Access and egress from service

Our ARRS mental health practitioners are an additional workforce intended to bridge the gap between primary and secondary care. ARRS practitioners are Mersey Care employees based in GP surgeries who are funded jointly by the PCN and Mersey Care.

Their role is to work with people with moderate mental health needs. ARRS practitioners are based in GP practices, working between primary and secondary care. They work with members of the primary care team, social prescribers and voluntary, community, faith and social enterprise (VCFSE) to meet the need of service users. ARRS practitioners liaise with GPs, offer advice and guidance to patients, signpost to other services and escalate to secondary care services if required.

Our Step Forward mental health leads, lead on the non urgent assessment process for referrals into adult mental health services. They work collaboratively with primary and secondary care to provide advice and support and are proactive around prevention and early detection of mental illness. They ensure that service users can access the right intervention at the point of need. The leads champion a population based approach to care, promoting recovery focus to meet service user need while also reducing stigma.

The service works collaboratively with GPs and primary care staff to help identify those service users who require a more specialised mental health assessment, which is achieved by regular GP interface with the leads. They additionally offer advice, support, signposting, and meet service user need where appropriate within primary care.

As part of the Community Mental Health Framework, community teams will be working closer with voluntary, community, faith, social enterprise (VCFSE) organisations in each place. VCFSE organisations work with specific cohorts of people and are able to support in ways that community teams are not. It may be assisting with leaving the home, supporting to attend a local social group, or having a regular chat on the phone. By building place based networks of support for individuals, we are able to provide care in the best possible way at the most appropriate stages of a service user’s journey. This work helps to build confidence in the patient and support on their pathway towards recovery.

VCFSE framework guidance

In the Framework released in 2019, the following guidance for VCFSE was advised:

• Implementing this Framework will break down the current barriers between: (1) mental health and physical health, (2) health, social care, VCFSE organisations and local communities, and (3) primary and secondary care, to deliver integrated, personalised, place based and well coordinated care
• Strengthening relationships with local community groups and the VCFSE will support the adoption of more rights based care based on greater choice and engaging early with communities to address inequalities
• Community connectors/social prescribing link workers, however, will work closely with the whole spectrum of community services and the local VCFSE sector
• Implementing this Framework, which involves triple integration of mental health, physical health and social care, will take time, requiring careful joint working across STP/ICS geographies by providers, commissioners, local authorities, local VCFSE organisations, service users and carers, and the local community
• The Framework proposed applies the collaborative model to the delivery of community mental health care. In this case, providers include VCFSE organisations, the local authority and other providers of social care, as well as statutory primary and secondary healthcare providers
• Agreed governance structures will be required for the effective operation of all services in this Framework, including the development of systems and processes to support the integration of primary care, secondary care mental health, social care, VCFSE organisations and housing and community services
• Local partners agreeing a multi year alliance contract with inbuilt flexibility could also help to focus efforts on the quality of care and help smaller VCFSE organisations to operate on a surer, sustainable basis
• To realise the joined up approach this Framework sets out, these teams would fully integrate their working with other local services, including PCNs, employment and housing support staff, key VCFSE organisations in the area and social support services. Care will be planned and delivered across this wider partnership.

The guidance has led our strategy and decision making for our VCFSE workstream.

VCFSE year one and organisations

A percentage of the community excellence transformation funding is to be allocated to VCFSE organisations to support those with serious mental illness based in our communities. In year one, Liverpool and Sefton took an approach to funding allocations as detailed below.

Liverpool and Sefton

The team began the VCFSE work with identification of need. In year one we identified that the following needs were most prevalent across our communities in Liverpool and Sefton:

1. Loneliness and isolation
2. Early parental mental health
3. Carers.

With the largest need identified as loneliness and isolation, we worked with members of the community to help identify the local established organisations that could best support the needs in these areas. Details of our year one organisations and services are listed below.

Age Concern

Liverpool, Sefton and Kirkby

Through Combat Isolation, Age Concern intend to launch a bespoke suite of services which will be led by a newly appointed service lead. Age Concern will deliver one to one community based social interventions, supporting individuals, building personalised community support programmes designed to supplement existing care plans and delivering activity programmes/volunteer befriending services.

Age Concern Liverpool and Sefton

Mind Connect

Kirkby and South Liverpool

The service provides an easy entry point for people with mental health needs who are ready to be stepped down into primary care by providing learning based opportunities to help manage their mental health, reduce isolation and loneliness, develop their skills and live independently in the community. 

The service provides evidence based education, tailored mental health support training and experience and signposting to professional services and other third sector support when necessary.  

Referrals are captured, which evidence the demographics of beneficiaries and the support they require, to ensure the support is person centred. Following each mental health and wellbeing intervention, beneficiaries are requested to complete another survey, to collect quantitative and qualitative data following the intervention. 

Mersey Care (mindconnect.org.uk)

Imagine Independence

Liverpool and Sefton

This service aims to enhance the quality of care being provided by the CMHT to those in scope for the intervention. The cohort in scope are those with severe mental illness who have a history of lengthy admissions to psychiatric hospital but remain socially isolated from their communities. This cohort will be supported to live better, more meaningful lives in the community, with the provision of social based interventions. This intervention is aimed at people who will be considered for the ‘community rehab’ pathway as per NHSE transformation requirements. 

