The Community Mental Health Framework (CMHF) was developed in 2019 as part of the NHS England’s (NHSE) Long Term Plan (LTP). This pledges to deliver £2.3 billion of extra funding to mental health services in England by 2023/24. Over the five years (2019-2024), £1 billion will be spent to expand and improve community mental health services around the country to meet people’s needs more fully – and, in NELFT, we have successfully bid for our share of this funding.

At North East London NHS Foundation Trust (NEFLT), we provide high-quality services, and we have worked hard over recent years to increase investment and improve our service users’ experience. The Framework is a radical change towards integrated core community mental health services, primary care, and secondary care brought closer together. The CMHF will be multiagency, multidisciplinary, and include the voluntary and community sector, Local Authority services, social care, primary care, etc.

The LTP commitment for expanded community teams will also be delivered around Primary Care Networks (PCNs) on a neighbourhood and community level, with strong links to more specialist services. The provision of community mental health services for adults (people aged 18 and over) with severe mental health illness (SMI) is one area that has lacked has sustained focus and investment, both locally and nationally.

Over the next three years, we will introduce a new community mental health care model in North East London. We received positive feedback from NHS England and NHS Improvement about our proposals. The core principles of the new model include:

• Tailored need-based services around our patients and their carers, which focus on the quality of their lives, not just on their mental health needs.
• Providing community services that are close-to-home to shape the needs of our local communities and our catchment area.
• Creating joined-up care by removing organisational boundaries to establish a one-team culture and whole system approach.
• Embedded co-production and co-design with our service users and their carers

The key features are:

• Improving patient experience and outcomes by removing the barriers that service users currently experience between primary and secondary care. This also includes improving physical health care for people with serious mental illnesses (SMI).
• Supported care that will be truly orientated towards promoting and maximising individuals' health, wellbeing, and independence.
• Reducing the health inequalities which are often experienced by people with SMI
• Targeted neighbourhood and community support by embedding the Mental Health and Wellness Team (MH & W Team), aligned with 26 PCNs and multi-agency partners across four boroughs of Redbridge, Havering, Waltham Forest, Barking and Dagenham with planned rolled-out over the next three years.
• Formally commissioned arrangements with the third sector organisations to ensure fair and equal provision of support across our local communities by creating Peer Support workers.
• Creating and embedding Peer Support Workers (PSWs) to work with MH & W Teams across four boroughs. Peer support workers have lived experiences of mental health challenges themselves. PSWs will join the MH & W teams to help support our service users' wellbeing and provide inspiration for their recovery.
• Creating the full range of multidisciplinary staff within each MH &W team who should collaborate to deliver effective mental health care for our service users and their carers
• Creating and embedding Additional Roles Reimbursement Scheme (ARRS) Mental Health Practitioners (ARRS MHPs) will work with the PCNs to provide care and support to our local communities.
• Providing bespoke training for existing and new staff who will join the MH & W Team. Including Trauma-Informed Care and Open Dialogue training. Open Dialogue is offered to the current and new staff who joined our services. Open Dialogue is a model of mental health care which involves a consistent family and social network approach where all treatment is carried out via a whole system/network meeting, which always includes the patient.
• Creating an individualised care plan based on our patients' needs that can be shared across the Trusts boundaries via improved interoperability.

We have created a training matrix which is being used to plan and track the MH & W teams’ training skills. We are currently training our staff who will be joining our MH & W teams in Open Dialogue which is a community-based and integrated way of engaging with families, or a person’s social network, from the very start of seeking help.

We are also integrating Trauma Informed Care (TIC) which recognises the presence of trauma symptoms and acknowledges the role trauma may play in an individual’s mental health and their quality of life.

We have also partnered with third sector organisation Mind who are recruiting PSWs who have lived experience of mental health challenges themselves. PSWs will join MH & W team to help support our service users’ wellbeing and provide inspiration for their recovery.

ARRS MHPs and GPs will work and collaborate closely together. The focus of this collaboration includes:

• Advising GPs with diagnosis, treatment, and referrals, so GPs get specialist support and service users can be supported by specialist mental health care professionals.
• Holding clinics for people with mental health issues
• Working closely with primary care and MH & W team to provide support in the community setting and services
• Creating a care plan with service users using strength-based assessment supported with reflective practice and trauma-informed care approaches.

