What's on offer?

One of the ways partners are working together is through the creation of enhanced multi-disciplinary teams, or EMDTs. There are 15 EMDTs across Lancashire and South Cumbria. These teams truly put this new way of working ‘as one’ into action.

They bring together different professionals within localities to discuss and plan a person’s care in a way which is personal to them and tailored to their specific needs. The person receiving care is at the heart of the discussions and care planning and is encouraged and supported not only to be involved, but to lead those discussions.

The teams can support people to tackle day to day problems and advise them about looking after their health and wellbeing, as well as how best to cope with stress and anxiety. Alongside the individual, the teams can develop a personalised plan of care which will address a range of needs.

The teams may vary slightly from place to place and will also change to reflect the specific needs of the person. However, generally speaking, this is how they are made up:

It should be noted that EMDTs are not the only way professionals can support people in this new way of working, but the ambition is this approach will happen on a daily basis as the new way of working becomes embedded.

Which areas do the EMDTs cover?

How do people access an EMDT?

If a mental health practitioner believes an adult with complex mental health needs would benefit from the help and support of an EMDT, they would request assistance from the relevant team. People cannot contact these teams directly.

Not everyone will be suitable for this support, those who are, will meet the following criteria:

• They will have complex mental health needs and require support and interventions from more than one organisation or professional.
• Their current care plan does not reflect their needs and wider support is required.

Primary care mental health practitioners (MHPs) have been introduced in several primary care networks (PCNs) across Lancashire and South Cumbria. A primary care network is a group of GP practices working closely together to provide services to its local population.

These mental health practitioners work alongside trainee and associate psychologists who will deliver primary care interventions for the people who need it. The MHP roles are funded through a partnership arrangement between Lancashire and South Cumbria NHS Foundation Trust, as the employer, and the PCNs.

Mental health practitioners support people with complex mental health needs to live well in their communities. They provide assessments, short term interventions and ongoing referrals for people who don’t meet the criteria for secondary care. They provide GPs and other primary care staff with timely support on the best ways to help people with complex mental health needs. Their role is about improving the management of mental health conditions in primary care.

The NHS Mental Health Implementation Plan 2019/20 – 2023/24 highlights the significance of community. This might be a geographical location, or it might be a group in which people find or place themselves. The plan also highlights that social determinants, the availability of services, assets and other resources can have a direct effect on the level of mental health problems in a community. 

A key aspect of really good mental health care is making sure communities can maximise the support they provide to people who need it. It is about addressing need through an asset-based approach – this means using the skills, knowledge and connections which already exist in local communities. 

The new way of working places community at the heart of mental health care. A partnership has been formed with multiple voluntary organisations to provide peer support workers to work alongside staff in our community mental health teams. Peer support workers encourage and support people with mental health needs to engage with services and VCFSE organisations who offer a range of activities and social connectivity.

Peer support workers service

From 1 December 2024, the peer support worker service will be provided by several local charities and community organisations, led by The Calico Group, across Lancashire and South Cumbria. The other organisations include Acorn Recovery Projects, Red Rose Recovery, An Inclusive Future CIC, and Lancashire Mind.

The service will include a combination of paid peer support workers and lived experience volunteers. These will be supported by senior paid peer support workers to ensure appropriate supervision and support. The service will include a training and development programme to enable volunteers to progress into paid peer support roles where appropriate.

What people will get out of the service:

• Connect to their communities and feel less lonely and socially isolated.
• Have choice, control, and feel empowered.
• Report and optimise physical and emotional wellbeing.
• Live safely and independently and optimise recovery.
• Be in stable accommodation and managing their life.
• Achieve economic wellbeing – ensuring people’s income is maximised, debts are managed and where appropriate applicable welfare benefits are accessed.
• Feel satisfied with service delivery and service outcomes.
• Be involved in service design, service offer and availability.
• Access a wide range of opportunities to support their personal recovery which include (but are not exclusively limited to): lifelong learning, employment, volunteering, social and leisure, healthy living support, including local opportunities to get fitter and make better lifestyle choices regarding food, smoking, alcohol.
• Stay in or enter employment.
• Be supported to be independent and manage their long-term conditions.
• Have increased social skills.
• Be appropriately supported to manage their recovery.

A key component of the transformation is to enable high-quality, personalised care and support planning. To make sure this happens people are assigned a named mental health worker, known as a key worker. The key worker provides a single key point of contact for a person throughout their care. They make sure the person has a care plan which is tailored to their current needs and has been produced with them, not for them. The key worker takes the lead on a person’s care, but this can change over time if the person’s care needs change. The key worker will always be someone who can offer the most appropriate support.

The introduction of key workers means we are moving away from the care programme approach (CPA). This approach was originally introduced to provide shape and coherence to the approaches taken by local services to supporting people with severe mental illness in the community, based on care co-ordination, care planning and case management. It has had a central role in secondary care mental health services and the principles underlying CPA are sound.

However, the care programme approach has not been updated for almost 15 years and policies and practice have changed a lot in this time. In recent years concerns have been raised nationally that the CPA, with a single person coordinating care, represented a major barrier to providing higher quality, more flexible and personalised care. The move away from the CPA to key workers aims to give people with complex mental health needs a more flexible, responsive, and personalised service, coordinated by a key worker who is best placed to support.

People living with severe mental illness, often referred to as SMI, face one of the greatest health equality gaps in England.

Their life expectancy is 15–20 years shorter than that for the general population, and this disparity is largely due to preventable physical illnesses.

People living with SMI have:

• 6.6 times increased risk of respiratory disease
• 6.5 times increased risk of liver disease
• 4.1 times increased risk of cardiovascular disease
• 2.3 times increased risk of cancer
• are 3 times more likely to lose their natural teeth

As part of the NHS Long Term Plan, the NHS committed to delivering a full annual health check and follow up interventions for people with severe mental illness.

These physical health checks can be done by primary or secondary care, or by voluntary, community, faith and social enterprise (VCFSE) partners.

NICE guidance recommends primary care should keep an up-to-date register of people living with bipolar disorder, schizophrenia and other psychoses – this is referred to as an SMI register.

The service

The aim of the outreach service in Lancashire and South Cumbria – which goes live on 1 December – is to work closely with primary care networks (PCNs) and general practices to identify people aged 18 and over on SMI registers who have not had a health check in the last three years.

The Calico Group is the lead provider of this service Blackpool, Blackburn with Darwen, Lancashire East, Lancashire Central, and Lancashire North. The other organisations providing this service include Acorn Recovery Projects, Red Rose Recovery, An Inclusive Future CIC, and Lancashire Mind. Spring North provides this service in South Cumbria.

Once these people have been identified, the providers will contact them to encourage them to take up their health check. Registered people who have not had a check for three or more years will be prioritised.

The Calico Group will work with the PCNs to understand the work already undertaken and develop a local plan for delivering health checks to these people.

A summary of the service:

• To work with individuals who have not had a health check in the last 3 years and those who have been difficult to reach (individuals and groups).
• Promote the need for the health check with identified individuals and groups.
• Work with the provider of the health checks and the patient to get the check delivered.
• Work with the patient to develop a personalised health plan. This plan will be an integrated care plan, including health, social care and other support needs. It will reflect what is important to the individual, what they want to achieve and reflect their priorities. It will have been developed through a shared decision-making approach and be “owned” by the individual.
• Support the individual in achieving their health plan.
• Ensure registers are updated in conjunction with practices.