Imagineindependence.org.uk

Sean's Place

Sefton

This project will provide an easy entry point for people with mental health needs who are ready to be stepped down into primary care by providing learning based opportunities to help manage their mental health, reduce isolation and loneliness, develop their skills and live independently in the community. 

This project will provide evidence based education, tailored mental health support training and experience and signposting to professional services and other third sector support when necessary.  

Mens Mental Health Support Sefton | Liverpool - Sean's Place 

"This video has been created by a member of Sean's Place, Mark Jones, who wanted to thank Sean's Place for the support he has received from us. Mark brought together some of our other members and asked them to take part in sharing what Sean's Place means to them. They also shared advice to others who are thinking about accessing support and how it can help. 

The guys who bravely spoke on this video came to Sean's Place either through GP referrals, self referrals or through our partnership with Mersey Care. It also features former Liverpool FC player, Chris Kirland and Mark Henderson from another of our valued partners, the LFC Foundation.

We are so thankful to those who shared their experiences and we hope this video will inspire others to get the help that they need too." Debbie Rogers, CEO and Founder of Sean's Place. 

​Sefton Council for Voluntary Service (CVS)

Sefton

Sefton CVS assist and support VCSFE organisations as well as providing a holistic approach to care to complement existing health services within Sefton. The CVS currently offer a high intensity intervention and signposting service which prevents people identified as frequent flyers from attending acute hospital through provision of proactive and targeted social interventions in the community.

The interventions are provided by trained support workers in collaboration with the patient’s clinical care team. The staff are highly trained to support users to improve their independence and develop coping strategies to prevent further crises.   

Sefton CVS will expand this existing service to provide interventions to people on adult CMHT caseloads who we have identified (through Business Intelligence) as high users of urgent support systems such as CMHT duty and acute care. This sits within the ‘CPA to CMH-F’ transition pathway by ensuring proactive and meaningful interventions to people on a non CPA adult CMHT caseload who frequently use high cost services such as CMHT duty and acute care. 

We have created a dedicated pathway for Sefton adult CMHTs to refer people from the current CMHT caseload (non CPA) directly to the service to provide proactive and preventative social interventions.  

Sefton CVS | Supporting Local Communities

Warrington, Halton, Knowsley and St Helens

In theses places, the transformation team opted for an approach of working closely with the Voluntary and Community Action (VCA) teams. Together they identified the benefits of a role of place based care coordinators.

The four care coordinators are employed by the VCA and work connecting patients being discharged from Mersey Care inpatient and community services to be linked in with place based organisations in the VCFSE sector that can support the patient step down process.

We will be working with the above organisations across all Mersey Care boroughs for year two and three of our funding allocations.

Age Concern by Holly Mannion

Client N was referred to Combat Isolation by Jessica Duggan, CMHN with the complex care team at South Sefton Neighbourhood Centre. Client N was referred for support to address loneliness and isolation due to having reduced mobility and a range of physical and mental health challenges. The client had engaged for a long time with psychological interventions and had accessed anger management interventions.

They had experience of self harm when feeling frustrated due to health concerns and being unable to get out and engage with others, having had a long career and previously being a sociable and busy person. The client had sadly lost their partner several years ago.

Client N was allocated to our Inclusion Support Worker, Jenny, who quickly established a rapport and plan for the client’s 12 weeks of support. Client N felt they would be unlikely to feel well enough to get out of the house to access activities in the community, however, would be happy to engage in befriending with a view to being matched with a volunteer befriender after 12 weeks with Jenny. The support sessions were overall a positive experience for client N.

Jenny and the client were able to build up trust and rapport and they spent some of their sessions reviewing some of the techniques the client had learned through their anger management intervention. The client felt able to speak with Jenny about their feelings at times when they are frustrated and how they wanted to move forward with this and utilise what they had learned. Jenny and the client spent some of their sessions exploring relaxation and meditation and were able to practice this together.

Other sessions were spent talking about memories and the client was able to reminisce and share happy times they had spent with their partner, speaking with Jenny about previous holidays and groups of friends they had. The client spoke fondly of their long career and the connections they made through this, having retired at 70.

The client felt the support from us had been of benefit to them and commented that they enjoyed having the opportunity to speak to Jenny each week as this helped them to feel calm and centred. At the end of their support, the client’s scores on the short wellbeing measure improved by two points and their feelings of loneliness decreased by one point on the loneliness measure. Client N will now be matched with a volunteer befriender for ongoing companionship.

Halton VCA by Fran Stulberg

Client 1: Following a referral from Psychologist, Lucia Fernandias Arias, Brooker Centre, my client has gone from being very isolated and mentally unwell, to volunteering at his local mental health hub, Space Runcorn, working up to become Volunteer Co-ordinator and to eventually being nominated and winning ‘Volunteer of the Year’ for the Halton area. This is his account of the journey he has been on.

Client 1: For many years, I have simply been existing. With each passing day, I felt no reason to leave my bed or my flat. I had no purpose. One day, I finally decided to make the decision to get my life back and find purpose in it again. This started when I was referred to Halton and St Helens Volunteer Centre by my mental health team.

Initially, I thought the service would be purely creating an online account and applying for voluntary positions. I was so wrong. I was invited to the Centre and offered a face to face appointment to assess my needs and to explore potential volunteering roles that were tailored towards my passion and interests.

Fran Stulberg, Mental Health Care Navigator, supported and encouraged me through every step of the process. I felt valued and validated. Through talking with her, she instantly knew my strengths and where best to apply them, by tailoring her service to my needs. