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How to support people with severe mental health in the community

How to support people with severe mental health in the community

By Nicola Hall
Transformation Lead, Rethink Mental Illness
22 December 2022

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Community mental health services play a vital role in helping people experiencing severe mental illness to stay well at home, preventing the need for hospitalisation. But they often require multiple services across the NHS, social care, housing and employment support, and there is a risk they fall through the gaps or have to re-tell their story to different services over and over again. Rethink Mental Illness is working to improve the way agencies collaborate to support people living with mental illness.

In Coventry and Warwickshire we have set up teams from different agencies and disciplines in PCNs. This enables voluntary, community and social enterprise (VCSE) organisations and partners to work in an integrated way in their community to provide a holistic package of support for people living with severe mental illness and who have complex needs.

The multi-disciplinary teams (MDTs) have access to a database of 141 professionals from more than 80 VCSE organisations which can provide support with people’s mental health and the wider determinants of their wellbeing, such as their housing, physical health, and employment. PCNs bring their complex cases to the MDT meetings to discuss the best way organisations can work together to meet the needs of the individual.

The MDTs have developed partnerships with stakeholders in the community, including GPs, district nurses, the police, improving access to psychological therapies (IAPT) and social care and housing providers, who attend monthly online meetings to ensure people don’t fall through the gaps between primary and secondary care.

This helps prevent the issue of siloed working and stops clinicians, people living with mental illness and their carers from having to navigate between different services, where they have to tell their story over and over again to get the support they need.

The client is the centre of the MDT meeting, with the partners discussing relevant organisations who can offer support to that person. This is then discussed with the client to agree a way forward. Once everyone is in agreement, a plan of care has been devised and all partners are contacted to begin to progress through it.

There are a number of complex cases in primary care and in the VCSE sector and by aligning and working in partnership with other agencies, professionals have the benefit of a team to take cases to and discuss and share concerns around risk. This is especially beneficial to small grassroots organisations, where in some cases there is only one person managing hugely complex emotional needs.

The multi-agency MDTs also provide a ‘training’ element, as by taking part in discussions, professionals feel able to work on complex cases with more confidence. A tenancy sustainment worker that we’ve been collaborating with spoke about how the MDT has fostered partnerships with other agencies in a really positive way. Having worked in his role for 18 years, he said this has been the most effective example of partnership working, and that it has really developed his knowledge of working with complexity.
MDTs take place online and the local lead from Rethink Mental Illness chairs these meetings. No information that can identify the client is discussed, allowing for a full and frank discussion between a wide range of partners. The outcome is discussed and agreed with the client by the case holder following the meeting.

Our approach
We initially met with VCSE providers in the community to gather details of services, gauge the capacity to take on cases and ask whether they would be interested in being part of this way of working. We found a contact within each organisation and developed a database and distribution list of VCSE providers and other partners in the area.

We also met several leads in secondary care who were part of the national transformation of community mental health, and began sharing our vision of developing multi-agency MDTs in primary care. The leads in secondary care were in favour of progressing this as part of the wider transformation and to build the foundational relationships that the wider transformation and secondary care could engage with at a later stage. We also met several clinicians in secondary care, in particular psychologists who were leading on workstreams within the community mental health transformation.

Taking a quality improvement approach in the development of MDTs, continuously making changes to improve the experience of people using services, we met with Navigation PCN in Coventry and agreed to deliver a three-month pilot and prove the concept. We delivered the meetings in September 2021 and sent a recurring monthly invite to all of the partners on the distribution lists and the staff from the PCN. We have had excellent feedback; one clinical director stated ‘The multi agency MDT was really useful, there was a level of communication we have never had before’.

At the end of 2021 we began to contact other PCNs to deliver across Coventry and Warwickshire. We are now linked to all 11 PCNs in the region, offering partnership working tailored to their needs for the benefit of patients.

This way of working has resulted in excellent relationships between a wide range of organisations in the community, more partnership working and support that is aligned and coordinated. Some providers have developed more formal partnerships from these meetings including venue sharing, training, bidding for partnership contracts and doing joint visits to clients. This has helped to promote the fantastic work of the smaller grassroots organisations and the wider VCSE.

The 81 people severely affected by mental illness that we support have benefitted from a wider menu of services and more coordinated support, and this has resulted in more positive outcomes for them, such as preventing them from slipping through the net between primary and secondary care.

We have developed a robust step-by-step model to implement this work, which is easily transferable and could be used in PCNs in other areas. This way other communities can reap the benefits for people living with mental illness.

Nicola Hall is the Transformation Lead for Coventry and Warwickshire at the charity Rethink Mental Illness. This work is funded by the Charites Aid Foundation, working within Coventry and Warwickshire to transform the way people living with mental illness are supported in the communityFor more information email [email protected]

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