Written evidence submitted by North Staffordshire combined Healthcare NHS Trust (CMH0084)

Call For Evidence: Community Mental Health Services Inquiry

UK Parliament: North Staffordshire Combined Healthcare NHS Trust (NSCHT) Inquiry Response

North Staffordshire Combined Healthcare NHS Trust is a leading provider of inpatient and community mental health, learning disability, substance misuse and primary care services in the West Midlands.  We are on an ambitious journey to deliver our vision to be outstanding – in all we do and how we do it.

In March 2019, we were proud to announce that the Care Quality Commission (CQC) had awarded the trust an overall ‘outstanding’ rating – the highest overall rating it can award.  The CQC rated Combined Healthcare as outstanding in ‘Caring’ and ‘Responsive’ domains. It was rated good in ‘Safe’, ‘Effective’ and ‘Well-led’ domains. 

The Trust has remained committed to delivering exceptional care within our community mental health services over the past three years. The following insights and feedback highlight examples of best practice, stakeholder perspectives, and areas for further development.

Person-centred care, underpinned by individualised plans that address both clinical and social needs, have been central to our local transformation efforts. To ensure alignment with the Professional Records Standards Body (PRSB) requirements for care planning, the Trust has facilitated direct engagement and training for staff in collaboration with PRSB. Building on this foundation, we have integrated care planning with the DIALOG+ domains, ensuring that social and societal needs are addressed alongside clinical considerations. 

NSCHT has prioritised improving access routes to community services, with the trusted assessor model playing a central role. The implementation of Additional Roles Reimbursement Scheme (ARRS) mental health practitioners has been instrumental in this success. By embedding specialist mental health resources within primary care, the assessment and referral process has been significantly streamlined, allowing individuals to share their story only once.

The local model extends traditional GP appointment durations to facilitate meaningful conversations and comprehensive mental health assessments from the outset. In cases where referrals to secondary mental health services are required, the close collaboration and system access afforded by ARRS practitioners ensure a swift, seamless, and needs-responsive process.

The infographic (see appendix A) reflects the shift achieved towards ‘no wrong door’, MDT approach to holistic care and an effective intervention offer.

Access to Trauma-Informed, Evidence-Based Interventions.  The Trust has ensured improved access to trauma-informed, evidence-based interventions, including psychological therapies and pharmacological support. These advancements have been made possible through transformation funding and a steadfast commitment to embedding trauma-informed care from the outset.

Innovations in pathway design and alignment have been achieved by implementing standardised assessment approaches at the beginning of a service user’s pathway. Tools such as the PCL-5 and CORE-OM are utilised to conduct comprehensive trauma assessments, ensuring that treatment and therapeutic interventions are tailored to the individual’s specific needs and requirements.

Pharmacological support has further added value to the community model.   Two new Advanced Clinical Pharmacist roles offer a responsive, patient focused, highly specialised clinical pharmacy service to patients and staff. The roles have become a vital part of the multidisciplinary team (MDT) to maximise patient care and ensure medicines are prescribed, administered, and supplied safely and effectively. Additionally, they have developed training on medicines management for clinical and non-clinical staff, as well as service users and carers.

Inclusive MDT and Enhanced Care Pathways.  MDTs have been pivotal in delivering seamless care pathways and providing comprehensive support for families and carers. The community transformation investment has enabled the introduction of a wide range of new roles, including pharmacy, psychology, and ARRS primary care practitioners.

Additionally, NSCHT has strengthened its service provision through collaborative commissioning arrangements with the Voluntary, Community, and Social Enterprise (VCSE) sector. These partnerships have enriched the core service offer, providing individuals with access to peer recovery roles, support for addressing social stressors, assistance with welfare benefits and financial management, and a designated service focused on health, lifestyle, and fitness. Together, these initiatives have contributed to a broad, diverse, and holistic approach to care.

These services are designed to reduce health inequalities within the service user population and address the significant disparity in life expectancy, whereby adults with severe mental illness face a reduction of 15-20 years compared to the general population.  By harnessing the expertise of the local VCSE sector, the Trust has enhanced coordinated care planning and ensured the flexibility to allocate keyworker roles based on the individual needs of patients. This collaborative approach has fostered a partnership ethos, enabling seamless integration of services and ensuring comprehensive documentation through the Trust’s electronic patient record system.

System Interoperability Challenges.  Despite significant progress in building effective relationships with primary care, barriers to system interoperability persist. Primary care systems vary between practices, preventing true integration across the entire footprint of the Trust. A notable challenge is the lack of continuity in SNOMED coding, which do not follow the patient, making accurate and patient-centric reporting to the Mental Health Services Data Set (MHSDS) problematic.