Primary care’s health care professionals, ARRS MHPs and MH & W team will be working in more flexible and dynamic ways to provide care that’s wrapped around our patients in our localities and close to their homes.

For an effective wrap around, an appropriate multidisciplinary skill-mix is also essential with effective delegation of tasks to the right level. For example, alongside of GPs, and practice nurses, ARRS MHPs support patients with mental health conditions. The MH& W team will have mental health skills; however, we will also provide specialist training as needed. The MH & W team will also have access to more specialist support from the specialist team such as the LD and older adult specialists.

Our MH & W team are multidisciplinary teams (MDTs) who are the system for organising and coordinating mental health care to meet the needs of our service users especially those with complex care needs.

The MH & W teams bring together the expertise and skills of different professionals to assess, plan and manage mental care jointly. Based in the community, and networked with primary care, and our ARRS MHPs, our MDTs are expected to work proactively to support our service users’ care plan and holistic care.

Through accessing a range of health, social care and other community services, our MH&W team will focus on keeping our service users well and independent, delivering the right care at home or in the community to prevent unnecessary hospital care.

There are specialist areas that fall into the remit of the CMHT programme, and we have multiple workstreams to ensure their progressive integration into the MH & W teams. They include:

• the needs of our patients with Learning Disability (LD) and Autism Spectrum Disorder (ASD)
• the needs of our patients with rehabilitation and substance misuse
• the needs of older adults
• the needs of younger adults (18–25-year-olds)
• the transition of young people to adult services
• the physical health of people with mental health needs

The MH & W teams do not offer a service specifically for LD and older adult patients. The LD and older adult specialists will interface with MH & W teams enabling patients with more complex needs to 'step up' to the community mental health services for more specialist care and to 'step down' to primary care as the patient's circumstances improve.

With 2022-2023 funding, new specialist areas will be added to the CMHT programme's workstreams.

We have already begun administering surveys to patients, their families/friends/carers, staff from the prospective MH & W teams and primary care staff. We are hoping to then repeat these surveys with all these groups once the MH & W teams have been live for several months. This will allow us to compare results before and after the introduction of the MH & W teams, make any necessary adjustments to services and to take an interim measure of success.

We are also planning to measure the success of the transformation with a formal five-part implementation evaluation in collaboration with UCL. This will include describing and evaluating the implementation process, providing a snapshot of the MH &W six months after they launch and getting feedback from staff, patients and their family/friends/carers about their experience of the implementation and of the MH & W teams.

We have staff consultation across our boroughs to ensure their feedback shapes progress from the outset of the CMHT programme. Three boroughs have completed their staff consultation, and the last borough will start their consultation soon. We also closely work with our service users who have lived experience of mental health issues to ensure that they are involved in our decision making by creating a service users' forum, which is being managed by the CMHT programme's central team.

Two new workstreams called "New Ways of Working" and "Admin Review" have been established focusing on "Personal factors rather than external factors," which take precedence over what matters to our multidisciplinary team to promote mental health and improve their emotional well-being during and after the transformation.

The Rio (Electronic Patient Record system) configuration working group has been formed to begin Rio's dynamic reconfiguration to provide MH&W with a robust operational guide.

A solution for interoperability has been identified, focusing on the East London Patient Record (ELPR), which is easily and readily available on RIO. ELPR data is fed from multiple external sources/records, including GP consultants, GP Views, Homerton, Newham Social Care, and London Hub, and in the next few months, it will be fed from BHR Social Care services. GP surgeries clinicians and ARRS, Mental Health practitioners, can now be identified through ELPR.

As part of the transformation, multiple Task and Finish Groups have been set up across four boroughs. The Task and Finish group involves relevant staff, partners from the PCNs, voluntary sector, local authorities, and service users to develop how the new MH &W teams will be formed and shaped.

We plan to integrate with Improving Access to Psychological Therapies (IAPT), which focuses on more targeted support. We are now working through the detail of this integration across some of our boroughs and its phased implementation with MH & W Teams over the next two years. 

We are also liaising with PCNs and third sector partners on collaborative work to ensure we create collective solutions for loneliness and those affected by gambling problems. We are creating new roles such as Family intervention practitioners and physician assistants who will join the MH & W teams in the future.

If you have any queries about the CMHT programme or would like to get involved as it moves forward, please email CMHTprogramme@nelft.nhs.uk.