Community Based Mental Health Re-design Project
Communication Brief August 2015
CURRENT MENTAL HEALTH SERVICE MODEL
Where we are now
General
Public
Third Sector
General
GP
Orgs
Public
IAPT
LYPFT SPA
A&E
Mon - Fri
24/7
24/7
Crisis
FUTURE PROPOSED MENTAL HEALTH SERVICE MODEL
Where
we need
to be
Information
Portal
Information & Advice
Prevention & self management
Primary Care Wrap around & New Models of Care
Mental health long term conditions and
Liaison mental health
24/7 access to advice and guidance inc.
psychiatrist, pharmacist
CMHT
Assessment Front Door
Tiered assessment
Third Sector
Orgs
same day wherever possible
Triage accessed via call centre
Crisis response & walk in
Navigator service
Mental Health Needs/ Cluster Pathways
Weaknesses of the current model
No public information on how to access services
Assumptions on what services can do
No central assessment service so when GP’s make a
referral it can be bounced back due to ineligibility
Results in inappropriate referrals
Repeat referrals and assessments increase waiting times
and dis-engagement with services
Requirements of any new model
Centralised Information and self-help resources
Better use of universal services to support the issues that many service users face
that relate to housing, debt, employment
Principle of no wrong referral or bounce back
Focus on early intervention avoiding unnecessary pathways into secondary care
Shifts some current secondary care resource into primary care to “wrap around”
GPs and contribute to the new models of care.
Uses cluster based standardised assessment process reducing the number of
repeat assessments
Community Based Mental Health Re-design Project
Communication Brief August 2015
Leeds has a range of mental health services provided by both statutory and voluntary community sector commissioned by NHS and LCC.
Feedback from users, carers and professionals using and working within services tell us that these services are valued and are of high
quality. However they also tell us that the system as a whole is difficult to understand or to navigate in a coherent way and hard to know
what is the right place first time.
In order to rebalance the system Leeds has developed a Mental Health Framework (2014)
which describes the near future direction and priorities for mental health services for 2014-17.
The agreed framework sets the direction of travel and commissioning priorities for health and
social care mental health services of the future by describing five key outcomes and principles
for our services. Accompanying this is also the intention to explore health and social care
pooled budgets in the future in order to reduce duplication and maximise efficiency.
From a series of Mental Health Framework implementation and provider& partner workshops,
four cross cutting priorities were identified which if developed would achieve a significant
contribution to the delivery of the five Mental Health Framework key outcomes. These are
crucial if the whole system is to rebalance towards prevention, early intervention and timely
access including extended and integrated offers of support that also address the wider
determinants of poor mental health.
The four priorities below now form the basis of a two year Mental Health Programme of work
hosted by Leeds North CCG on behalf of the 3 Leeds CCG’s, supported by Leeds West & Leeds South & East CCGs and programme managed by
Jenny Thornton. A project manager has been appointed for each priority.
Information
Community Based Mental
Health Re-Design
Crisis & Urgent Care
Children & Families
Community Based Mental Health Re-design Project
Communication Brief August 2015
The Community Based Mental Health Re-Design Project - Consultation Phase.
Consulting on a broad outline model of 3 key areas:
Community Based
Mental Health ReDesign
1) Primary Care Wrap
Around-New Models
Of Care
2) Single Point of
Assessment
3) Mental Health
Needs(Cluster)
Pathways

The development of a web based Information Portal is a first and integral ‘front end’ discrete project of the Mental Health Framework.

The draft proposal model is based on a range of engagement events and meetings with user and carer groups, providers and partners and
national reviews of best practice models across the country over the last 18 months. Through this work three key areas for change have
emerged (above).

An extensive service user consultation has been initiated to inform future models and agree core principles.

The Community Based Mental Health Re-Design project has now begun the consultation phase with stakeholder groups exploring the
broad outline model and three key areas for change.

This transformation programme sits in a national context of developing New Models of Care for Primary Care and it is vital that mental
health redesign is integrated into the development of these new models.

Feedback from consultation will be used to further refine and develop the design of a more detailed model. Regular communications on
progress will be made and stakeholders will be invited to use co-production methods to develop and test thinking and options.

A final revised model will then return to the stakeholder groups and governance process for approval.
Community Based Mental Health Re-design Project
Communication Brief August 2015
Information Portal
Information & Advice
Prevention & self management
Community Based Mental Health Re-Design Project
Primary Care WrapAround/New
models of Care
One Assessment Front Door
Mental Health Needs /Cluster
Based Pathways
IP Project Manager appointed- Alicia Ridout aridout1@nhs.net
Website development - procured via YOUMEE.
Project Manager appointed 1st July marrisa.carroll@nhs.net
Broad outline model contains three high level work streams
identified & now consulting for continuing design and coproduction planning
Continuous Engagement and Consultation on:
Primary Care Wrap around & New Models of Care Work Stream
Mental health long term conditions and
24/7 access to advice and guidance inc.
Liaison mental health
psychiatrist, pharmacist
Continuous Engagement and Consulting on:
One Assessment Front Door Work Stream
Tiered assessment
same day wherever possible
Triage accessed via call
centre
Crisis response & walk in
How might new models of care look?
Exploring how interventions concerned with addressing the
wider determinants of poorer mental health could be
Exploring possibilities for enhanced models of care within GP &
integrated teams.
Continuity/Navigator service
Multi-disciplinary & multi-agency assessment hub for primary,
secondary ASC & third sector
Crisis & non-crisis pathways
Same day triage & tiered holistic assessment, stepped model
Low intensity intervention offer as standard, e.g. stress
management seminar session
Continuous Engagement and Consulting on:
Mental Health Needs Cluster Based Pathways Work Stream
Tiered
Intervention
linked to
needs/cluster
bands
following NICE
guidance
Specialist staff
prioritised for
most complex
needs & for
advisory
supervisory
roles
Recovery
focussed
culture & asset
based care &
support plans
New ways of
delivering
Care
coordination
Increased and
enhanced
psychological
thinking
Increase in
support
worker/ peer
support staff
level
Use a single
recording
system used
across agencies
How a re-designed whole community mental health support
system could be in the future
Tiered intervention linked to needs /21 cluster bands following
NICE guidance
Care Coordination by most appropriate, suitably trained person
across agencies
Specialist professionals focus on most complex needs
Partnerships delivering recovery focused & asset based care
coordinated support plans
Shared single recording systems across agencies