Acute and community transformation – the way we deliver community services is changing

We need to transform our services to make sure they continue to meet people’s needs, and so that they offer the best care and better outcomes for our service users. We also need to make sure our services are the best value for money.

We’re proposing a new model of care for acute and community mental health services which will

  • help us be flexible around services users’ needs
  • bring the skills and experience of staff together
  • include a single point of access (SPA) into secondary care which makes it easier for people to get treatment and helps avoid repeat assessments
  • help us provide more recovery-based care
  • involve listening to and working with service users, carers and partners

All this means safer, higher quality care as well as reduced risk and cost.

Integrated care pathway steps









Single Point of Access

To help service users access healthcare effectively, safely and without unnecessary delay, we’re developing a single point of access (SPA) service.

The SPA will be the pathway into the Core, Enhanced and intensive home based treatment teams. The SPA will help service users and GPs to easily access a range of mental health services, and improve the way referrals are managed and received.

The service will work extended hours, to cover main GP hours of work. Outside these hours, phone lines will transfer to the intensive home based treatment team, which runs a 24 hour service.

Core Pathway

The core pathway will provide secondary care community services to people whose needs are not considered complex or high risk, often requiring shorter term interventions. Support will be tailored to each service user with a focus on recovery.

The main focus for the pathway is:

  • Support that is tailored to each service user.
  • Working with service users to find the best plan of care for their needs.
  • Helping service users stay well and work towards recovery.
  • To work more closely with GPs, physical healthcare providers, partner organisations, recovery colleges and Creative Minds.

Staff involved in the core pathway will be multidisciplinary. This will include psychiatrists, clinical psychologists, social workers, mental health nurses and occupational therapists.

Enhanced Pathway

The enhanced pathway will provide secondary care community services for service users with complex care and treatment needs who need co-ordinated treatment and care, perhaps for several years. The service will work across a seven day week.

The team approach will be based on a flexible assertive community treatment (FACT)

model of care, which is derived from the assertive outreach model. Caseloads will be lower but needs will be more complex.

Acute care pathway/ Intensive home based treatment teams

In a mental health crisis these teams provide support at home so that people don’t have to be admitted to hospital. Their focus is on recovery.

The service would operate 24 hours a day, seven days a week, and respond within four hours. All teams would include nurses and medical staff and some would include social workers and psychologists.

The intensive home based treatment team would provide the single point of access service outside GP hours of work.