%) have been referred to adult secondary care.
Preliminary analysis in sample sites found that GPs with GPimhs/MHICS had a reduction in referrals to adult secondary care.
The wider policy context
These changes have been envisaged by NHS England as a way of ‘revitalising’ community mental health services.
The NHS Long Term Plan envisaged integrated models of primary and community mental health care for adults and older adults with severe mental illnesses, integrating mental health, physical health and social care.
The Community Mental Health Framework for Adults and Older Adults, published in 2019, called for a move away from siloed, hard-to-reach services towards placed-based, joined-up care and whole-person, whole-population approaches.
It calls for more focus on people ‘falling through the gaps' and the problem of patients being ‘bounced’ between primary and secondary care.
This ambition is supported by an additional £1 billion funding nationally per year by 2023/24 to transform the provision of community mental health care for adults and older adults with severe mental illnesses.
Next steps
We will continue creating better community mental health services, we are entering the next phase of redesign, focused on bringing together the Community Mental Health Recovery Service (CMHRS), the Older People's Mental Health Team (CMHTOP), and GPimhs/MHICS.
This initiative is part of a broader effort to ensure our services are sustainable and accessible to people with significant mental health needs, whose conditions may fluctuate between primary and secondary care pathways.
As we move forward, our focus will be on developing our aims through collaboration with people who use our services, our staff, community partners, including local authorities and voluntary sector organisations. This integrated approach will enable us to work more closely together to deliver better outcomes for the people we serve.
How can I get involved?
We are actively seeking input from staff to shape the future of these services.
Your experience and insights are vital in co-designing the integrated model.
Whether you're a frontline staff member, part of a multidisciplinary team, or working in a partner organisation, we welcome your participation.
Email us at cmhtp.oneteam@sabp.nhs.uk.
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