Working at the Neighbourhood Level
Getting neighbourhood working right appeared to us to be one of the most important challenges to take on. It requires bringing together the issues of achieving access, changing culture and supporting workforce through collaborative leadership.
Key neighbourhood problems that the Community Mental Health Framework (CMHF) is aiming to address include:
The large gap in provision for people ‘too complex' for NHS talking therapies in primary care and 'not severe enough' for secondary care, whose GPs are often the only health worker involved.
The lack of sustained, coherent investment in social interventions and voluntary sector services.
Lack of geographical co-terminosity between primary care and mental health teams.
Single Point of Access (SPA) systems covering large populations (100,000 to one Million) can become bureaucratic and lose touch with local resources.
The focus of previous systems on specialist intervention and not other resources, such as community assets.
Representing populations of possibly 35,000 to 100,000 individuals, multiple neighbourhoods make up the much larger populations of Integrated Care Systems (ICSs). As mini systems themselves they are likely to need nurturing.
We have seen important examples of work starting to address these issues:
A range of placed models operating at the 'Locality’ and primary care network (PCN) levels. Examples of this include agile workers integrating into different teams at the Locality level and teams composed of a GP, an experienced mental health worker, and a VCSE worker with rapid referral paths and inhouse supervision at the PCN level.
Working together as one system – e.g. practices which build relationships across teams; shared use of language to promote new cultures of care and ways of thinking across systems; and cross sector leadership meetings supporting integration
Interventions to fill gaps in need – e.g. Specific therapies e.g., DBT, Pharmacy, social interventions.
Neighbourhood Multi Disciplinary Meetings / hub / locality meetings – and how they can generate a range of outcomes, such as shared culture and understanding and trust across team, ideas for service improvement and decisions for individual service users.
These are described in more detail below.
For more in this section you can also see our pages on workforce issues, how to approach risk, collaborative leadership and adopting a needs-led approach.
Neighbourhood challenges and place-based approaches
Challenges for CMHF transformation at neighbourhood level
The Community Mental Health Framework proposes mental health support at a neighbourhood, ‘place’ level. This requires a radical shift from team-based to neighbourhood thinking.
It is suggested that place-based systems could operate at population levels of 30-50,000 people (the population of a PCN), and/or at a ‘Locality’ population level of 250-500,000 people for intensive, targeted, and longer-term input for people with more complex needs.
Population or neighbourhood-based approaches require staff to think about where an individual might be best cared for in the system – rather than just focussing on whether they meet a specific team’s criteria.
One key challenge is that of bringing together resources from across multiple teams in a way which is coherent and transparent for service users and staff – but also flexible and not reliant on long, repeated assessments.
We have also seen teams struggle to develop neighbourhood working:
Confusion and lack of co-ordination as new teams are developed in neighbourhoods – each with their own protocols (flow rules) – often leave practitioners feeling as bewildered as service users. How teams and other resources are configured is often not well described.
Uncertainty about ‘how big is local?’ or ‘what is a neighbourhood?’ and how much community assets should be included in neighbourhood models.
Working out how to work with primary care is a common challenge. GP teams have different perspectives from each other and mental health services. The Additional Roles Reimbursement Scheme (ARRS) is led from PCNs and the new primary care based workers can be joint funded and supervision can be contested.
System leaders have not always articulated both a vision for the future (an underpinning organisational and clinical principles/philosophy) and a clear operational plan showing how teams should link, practitioners should work together, and individual service users should move around neighbourhood systems.
Charlie Hobson-Merrett discusses how to work in a new way, reflecting on new roles and team working.
Mapping the relationships between stakeholders within a transforming system
Teams may be wondering about structural issues:
What size of neighbourhood is appropriate? Primary Care Network size (35,000 population) or 100,000 or more?
Should we talk about Neighbourhood teams/hubs when in effect they are several sub teams working together? Are Talking Therapies (IAPT), general practices and local voluntary sector part of the ‘team’? (See the above figure.)
What should the access arrangements be for each team (single point of access to neighbourhood team/hub or direct referral to each local team making up the neighbourhood)? How is care shared across different people and teams in the neighbourhood?
How should neighbourhood teams link to more specialist teams working at a larger population level (100,000 to one million)?
To what extent is co-location important, and where should any co-location be?
Teams will also need to decide how to address relationship issues:
How are power dynamics between different staff addressed?
How can coproduction be embedded in leadership and service development?
How to address differences culture and in ways of working across different providers?
How will voluntary sectors be empowered / enabled to work with statutory services?
