23 February 2023

Agenda item: 6 (Public session)

Report by: Claire Murdoch, National Director for Mental Health, Learning Disability and Autism; Sarah Holloway, Head of Mental Health.

Paper type:  For discussion

Organisation objective

• NHS Long Term Plan

Executive summary

This paper provides an overview of the adult Community Mental Health (CMH) Transformation programme, progress to date and how it aligns with the new roles of integrated care systems (ICSs) taking a population health management approach. This paper also focuses specifically on the critical role of the voluntary, community, and social enterprise (VCSE) sector within this transformation, and how ICSs can maximise the benefits from partnership working with VCSE partners to improve patient care and address long-term system pressures in mental health pathways.

Action required

The Board is asked to note and comment on the information provided in the report, and to continue to support CMH transformation across all ICSs in 2023/24 and beyond.

Background

Community Mental Health Transformation

The much-awaited expansion and transformation of CMH services for adults and older adults with severe mental illnesses (SMI), funded within the NHS Long Term Plan (LTP), provides ICSs with a hugely significant opportunity to fundamentally rebalance mental health pathways, reduce over-reliance and bend the demand curve on care at the crisis and acute end of the pathway, and begin to reduce the significant treatment gap for adults with severe mental health needs.

The new model focuses on earlier identification and intervention, supporting patients to live well in their communities rather than in restrictive settings, and therefore is better for patients and a critical piece of the answer to quality issues identified within mental health inpatient settings. It is also the foundation on which systems will be able to deliver on the vision set out within the Reform of the Mental Health Act, with a focus on: choice and autonomy; least restriction; therapeutic benefit; and treating the person as an individual.

This is the largest area of investment within the wider LTP for mental health, with additional funding in community mental health services across England reaching almost £1bn by 2023/24. The headline aim is that by 2023/24, 370,000 people will be supported through newly integrated primary and community mental health services.

In addition to the headline LTP commitment, the NHS has set out additional goals for this transformation: more, faster, better care, and for all. This will help to address backlogs compounded by the pandemic and will be measured by: a) delivering a 5% annual growth in access to CMH services; b) introducing and improving waiting times; c) measuring and improving the quality of care delivered; and d) advancing equalities.

(Graphic descriptor) The graphic below shows three boxes in a line, the first is green, with a pyramid of people and states, increasing access to community mental health services, the second is blue, with a clock and states improving waiting times to community mental health services, the third is yellow, with an open hand and states increasing the quality of care available for those accessing services. An arrow runs through all 3 boxes and states, advancing equalities across all three aspects of transformation.

The model marks a radical shift away from traditional disjointed pathways of care towards whole-person, whole-population health approaches, geographically aligned with Primary Care Networks (PCNs). In this way, the model aligns with the recommendations of the Fuller Stocktake to ensure primary care is resourced with multi-disciplinary integrated teams at neighbourhood level to deliver holistic care.

If delivered in full, the model will start to close the historical gaps in care for people with mental health needs, in particular the gap in care that has historically existed between primary and secondary care – with too many people having fallen into the gap between NHS Talking Therapies for anxiety and depression, and secondary care mental health services, and with people’s needs being deemed too severe for the former, but not severe enough for the latter.

The model also aims to address rising levels of premature mortality for people with SMI, by providing annual comprehensive physical health checks and follow up care. Recent data from OHID shows rising premature mortality, with people with SMI 4.9 times more likely to die prematurely than those who do not have SMI. This makes this work all the more critical for ICSs as part of their responsibilities to maximise partnership working to reduce physical health and other inequalities.

Partnership working across both NHS and non-NHS organisations is integral to the delivery of this transformation. Systems are required to build stronger relationships across primary and secondary services, as well as to involve VCSE organisations as strategic and delivery partners within new models of integrated care underpinned by recurrent, sustainable investment. The new ICS structures are therefore well placed to deliver on the aims of this significant transformation, given their scale, focus on partnership working and focus on population health.

