The first five steps

This is a short, practical guide to the first five steps needed to begin redesigning a community mental health model in the next six months, ahead of the transformation funding entering the system in April 2021. These five steps are in chronological order but will overlap in implementation.

• Overview

  This guide will set out steps on how to develop:

  • A ‘leaders group’ of experts by experience and staff who can sign off decisions.
    
    
  • A ‘co‑production project group’ of people with lived experience and staff gaining local insights, co-producing a new model and feeding back to the community.
    
    
  • A comprehensive understanding of who is currently delivering support for people severely affected by mental illness and their clinical, practical, social and financial needs.
    
    
  • An alliance of voluntary and community organisations coming together, ready for procurement.
    
    
  • A new model of community mental health care forming (but not necessarily finalised).
    
    
  • A workforce plan and recruitment starting with role adverts published.
• Leadership and governance

  The first few weeks will be about identifying the leaders at different levels within the STP/ICS who are going to develop, sign off and deliver a redesigned community model. They will need to be identified and a matrix ‘leaders group’ formulated to oversee the next four steps and the co‑development of the proposals to NHSE and NHSI and quickly sign off decisions.

  This group must include:

  • The STP/ICS, including relevant people from both the NHS (i.e. Primary Care Networks, CCGs and mental health providers) and local authorities (e.g. social work leadership, Directors of Public Health, Directors of Adult Social Services, housing leads or relevant Councillors)
    
    
  • Voluntary and community organisations that provide local services.
    
    
  • Experts by experience leader(s) – it’s good practice to advertise for roles (see Appendix 1 within the PDF version of this guide for a draft role description) and this can be disseminated through, for example, independent mental health networks, charities such as Rethink Mental Illness or local involvement coordinators 
    
    
  • Individuals from BAME communities and other protected or marginalised groups. 

  
  The group should include senior people with the following characteristics:

  • Authority to get ‘buy in’ and sign off – particularly the power to commission services differently if needed
    
    
  • Time and capacity to focus on this important new model
    
    
  • Knowledge and understanding of mental illness and why the system needs to be redesigned.
    
    

  To meet the tight time frames in the coming months you will need to meet regularly to agree governance and ways of working. These will need to be agreed from the outset and included in the terms of reference. Terms of reference should cover: what is the scope of the transformation and agreed approach, whether everyone should attend all meetings or send a deputy, how should decisions be agreed (vote, consensus, by leads), how to build trust through collaborative working and open and transparent communication and commitment to co‑production.

• Co‑production

  NHS E and NHS I will be looking specifically for how you intend to co produce your new model in partnership with local people with lived experience of mental illness and their families and carers.

  What is co-production and why is it beneficial?

  Coproduction is the active involvement of people with lived experience of mental illness in service design and delivery. Experts by experience are partners in design where their perspective is valued equally to the staff (experts by training) perspective in making decisions.

  
  Co-production is more comprehensive than simply patient involvement. Co-production empowers those who use services and makes the most of their expertise and assets. It helps improve outcomes and it can save money by lessening the burden on services through, for example, reducing emergency and unplanned admissions.

  How to start co‑producing

  There is no rigid process or method for co‑producing and it’s important to be practical and flexible – and keep things as simple as possible. Here is a suggested timeline:

  1. Together with expert by experience leaders identified in step 1, discuss the benefits and aspirations of co‑designing a new model of community care.
     
     
  2. Define the scope – what’s in scope for redesign and what’s out? This can be based on NHS E and NHS I’s Community Mental Health Framework.
     
     
  3. Form a ‘coproduction working group’ involving representative experts by training and experts by experience.
     
     
  4. Co‑produce an action plan (what, how, who, when). This should include:
     
     Obtaining insights from representative groups of people with lived experience in different local communities. Ensure they’re diverse and representative and make it as easy as possible for everyone to participate (accessibility, including language and format). This may mean going to existing groups that are meeting rather than asking people to come to you – and time must be factored in to allow this.
     
     Obtaining insights from staff and peer support workers about what works well and not so well, and what’s missing.
     
     Mapping local assets (see step 3 below)
     
     
  5. Carry out a number of workshops to share insights, and develop your local model based on the Community Mental Health Framework. This could involve considering elements that haven’t worked before and discussing what it would look like if it was working. Facilitation will be key.
     
