MHCCs are funded as mental health practitioners through the Additional Roles Reimbursement Scheme, and the service echoes the primary care networks’ social prescribing services. The service is aligned to primary care networks and delivered collaboratively. Although there are 2 providers, Greater Peterborough Network and Cambridgeshire, Peterborough and South Lincolnshire Mind, they work to 1 model, have 1 system and share key performance indicators.

MHCCs work in close partnership with primary care network colleagues. They share skills, resources and knowledge with the social prescribers to provide a social prescribing service for people with complex mental health needs who do not meet thresholds for secondary care and are not suitable for NHS Talking Therapies.

This service is designed to meet the needs of people whose severe mental illness results in frequent attendance to their general practice. During the initial session, personalised goals are set, and support typically lasts 8 to 12 sessions, although this varies based on individual needs.

The MHCC service aims to address health inequalities faced by individuals with severe mental illness, who experience significantly poorer health outcomes and a life expectancy 15 to 20 years shorter than the general population. The service supports key priorities, including reducing poverty through improved housing, employment and skills, as well as promoting early intervention and prevention for better mental health and wellbeing. The intention is to support people to achieve their goals by making sustainable connections in their communities.

People can re-refer themselves to the service without the need to see their GP. The service addresses both mental health needs and the broader determinants of health, providing holistic support while reducing pressure on GPs.

Key learnings

• Complementing existing services: In Cambridgeshire and Peterborough, many primary care networks had already developed personalised care teams which included social prescribing link workers and health and wellbeing coaches. It was therefore important that the MHCCs were flexible enough to meet the needs of individual primary care networks and their existing staff while also ensuring consistency in the functions they provide. Person-level case studies were used to help illustrate the distinctions between the different roles.
• Addressing concerns and providing clear messages: Time was dedicated to building relationships and explaining the joint funding and joint ownership of these roles across primary care and mental health services. Key concerns about space in practice buildings were addressed, and solutions were found where MHCCs could use mental health provider and community spaces.
• Supporting staff: Some MHCC staff reported feeling isolated based in primary care networks. Efforts were made to build a MHCC team across primary care networks and ensure that MHCCs are supported by their “host” primary care network.
• Evaluating performance: Evaluation is key to securing ongoing funding. It is important to build in key performance indicators that are feasible to measure and meaningful from the start, as well as a plan for evaluating the experience of people, carers and staff.

Key strengths of the MHCC service include:

• staff skills and capacity to engage with individuals with complex needs, particularly those with negative past experiences with mental health services
• structured and frequent sessions tailored to the individual’s needs
• participation in multidisciplinary forums which include mental health clinicians, adult social care, voluntary, community and social enterprise partners and members of the wider integrated neighbourhood team, which enhance the broader team’s knowledge of mental health services and pathways

Impact

As of November 2024, the MHCC service reports the following key metrics for 2024/25:

• 1,395 individuals supported, exceeding year-to-date targets, with approximately 280 active cases at any given time. Many of these individuals would have otherwise been referred to less specialised social prescribers
• an average 4 contacts per month per active case, with 15,591 contacts made so far this year, surpassing the year-to-date target of 13,380
• around 100 new referrals each month, and interest from additional primary care networks to offer a MHCC service

Primary care network staff value the MHCC service, strongly endorsing it for enabling social prescribers to access in house mental health expertise and for reducing pressures on primary care.

Publication reference: PRN01756_ii