This issue is particularly evident in the context of Severe Mental Illness (SMI) health checks. Although an electronic form has been developed to transfer SMI health check information from the Trust to GP systems, system interfaces are unable to intelligently recognise core details or automatically code completed checks. As national reporting is derived from GP systems, this presents challenges not only for data accuracy but, more critically, for ensuring patients receive timely follow-up care. Careful consideration and thorough analysis of health check results remain essential to ensure appropriate actions are taken.

Streamlined Assessments and Holistic Care Planning.  Efforts to minimise repeated assessments have focused on ensuring clear communication about care plans and integrating social determinants of health, such as housing and employment, into care pathways. The trusted assessor model allows individuals, families, carers, and friends to share their story once, reducing duplication and enhancing the care experience.

Progress in care planning has aligned practices with PRSB standards, while also adhering to the national directive to utilise Patient Reported Outcome Measures (PROMs) for addressing holistic care needs. A key feature of the new care plan is the inclusion of the ‘About Me’ section, ensuring the patient’s voice remains central to their care, intervention and treatment pathway.

Use PROMs to track recovery and service impact but consider this alongside clinical perspectives and insights. More time is needed to embed mandated PROMS and build system interoperability to enable digital patient interfaces for completion of PROMS.  It also should be recognised that patients may choose to opt out of completing PROMS (given there are 3 mandated, all to be used at multiple junctures throughout a patient’s journey through services).

Monitor waiting times, referral pathways, and service utilisation.  New proposed waiting times standards are ambitious given the multi-faceted requirements needed to ‘stop the clock’.  Internal audit processes will assure the quality of care plans but regular feedback from service users and their significant others will provide additional, vital insight. 

Conduct regular qualitative feedback from service users and staff. Coproduction has been at the heart of the transformation in North Staffordshire.  A dedicated workstream has seen a coproduction kitemark and criteria developed and operationalised in the Trust.  This provides a platform to champion the value of expert by experience voice.  Using a range of engagement and feedback routes has provided insights that have been used to shape services, something that will continue as we move forwards.

Enhancing Access and Streamlining Care in Community Mental Health Services.  The Trust has developed services to improve access and reduce waiting times, ensuring that evidence-based interventions are central to the treatment provided within Community Mental Health services. Teams are structured to focus on the formulation of service users’ needs from the outset, enabling treatment to be planned and delivered effectively.

A diverse range of bio-psychologically informed interventions is offered by wider team members, helping service users gain a better understanding of their difficulties and develop greater stability. For service users, this means clarity from the point of referral: they know what to expect, what the team will provide, and what their role is within their recovery journey. Pathways are now clearly mapped from beginning to end, detailing available treatments at each stage. Discharge planning is introduced early in the pathway to ensure interventions are focused and time-limited, with discharge occurring either upon the completion of a treatment phase or, where appropriate, if the service user is not ready to engage actively in treatment.

The Triage and Assessment Pathway serves as the entry point for interventions within Community Mental Health Teams (CMHTs). The triage process has been refined to deliver a responsive, service user-centred approach, ensuring the most appropriate treatment is identified, whether it falls within the Trust’s own services, those of partner organisations, or a combination of both.

Referrals are now reviewed, and an Initial Assessment is offered within days of receipt, informed by factors such as presentation and risk. These assessments are conducted by an MDT of health professionals from all professional groups. Appointments are available through a variety of formats, including face-to-face (virtual via Attend Anywhere or in person). Initial Assessments are generally completed within a single session, after which the case is reviewed by the MDT. Service users are then either signposted to appropriate services, discharged, or progress to the next stage of care within CMHTs via the Standard Assessment Framework (SAF).

The SAF is completed by a designated Keyworker to provide an in-depth assessment and formulation. In most cases, service users are allocated to one of the Care Pathways for tailored, evidence-based treatment and support, ensuring a structured and person-centred approach to care.

Adherence to Treatment Targets and Alignment with Waiting Time Standards.  Early Intervention Teams consistently meet the mandated two-week treatment targets. Across community services, new waiting time standards have been carefully integrated with pathway development to ensure holistic assessments, utilisation of PROMs, and robust care and intervention plans.

To improve reporting, national waiting time measures for CMHTs have been adopted locally.  A shadow reporting approach has been implemented to monitor compliance against these new standards. As the holistic assessment tool and revised care plan approach become more established, they will further support the ambitious national waiting time requirements.  The redesign of the care plan has necessitated a review of the Trust-wide assessment tool. A newly developed holistic assessment document now interfaces seamlessly with the care plan within the clinical system, reducing duplication for patients and enhancing staff productivity.

However, the uptake of PROMs remains a concern. While PROMs are integral to achieving waiting time standards, the option for patients to opt out poses challenges to compliance and reporting. Addressing this issue will be critical alongside developments to support digital solutions for PROM completion.