Progress to date with CMH transformation

Following a two-year planned testing stage involving 12 ‘Early Implementer’ sites ahead of full national roll-out, all systems began receiving Service Development Funding (SDF) for community mental health transformation from April 2021. Transformation is now well underway across the country, with a ‘roadmap’ developed by the national team to support local implementation of the key elements of the transformation.

Systems are transforming PCNs in their areas in a phased approach. At Q2 2022/23, 429 PCNs in England (34%) were reported as providing access through fully transformed models of care, as defined by a set of national criteria for transformation. A further 285 (23%) had met 3 of the 5 transformation criteria, 178 (15%) had met 1 or 2 of the criteria, while 358 (28%) were not yet meeting any criteria. NHSE will continue to develop resources and guidance, as well as providing direct support to systems via regions as transformation continues to progress.

Taking the four headline aims of the model in turn:

• Increasing access to community mental health services : The most recent data from July 22 shows that 504k people accessed community mental health services in the preceding 12 months – a growth in access on the March 2021 of 28k (5.9%).
• Improving waiting times: A new waiting time measure has been developed to support quicker access to care within the new integrated model within 4 weeks. NHS England is working with systems to improve data quality to enable a reliable picture of current performance ahead of determining next steps to support measurement of waiting times.
• Increasing the quality of CMH care: Improvements in quality of care are being introduced via expansion of evidence-based psychological therapies for SMI, and by introducing and measuring patient-reported outcomes. We are expanding the supply of therapists by commissioning a range of courses and funding c.560 new therapists in 2021/22 and 2022/23. Tracking outcomes scores will ensure services can monitor quantified improvements throughout the patient journey and focus on the most impactful interventions.
• Advancing equalities: Historically, Black, Asian and minority ethnic communities have been overrepresented in crisis and acute services, and we know that better care in the community can reduce crisis, A&E, and inpatient presentations. NHS England provides data on proportion of people admitted to acute mental health services without prior contact with community mental health, broken down by ethnicity. For the overall population, between May 21 and May 22, the proportion of admissions without prior community contact dropped from 16% to 14%. While Black, Asian and minority ethnic communities are more likely to be admitted without prior community care, initial data shows the gap is narrowing. A 7% difference in the rates for white and Black, Asian and minority ethnic groups reduced to 4% between May 21 and 22, based on the Mental Health Services Dataset (MHSDS). This positive trend will need to be monitored before any firm conclusions can be drawn about the impact of expanding community provision on inequalities in mental health services.

Workforce expansion and development of new roles has been central to delivering the transformation of community mental health services. Key progress includes:

• 717 PCNs (57%) now have an ARRS Mental Health Practitioner (MHP) role in post. These roles are jointly funded between PCNs and community mental health services, and are based in primary care settings providing support to people with SMI. From 2022/23, employment of these roles can also be sub-contracted to a VCSE organisation.
• 515 graduates began training as Mental Health and Wellbeing Practitioners (MHWPs) in 2022/23, with a cohort of 560 trainees planned for 23/24. This new role is designed to support collaborative care planning, alongside other members of the multi-disciplinary team. They will also deliver a set of brief wellbeing-focused psychologically informed interventions, and will be a major part of the pipeline for the growth of psychological therapists within services.

The role of the VCSE in transformation

Whilst a key aim of the transformation is to increase access to clinical treatments such as psychological therapies, a significant amount of the unmet need can be met by non-clinical staff. VCSE providers are well placed within communities to provide support to meet the social needs of people with SMI, supporting people to manage their condition or move towards individualised recovery on their own terms in their local community. Furthermore, VCSE organisations, particularly grassroots organisations, have a key role to play in reaching previously underserved communities, thereby advancing equalities in access, experience and outcomes.

The scale of growth and depth of transformation required to meet the LTP ambitions cannot be delivered by the NHS alone, and this is especially true of the workforce growth that ICSs need to deliver locally. ICSs are therefore developing genuinely integrated workforce plans between the NHS and VCSE to deliver CMH transformation in recognition both of the inherent value of local VCSE organisations and the reality of current NHS workforce shortages.

Significant progress has been made by ICSs in developing strategic partnerships with the VCSE through this programme and, by the end of 2021/22, almost all ICSs across the country (93%) reported that their CMH transformation governance structures included VCSE representation at Board level. Analysis of SDF planning submissions for 2022/23 indicated that systems intended to spend an average of 22% of funding via VCSE organisations, with the largest proportion of planned spend being 48% in one system. This is a strong indicator of the critical and increasing role of the VCSE within community services for adults and older adults.

The national team will continue to work with regional and system colleagues to support them to overcome potential barriers to VCSE partnerships and investment, and strengthen and expand these partnerships. This includes:

• Providing guidance and examples of innovative approaches to NHS on joint NHS-local government contracting and procurement with the VCSE, such as alliance contracting;
• Supporting VCSE providers to submit data to the Mental Health Services Dataset (MHSDS) to improve the ability of the NHS to measure their impact and contribution; and
• Encouraging systems to undertake joint workforce planning, to ensure VCSE organisations are included in system workforce plans.

Example of VCSE involvement in CMH transformation

As the following example shows, increased commissioning of VCSE organisations as part of CMH transformation is already bringing real benefits both to people seeking support, and to organisations and systems themselves. NHS England is currently drawing together similar examples from across the country; we will shortly be promoting them to share innovative practice and support ICSs to raise awareness among local stakeholders of the work underway to transform services in their systems.

North East and North Cumbria, Mind Concern

As part of CMH transformation in North East and North Cumbria, Mind Concern work in partnership with Cumbria, Northumberland, Tyne and Wear NHS Trust’s Community Treatment Teams (CTTs) to manage a cohort of people with SMI that historically would have been treated by secondary care services. Mental Health Concern work with people whose SMI is due to practical, social, or emotional issues and does not necessarily require specialist clinical intervention. One member of the team will support around 100 people per year, with support lasting 3-6 months. The service also helps address the capacity and demand challenges facing secondary services, ensuring people don’t suffer alone with SMI for long periods of time, and reduces burden on specialist teams, acute hospitals and GPs.

Outcomes:

• 508 people referred Oct 21 – Sept 22.
• 324 (64%) people no longer need input from CTT. This is 11% of the total CTT caseload.
• 100% of patients contacted within 96 hours of referral.
• 84% showed increase score in WEMWBS during intervention.
• 58% report reduction in attending GP practice after intervention.
• Over 12 months, the implementation of the initiative reduced 203 calls to specialist community crisis teams and 50 attendances at A&E.

Conclusion and next steps

The formal establishment of ICSs last year provides further opportunity to make the most of the investment into transformed community mental health services and within this to strengthen the role of VCSE organisations as key strategic and delivery partners.

CMH transformation has shown VCSE organisations to be crucial partners, able to support ICSs to achieve each of the ‘ten principles for how ICSs work with people and communities’ set out in NHS England’s guidance on establishing ICSs published in September 201[1]; local CMH transformation is precisely the kind of change programme that ICBs and their new integrated governance will be able to deliver on, supported by integrated care partnerships.

There is more to do to ensure all areas are fully realising the opportunity and investing in VCSE organisations. We expect to see significant expansion in access to transformed models of care in the final year of the LTP; however, transformation will need to continue beyond 2023/24 to continue to reduce the historical treatment gap for adults with SMI.

NHS England will continue to promote and share good practice in this area, encouraging systems to invest a greater proportion of funding in VCSE as well as to recognise the VCSE’s contribution as strategic partners.

The Board’s continued support and championing of this work will be important as we continue to improve services and help ICSs to meet their full potential over the coming years.

Classification: Official
Publication reference:  Public Board paper (BM/23/04(Pu)