How we are improving community services

Our Trust has rolled out new multi-professional services to GPs’ surgeries where it is called the:

• GP Integrated Mental Health Service (GPimhs) across Surrey
• Mental Health Integrated Community Services (MHICS) in Surrey Heath and Farnham, Hampshire

The services operate from nearly 100 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 partners, including 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. 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 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’. 

The Managing Emotions Programme supports people struggling with fluctuating, intense emotions, including people with complex needs and traits of personality disorder. 

The programme offers easy access to psycho-educational courses, designed to equip you with a range of tools and skills to enable you to manage your emotions more effectively.

We also offer a separate course for carers of people having difficulty managing intense emotions. We are a ‘co-designed and co-delivered’ service. This means that the team is made up of a mixture of clinicians and people with lived experience of emotional difficulties, including personality disorders.

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. 

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.

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. 

SABP’s Community Mental Health Transformation programme is delivering this transformation as part of the early implementation sites in Frimley and Heartlands ICSs. It started as a pilot with three GPimhs teams in Surrey Heartlands in Spring 2019 and expanded to Primary Care Networks (groups of local GP practices) across the two ICSs.

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 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
   

People who use our services often complained they had to repeat their stories at repeated assessments. This improvement is designed to prevent this.

Another frequent complaint was that people fall between the gaps, they are considered not ill enough for secondary care but too severe for Talking Therapies.

Some people faced a cliff-edge of being discharged with no support. The improvements 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.

Pathway Forums are multidisciplinary meetings that bring together professionals from healthcare, social care, talking therapies, and voluntary and community sector (VCSE) providers. These forums are designed to coordinate care, identify needs, and make joint decisions to ensure people receive the right support at the right time.

By including a wide range of partners, Pathway Forums improve communication and service delivery, creating a more integrated and holistic approach to care across Surrey and North East Hampshire. They also help identify gaps in services, shaping future commissioning decisions and enhancing the support available for individuals.

Evolving to Meet Local Needs

Pathway Forums have expanded over time to include more partners and services. Regular workshops and feedback sessions have improved collaboration, enabling teams to provide more integrated, personalised care.

With ongoing participation, members gain a deeper understanding of local services, build confidence in managing complex cases, and work together to improve outcomes. Pathway Forums aim to allow seamless transitions between services and address both physical and mental health needs.

If you would like to participate please email us at cmhtp.oneteam@sabp.nhs.uk

We are actively seeking staff input to shape these services' future. 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.

Our new Trust Community Offer

We’re entering the next phase of our community mental health service redesign, bringing together the Community Mental Health Recovery Service (CMHRS), the Older People’s Mental Health Team (CMHTOP), and GPimhs/MHICS by June 2025.

This integration will create a more sustainable, person-centred service that supports adults with mental health needs whose conditions may fluctuate between primary and secondary care.

Our priorities include simplifying referrals, integrating older adult care (including frailty and dementia), and improving access to psychological therapies. We’re also working to create more efficient processes and develop central community hubs where our teams can collaborate and provide easier access to services.

Building Integrated Mental Health Teams in Local Communities

We’re working toward creating integrated teams that provide mental health support closer to where people live, work, and learn. Our goal is to build a system that adapts to the unique needs of each of the six local areas (referred to as “Places”) across Surrey and North-East Hampshire, offering a clear and streamlined pathway for routine referrals.

By bringing together professionals from health, social care, and voluntary services, we’ll provide a more holistic, person-centred approach. Each Place will have its own local delivery group to ensure that services are designed around its community’s specific needs.

We’re working closely with system partners and local teams to refine and test this new way of working. By March 2025, we aim to have fully developed integrated teams across all six Places.

Integrating Specialist Services into Local Mental Health Teams

We’re working to better align specialist services like Substance Misuse, Early Intervention in Psychosis (EIIP), and Criminal Justice with our needs-led, person-centred approach. These services will become part of local, multi-speciality teams based in the community (known as “Places”) to ensure more seamless, joined-up care for people with complex needs and multiple disadvantages.

Strengthening Partnerships with the Voluntary, Community, and Social Enterprise (VCSE) Sector

We’re developing a long-term approach to working with VCSE organisations, ensuring they are fully integrated into our community mental health services. This initiative focuses on strengthening partnerships, reducing reliance on short-term contracts, and simplifying contract management processes. By building sustainable relationships, VCSE partners can play a central role in supporting people with significant mental health and complex needs, while also addressing the broader social factors affecting well-being.

Roles such as Community Connectors, SUN Peer Support Workers, Lived Experience Practitioners, and Recovery & Connect Workers will become core parts of our community mental health model. This approach will strengthen the workforce, improve service delivery, and provide more consistent, high-quality care for individuals and their carers.

Strengthening Our Partnerships

Surrey County Council, in partnership with Surrey and Borders Partnership (SABP) and voluntary, community, and social enterprise (VCSE) organisations, is working to create a sustainable, multi-disciplinary approach to delivering adult mental health services. This collaboration aims to provide care that meets the needs of individuals, families, and carers through closer partnership working.

Why This Matters

Strong partnerships between health, social care, and voluntary services are essential for delivering high-quality mental health care. This collaborative approach addresses not only mental health challenges but also the wider factors affecting well-being, such as housing, employment, and social support. It will help improve care planning, enhance service quality, and increase access for underrepresented communities, ensuring a more equitable and inclusive system.

What’s Next?

The next step is finalising a formal partnership agreement between Surrey County Council, SABP, and VCSE partners. This agreement will outline new ways of working, ensuring all system partners are aligned and ready to implement the integrated care model. Once in place, these collaborative methods will be rolled out across the region, supported by continuous engagement with all partners to ensure long-term success.

Together with our partners across health, social care, and the voluntary sector, we are building a more connected, sustainable, and person-centred mental health system. By integrating services, strengthening community partnerships, and simplifying processes, we aim to create a seamless experience for people who use our services, families, and carers. As we move forward, we remain committed to collaboration, continuous improvement, and ensuring that everyone receives the right care, in the right place, at the right time.