Important related issues are described on other pages:
Collaborative Leadership work as a means of starting and maintaining change
Key new CMHF roles as a part of a wider workforce which needs to be nurtured
How flow rules contribute to access in local systems
A range of place-based models
We have seen many place-based models emerging, depending on:
Historical arrangements.
Grade, profession, skill and role function of new and existing workers.
Emphasis from system leaders on creating seamless systems vs tightly run teams with different.
Interest from primary care in being part of this work.
We describe the range based on four types, but recognise that these are overlapping and that potential variation is very great.
The relationship of a neighbourhood mental health team to extended teams as well as community and specialist services. Diagram from East London.
1. Larger locality ‘neighbourhood’ teams or hubs, led by the mental health trust with or without voluntary sector co-leadership
These teams, or networks of teams connected by hubs, might be made up of one community mental health team and three-five primary care networks, and might cover a population of 100-200,000 people. Often, the core is formed by a set of practitioners in new roles, employed by the mental health trust (and/or VCSE), designed:
a) To fill the service gap between general practice and community mental health – through new teams and roles
b) To improve relationships / signpost across primary / secondary and voluntary sector service teams (e.g. liaison navigator roles).
Sub-teams might be those with specific functions or roles such as community connectors, psychological therapy, and primary care (i.e. general practice) based mental health practitioners. The latter may be funded by the Additional Roles Reimbursement Scheme (ARRS).
They also often involve the community mental health team, representatives from GP practices or representatives from specialist secondary care mental health services (psychology, personality disorders, eating disorders, etc). Their engagement in both clinical discussions and meetings to agree service design can be patchy.
Involvement of the voluntary sector appears to work well if there is a voluntary sector lead organisation for each team, and if the voluntary sector is supported by a voluntary sector alliance, with additional funding allocated to improve voluntary sector provision.
Example of the many teams in a transforming community system
This diffuse ‘team’ of teams therefore has a range of potential functions:
Working together to decide on the appropriate service to offer people who ask for mental health support (see also flow rules).
Sharing responsibility for considering the population as a whole – from prevention to care of those with most significant need.
Training and supervision.
Creating a coherent system and maintaining relationships and a clinical culture.
Making changes to team configuration, roles, ‘flow rules’ etc. – this may be done as co-design with lived experience and point of care practitioner input.
Autonomous locality working
Another key mechanism for some of these wider neighbourhood teams is the flexibility allowed by senior management and taken up enthusiastically by experienced managers. Managers were encouraged and allowed to create roles dependent on who was available and their skills, and to operate flexible pathways developed for their locality. Interestingly, the staff involved appeared to have a very significant range of experience outside of mental health work, for example having been involved in skilled trades and management outside of the NHS.
2. Small primary care network sized teams, led by the mental health trust
These teams might be designed by change managers employed by the mental health trust. Changes have some strategic ICS level oversight, but with opportunity for localised approaches to be instituted. There is a core team of staff who focus on the population of one or two PCNs. The core team is mostly employed by the mental health trust, but might include a community connector employed by the voluntary sector and even a GP lead.
Specialist staff from different services with responsibilities across multiple teams ‘plug in’ to these teams. Again, new roles focus on filling in the gaps between primary and secondary care and liaising / signposting across primary / secondary and voluntary sector services (community connectors, clinical associate psychologists).
Integrating and Liaison Roles
In one integrated care system a small group of highly experienced mental health practitioners took on the role of integrated mental health workers. The role was designed to work into Primary Care Networks as well as to link into a small single point of access team. They managed to carry out a flexible function of supporting assessment and brief treatment of individual patients, as well as these integrating liaison roles to other teams.
3. Primary care-led teams
General practice has a forty year history of developing general practice-based teams for mental health, incorporating community psychiatric nurses, practice counsellors, and clinical psychologists. These models have often been dismantled during wider reorganisations – mental health staff were withdrawn from general practice to be part of community mental health teams, and, later, clinical psychologists and counsellors were withdrawn to be part of wider IAPT teams.
In the years leading up to the CMHF, a number of systems, including in London, Cambridge, Plymouth and Nottingham, developed innovative roles for addressing the gap between IAPT services and secondary care. With the advent of Primary Care Networks, the Additional Roles Reimbursement Scheme (ARRS) started to potentially include mental health practitioners. Some were managed by practices, others by mental health providers, and their roles varied between extremes of seeing general practice presentations of mental health and supporting more complex cases, including psychosis. Some practice-based workers were jointly funded by the ARRS and CMHF.