Proposed Opportunities for Improving Access

To enhance access to mental health services, several opportunities have been identified:

• Expanding Public Awareness Campaigns: Promote services and referral pathways across the full range of emotional and mental health services, ensuring individuals receive support at the earliest possible stage.
• Safeguarding Mental Health ARRS Funding: Ring-fencing ARRS funding for mental health roles in primary care would protect these resources and allow them to build on the progress already achieved.
• Investing in Infrastructure: Focus on reducing waiting times and increasing service availability through infrastructure improvements, including enhanced digital interfaces between primary and secondary care.
• Strengthening Integration: Improve collaboration with primary care, the voluntary sector, and social services. Building and nurturing trusted relationships across organisations is essential for achieving seamless cross-organisational working.
• Addressing Inequalities: Continue efforts to tackle inequalities in access, experience, and outcomes through initiatives such as the development of a health equity framework and community grants targeting under-represented groups. Prioritising health literacy in service delivery and communication is vital, as is sharing innovative approaches to reducing inequalities at regional and national levels.
• Promoting Innovative Work: Highlight and share impactful initiatives to raise awareness, myth-bust and showcase service outcomes. For example, the Early Intervention/At Risk Mental State Service collaborated with staff, service users, students, and a film production company to co-produce an award-winning educational film, The Edge of Reality, which explores the experiences of young people with an at-risk mental state and provides guidance on accessing support services.

• The Edge of Reality Film: https://www.youtube.com/watch?v=BSs3e-bz1Ao
• The Edge of Reality Behind the Scenes: https://www.youtube.com/watch?v=PrZXk3PXWiM

Yes, undoubtedly the framework has served as an overarching tool to drive delivery across a complex piece of transformation work. In the first year of the transformation programme particularly the framework served as a guidance tool until the detail behind the transformation roadmap emerged nationally in year two.

• By taking opportunities to consider VCSE commissioning models, grant provision, contributions to wider community partnership models of support that exist, such as the community lounges in Stoke-on-Trent where the Trust provides mental health support as part of a wider social support model: https://localoffer.stoke.gov.uk/directory-record/2739/community-lounges).
• Strengthen partnerships with social care, the third sector, and local government.  This includes staying close to the ever-changing and emerging initiatives that can often support the wider, holistic needs of an individual.  Community connectivity is recognised by the Trust as a significant factor in someone’s recovery journey.
• Embed peer support roles and social prescribing within MDTs to address broader determinants of health and provide a unique support structure for service users where shared experience and insights can instil hope through a solution-focused lens.

Ensure multi-year, long-term funding allocations to sustain and further enhance transformation initiatives. This is particularly pertinent when considering procurement regulations and timescales for commissioning VCSE services for example.  Longevity of services and reciprocal partnership relationships take time and effort to build.  Locally we have ambitions to explore collaborative commissioning models but this will require maturity of partnership relationships and a shift away from typical provider-commissioner relationships.

Blockers: Staff shortages, inconsistent referral criteria across services (internal and external), and limited service integration, particularly across computer systems within and outside health services can mean that truly joined up care is made more challenging.  

Enablers: Funding stability, enhanced digital tools, plus clearer communication across national and regional networks to support ease of transformation and clarity of requirements.

The Edge of Reality video exemplifies the powerful outcomes achievable through a commitment to co-production. While co-production can sometimes extend development timelines to ensure sustained engagement, this video clearly demonstrates the value added. Sharing resources like this across regional and national networks could not only raise awareness and foster engagement but also drives broader innovations in mental health services.

Step On Provision offers Individual Placement and Support (IPS) services, aimed at helping individuals experiencing mental health difficulties who are ready to seek and maintain meaningful paid employment. Community Mental Health Transformation has successfully removed the boundaries between primary and secondary care, opening up new work environments, including Primary Care Networks (PCNs). This service development now provides greater access to IPS support for individuals who have recovered from severe mental illness (SMI) but are not currently engaged with secondary mental health services. The Step On team boasts a 70% rate of lived experience among staff and a 35% success rate in helping service users secure and retain employment.

The CASTT provision, which provides long-term support for individuals with personality disorders, has evolved over the past four years. The service offers an evidence-based Structured Clinical Management therapeutic model, yielding excellent results for patients. The expertise within this specialist service has been essential in providing in-reach support to community mental health services. Additionally, the team has shared its knowledge with staff at a nearby acute hospital, helping to manage patients with personality disorders who may present challenges or complications.

The introduction of Peer Recovery Coaches into the community mental health workforce has been a significant advancement. These coaches champion the voice of those with lived experience and offer invaluable support to patients from individuals who understand mental health services firsthand. Feedback from both patients and staff has been overwhelmingly positive, and the impact of these roles is reflected not only in performance metrics but also in the wider adoption of peer roles in other specialist community services.

• Develop national frameworks for replicating successful models.
• Provide training and resources for MDTs to adopt innovative approaches, appreciating the known skills deficits is professional groups within the MDT model and therefore the organisational challenges faced in delivering under this model (psychology for ex).
• Ensure consistent monitoring and evaluation to refine practices over time.

February 2025