Sheffield primary care mental health transformation

Key benefits and outcomes

• Nearly 90 per cent increase in mental health access rate for minority ethnic groups presenting to secondary care, from 11.6 per cent to 22 per cent. 
• Over 1,900 patients were seen with complex needs/trauma during June 2020 and August 2021, and 15,000 virtual and telephone appointments.
• As a result of the work with the voluntary sector, £1 million will be invested into primary and community mental health services in Sheffield over the next three years.
• Whole-system working has broken down siloes and enabled a focus on sustainable workforce planning.

What the organisations faced

In Sheffield there are over 138,000 people who have a serious mental illness (psychosis, severe depression, personality disorder). Despite a set of passionate and dedicated staff who wanted to achieve the best for the city’s residents, they were facing increasing demands for services and residents with a serious mental illness who were having to wait longer to access them. It was acknowledged that for too many years there had been a fragmented mental health system, with people bouncing around the system and falling through the gaps in services. 

Sheffield Health and Social Care NHS Trust, Primary Care Sheffield, NHS Sheffield Clinical Commissioning Group, Sheffield City Council, Sheffield Mind and Rethink Mental Illness realised there was a chance to make a real difference and collaborate across organisations to provide community-based support and improved access to care and medicine management for patients with serious mental illness. They are one of 12 national early implementer sites testing and delivering the community mental health framework – a vision for whole person care delivered at place aligned through PCNs.

What the organisations did

The organisations came together, with a pooled transformation budget, to develop the primary care and mental health transformation programme.  They adopted a novel approach to mental health provision, working through PCNs and the voluntary sector to bring care closer to home.  The programme took a population-based health inequalities perspective that everyone could sign up to, which helped prioritise which PCNs to start with first.

Rather than being driven by a board or committee, a clear set of objectives and requirements were established at the outset and a small core team of executive leads, clinical leads and management were empowered and trusted to undertake the work with only minimal board oversight.   

This focus on purpose, and a set of shared values that was not defined by organisational boundaries, enabled greater flexibility to apply bespoke solutions with bespoke partners to meet the needs of the community. Initially, the collaboration focused on the four PCNs, covering 30 per cent of the city, where there was the highest deprivation. They worked within the PCNs to increase the mental health offer at the front door of GP services, offering a way into the mental health system through a more personalised and trusted approach.  Rather than being referred to an anonymous clinician in secondary care and having to be seen in a secondary care setting, the patient could access mental health services through their nominated GP and be linked up with support from within their local community. 

They took advantage of the opportunity to collaborate with the voluntary sector to employ community connectors and health coaches to tackle the integrated mental and physical health challenges for people with serious mental illness (SMI). As part of the collaboration, the secondary care provider (SHSC) placed honorary contracts with the voluntary sector organisations so they could provide the necessary IT and pay, and reduce the interoperability challenges that the third sector often encompasses when working with health organisations.

The collaborative used the apprentice scheme to fund ten places on the new clinical associate psychologist programme (graduate psychologists who are trained to master's level), increasing capacity to deliver psychological therapies. They also brought in specialist mental health pharmacists to support primary care and focus on medication reviews and deprescribing.

Results and benefits

By working together, with a system oversight, the collaborative could best exploit opportunities to look at where the workforce was needed and best placed. Working with the voluntary sector enabled them to enhance the mental health offer and employ community connectors and health coaches. Some of these charities were very specific to the local population, such as Sheffield African Caribbean Mental Health Association (SACHMA) and could reach into communities to reduce the stigma around mental health and help residents access the care that they needed.

Rather than needing to be referred into secondary care for an appointment, patients could access wraparound mental health care via their own GP. During June 2020 and August 2021, over 1,900 patients were seen with complex needs/trauma, and 15,000 virtual and telephone appointments were made.

Working with the voluntary sector, and through a population health approach within PCNs, has enabled the project to work closer with communities and tap into unmet demand. As a result, in some of the PCNs they doubled the mental health access rate for minority ethnic groups presenting to secondary care, from 11.6 per cent increasing to 22 per cent. 

As a result of the work with the voluntary sector, £1 million will be invested into primary and community mental health services in Sheffield over the next three years, through national charity Rethink Mental Illness. The charity has selected Sheffield to be one of four national sites in England to develop new models of delivering mental health care with voluntary, community and social enterprises (VCSEs).

Overcoming obstacles

Bureaucracy and funding: Although there is an expectation nationally to invest more in the voluntary sector, the systems and governance do not always facilitate this. Commissioning procurement rules made it difficult for small VCSE organisations to respond to the tenders. And as a result smaller charities who could work specifically within local communities in the early stages of the project missed out on opportunities. Working with the commissioners, the collaboration was able to refine a lighter-touch process that supported individual organisations and collaboration. There has now been a move to build a VCSE mental health alliance for Sheffield so it can help to galvanise support, with the aim of having an accountable VCSE organisation for mental health that can place funds much more seamlessly with mental health providers.

Workforce: When commencing the project to shift care from large community mental health teams covering a population of 250,000, to small PCN teams covering 30,000 to 50,000, there was a risk of destabilisation if resources were taken from one area of the system too quickly.  However, through the collaborative approach with the voluntary sector, the collaborative was able to help complement and widen the workforce, rather than deplete it

Sustainability: It was soon established that the traditional short-term view of producing 12-month contracts for the voluntary sector is counterproductive. To be able to set up roles and recruit the right people, the voluntary sector needed a more secure and sustainable approach. By creating an equal footing with other services’ contracts, the commissioners were able to provide two-year contracts, with a one-year extension. This enabled the voluntary sector to help to recruit the right people for the roles and offered a level of security.  

Takeaway tips

• Ensure a set of values, objectives and shared purpose is created that is not defined by organisational boundaries. 
• Be clear on the impact and the point of delivery for interventions to ensure maximum benefit and value is achieved for partners and, most importantly, patients, family and carers alike. 
• Ensure that each partner is an equal stakeholder. Everyone has an essential role to play, regardless of size, structure or traditional power dynamics. The creation of a level playing field has to be established from the outset as a core principle.  
• Build relationships with partners (including communities – not just organisations) formed by respect, trust, listening and investing time/energy to directly support each partner.  
• Take risks and try something new. Often we are solving long-term challenges where traditional approaches have failed to work.
• Act as an integrated unit that works across and within multiple partner organisations simultaneously.  
• Work with your local voluntary sector as they have a lot to bring to the table.

Further information

For more information on the work in this case study, please contact:

• Dr Fiona Goudie, Clinical Director Strategic Partnerships, Consultant Clinical Psychologist, Sheffield Health and Social Care FT. Email: fiona.goudie@shsc.nhs.uk
• James Sutherland, Head of Commissioning – Mental Health, Learning Disabilities, Autism & Dementia, NHS Sheffield CCG. Email: james.sutherland4@nhs.net