We have seen a very wide variety of approaches. Those based within practices risk having insufficient supervision and providing mainly reactive care as a part of practices’ same day access priority. In contrast, some so-called primary care-based workers risk being drawn into another tier of specialist mental health with few links to general practice teams.
Primary Care Network-led approach
We observed one Primary Care Network where an active, experienced general practitioner took the lead and negotiated for time to be dedicated to a primary care-based team. This team involved a local MIND-employed worker and an experienced mental health nurse from the wider locality CMHF mental health team (later replaced with an ARRS-funded mental health worker). They were keen to call this a Primary Care Mental Health Team.
In this set up, referrals came from all the practices within the Primary Care Network, and the team operated out of two or three consulting rooms, with the experienced GP being on hand to provide support and supervision ‘in the moment’. This team also worked collaboratively with the community mental health team, with the GP and psychiatrist holding regular meetings to discuss difficult patients who required proactive care.
One of the key mechanisms they invoked was ensuring that meetings only occurred if a senior member of staff able to take clinical responsibility was available from both the secondary care and primary care side. While this appeared to be quite a medical authority driven model, the voluntary sector staff involved were very satisfied and felt very much part of the team.
Because of their ethos of positive risk management and avoiding referring onwards, having experienced clinicians taking this responsibility appeared to us to be the key mechanism to support relatively inexperienced staff to look after complex people in a primary care setting.
4. Primary Care Network (PCN) linked teams, led by the voluntary sector
In these teams, change may be co-led by voluntary sector providers (e.g. with funding for roles passed from secondary care providers holding wider CMHF or mental health budgets) and PCNs. These teams are small, focusing on the population of one PCN. Changes may be locally driven, rather than led by a trust-wide strategic plan.
Theoretically, these teams could have the advantage of being closely linked to local communities and can be embedded within practices, with workers having honorary contracts and with referrals on from primary care as well as direct from the community.
Key mechanisms for success:
The need to develop additional links with mental health services (to ensure smooth flow) and to have the potential for supervision from mental health service practitioners (as well as or instead of supervision from GP team members).
Being part of general practice teams (including attending formal and informal clinical team meetings), being embedded formally within those teams (e.g. with honorary contracts) and having access to, and understanding of how to use, primary care record systems (e.g. to ask (‘task’) GPs and practice nurses regarding medication or physical health).
Supporting VCSE-employed workers to be accepted as part of the NHS workforce and being made part of the Primary Care Network multi-disciplinary team (e.g. working alongside Social Prescribing Link Workers and ARRS funded practice mental health workers).
At present we don’t know much about this approach – we invite contributors to share their experiences by emailing us at: cmhke@plymouth.ac.uk.
How to work together as one system
Perhaps the most challenging problem is how to bring together sub-teams within a locality (i.e. hubs or neighbourhood teams). These sub-teams might include Trust teams dealing with particular populations (e.g. Complex Emotional Needs/Personality Disorder) or be made up of particular staff groups (e.g. community connectors or psychologists), voluntary sector led or peer support teams. Bringing together these teams as a coherent system with flexible, yet understandable and coherent pathways between teams is not easy.
Specific challenges we have seen:
The way that general practitioners work means that the meeting-style of relationship building is not useful to them.
Meetings can become too NHS-style (e.g. using NHS numbers and language), which can create a power imbalance with voluntary sector providers. Tactics such as varying the chair and the style of the meeting can be used to address this.
Place-based provision may improve access and provision to mental health services, but may still leave people belonging to some communities behind (e.g. people of colour, rural communities, people who are neurodivergent). Additional projects may be useful in tackling.
Existing teams may not have good relationships, making it difficult to then create relationships across teams. Intra- and inter-team relationships will then need to be worked on.
Status / hierarchy challenges within and across teams makes it difficult to work together at a neighbourhood level. Where this is the case, leadership will need strategies to break down hierarchies, for example between practitioners of different levels / types of training.
If staff turnover within teams is high, this makes it more difficult to form relationships across teams. However, it should be noted that some staff turnover may be beneficial in order to create room for those who are philosophically aligned with the end goals of transformation.
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We know that it is difficult to create meetings and away days (or other relationship building activities) that fit into the structure of the working day of a GP – we invite contributors who have had success in this area to share their experiences.
Key relational outcomes to aim for include:
Trust within and across teams in clinical working.
The belief you are united together helping people.
Trust in the assessments and work of others.
Believing other staff are doing their best, even when things are difficult or mistakes are being made.
The ability to share concerns and errors - and learn together.