     
  6. Feedback to each other on progress and challenges regularly.
     
     
  7. Expert by experience leaders feedback regularly to their communities to continue obtaining insights and raising awareness about a new model of care. Time must be built in to deliver this.
• Mapping community assets

  What support is already provided in your STP/ICS to help people affected by mental illness to recover and stay well? The co‑production working group, or a few people tasked within this group, should build on asset mapping that has already taken place within your area but through the lens of moderate to severe mental illness and complex needs.

  This should include clinical, NHS funded support, social care funded by the local authority and wider support for the social determinants of mental health such as supported housing, financial help, employment support, community and physical activities and more. Assets could also be physical community spaces, active forums or groups, peer networks or even individual people who are champions or influential in communities or sectors. It is vital the asset mapping goes beyond solely mental health provision recognising the wider determinants for mental health. The tool that was used within Somerset STP early implementer site could be a useful guide. This is available in appendix 2 in the PDF version of this guide.

  Within a few weeks this should be filled out and will enable you to identify where there are gaps in provision when mapping on to the co-produced model.

• Alliance building

  A VCSE alliance

  In order to meet the gaps identified in the new co produced model and asset mapping, you will need VCSE providers to come together to deliver existing and new offers of support. These must be the right organisations who can reach the right groups of people – including those most vulnerable and marginalised. A way to do this will be to build an alliance, formal or informal, of VCSE organisations who can commit to a shared vision and ethos, to co production and to working together to achieve transformation over and above individual organisational ambition.

  The alliance model requires huge shifts in behaviour from the voluntary sector. In most places larger charities operate as commercial rivals and smaller community organisations are not set up to undertake statutory work. Therefore consider procuring a ‘partnership’ to deliver the new model as a whole rather than individual organisations to deliver specific services. Providing funding via longer term joint CCG local authority contracting through an alliance model has the significant benefit of removing or lessening competition for funds, generating a more efficient use of the public pound and encouraging collaboration and sustainability.

  This is particularly crucial in ensuring the sustainability and survival of smaller / micro grassroots and community organisations, many of whom have been significantly adversely affected by the current pandemic yet who remain vital to supporting some of the most disadvantaged and disconnected groups of citizens. Alliances are key to building a diverse and thriving local VCSE sector, particularly at a time when so many organisations are facing extreme pressures.

  What are the key factors in building an alliance of VCSE organisations?

  • Relationships are vital to develop and nurture.
    
    
  • Agree principles and ways of working early on and form a terms of reference that includes how decisions will be made.
    
    
  • Build trust between VCSE partners – organisations that used to compete are now working together.
    
    
  • Transparency is vital to achieve this trust – particularly around being open about possible points of conflict.
    
    
  • Leadership is important in driving the alliance and preventing mission drift. 
    
    
  • Financial support – VCSE sector funding has been particularly affected by the COVID-19 pandemic, particularly for local organisations.
    
    
  • Go beyond mental health charities to involve other local groups and organisations.
    
    
  • Reflect the diversity within the local community

  
  NHS, local authority and VCSE alliance working

  More broadly, you may then want to consider an alliance between the NHS, CCGs, Local Authority(ies) and VCSE. The effects of austerity, more recent legislation like the Care Act and more robust performance and inspection criteria has had the effect of weakening or changing partnership working in many areas.

  However, the current pandemic has also seen an extraordinary shift to many barriers being removed by local partners working more effectively together for the benefit of local communities. The key is to create new alliances based on the principle of organisations coming together to use their skills, resources and statutory responsibilities to improve local services and place the needs of local people and improved access at the centre of community mental health services.

• Workforce

  When the new model of community care is nearly agreed it will be important to have a clear understanding of the workforce needs of your local area to be able to implement your plans.

  You will then need to start recruitment to ensure staff are in place from April 2021 when the funding enters the system. The workforce will very much depend on the co produced new model and it will be vital to agree this first. Form must follow function.

  In the past we have seen that existing staff have simply been moved around, meaning some parts of the system are short-staffed. While this may be appropriate in some areas, it will be important to think creatively about how to fill roles – for example, how can peer support worker roles be used most effectively or how can the VCSE be part of the model in a genuinely integrated way?

  The ‘New roles in mental health’ programme led by Health Education England (HEE) has reviewed the developments required to support a more preventative and community based model of mental health support. This includes nursing, allied health professionals, psychology, social work and peer support. HEE will be making these developments available to the CMHF sites as required.