Shared understanding about how the system should and does work.
Motivation to support the population as well as individuals.
Mechanisms we have seen operating include:
Having roles which operate across teams within the neighbourhood (see the Integrating Liaison Role example above).
Discussing cases, both atypical and routine, both to decide where in the system they should be seen, and to generate ideas about service improvements, detailed flow rules, eligibility criteria, etc. But we suggest that not all cases are discussed as this is likely to be wasteful.
Active participation in the range of collaborative leadership work – e.g. practitioners reaching out to each other across teams to discuss cases or team leaders routinely linking informally to troubleshoot.
Engagement of members across individual teams in service improvement projects, evaluation and codesign work with experts by experience.
Taking time out together to allow personal, one-to-one and group reflection (away days, professional development, training).
Key tips:
Prioritise relationship building now – while appreciating that it takes time to do so.
Particular attention should be paid to the perceived imbalance in power that exists because secondary care is seen as being able to agree or deny access to services in a way that primary care and voluntary sectors services may not be able to.
Have designated administrative support and consider different working practices and pressures across primary care, secondary care, and the voluntary sector.
Previous ways of working within the voluntary sector, including competition for funding, may make it necessary to find ways to enable voluntary sector co-working and alliance working. This will enable trust and new ways of commissioning between statutory and non-statutory services.
The Care Programme Approach (CPA) has been phased out in most areas. We know that sites are rethinking the role of the care coordinator in this new system, but currently have limited knowledge about approaches – we invite contributors to share their experiences.
Specific interventions to fill gaps
Neighbourhood functioning is likely to be enhanced by examining gaps in provision – according both to lived experience concerns and lack of evidence-based provision.
Additional statutory provision:
If there is little provision for people who have low mood and anxiety, but do not meet the threshold for IAPT, short psychological therapies might be provided by trainee assistant psychologists.
Long-term psychological input for people with severe and enduring mental illness.
Depending on the exact gap identified these roles may or may not be funded using ARRS and based in GP practices.
Additional non-statutory provision:
Provision focuses on addressing issues that make people’s lives more difficult or which provide resilience or prevention, as well as specific activities for people with mental health problems:
Local mental health helpline.
Citizen’s advice, debt advice, etc.
Exercise / activity / sport.
Support groups.
These can help ensure that no one is ‘discharged to nothing’, and that there are resources that help mental health problems from occurring or re-occurring.
MDT Meetings
Can they be Effective, Efficient, and Motivating?
Multi-disciplinary team meetings within a wider system
Multi-disciplinary Team (MDT) meetings have become commonplace across the NHS and social care. They are one aspect of multi-disciplinary working. As a means of delivering multi-professional care, they are an obvious part of solution and often involve discussing the patients, sometimes all patients, quickly or in depth.
There has been an understandable counterreaction from many who feel that meetings such as these can be costly ‘talking shops’, which are unproductive and wasteful. There is a good theoretical case for arguing that they need to generate something special from the resource take up by staff discussing individuals who are not themselves present.
We have seen a range of MDT meetings operate successfully, and common ingredients include:
A genuine desire to achieve a No Wrong Door approach and think together about what’s best for the patient.
Rotating chairing between the voluntary sector, primary care, and mental health teams.
Being well-organised to ensure cases discussed are relevant to those attending.
There appear to be several key functions and positive outcomes that can generated from good MDT meetings:
Supporting patient flow decisions. Discussing difficult cases can be a helpful way of getting the individual to the right place. However, discussing all potential flow decisions is unlikely to be cost effective, and we therefore recommend that MDTs, unless very small, only discuss a minority of cases, while making sure to include both routine and extreme cases.
Involving patients in shared decision making. We did not see this operating anywhere, but there is now potential for bringing patients themselves into MDT meetings with video links, etc., so that decision making can fully involve patients.
Building a team culture. Discussing cases, both routine and complex, and having confident collaborative clinical leaders present, can lead to the development of a shared understanding about how mental health is perceived and what kind of cases can be supported. In addition, a culture of collaboration across sectors can be supported.
Getting ideas for redesign. Team meetings can show where current design of services is inadequate; within one meeting several issues for redesign of services are often be brought up. Not all need to be acted on, and some ideas for redesign could cause more problems than they solve, but others can be acted on quickly, with rapid changes and improvements to neighbourhood working.
Development of trust between individuals. Just by being in the same room, or even in the same team meeting, and discussing issues together, collaborative trust across the system can be strengthened. This requires good chairing and effective resolution of difference.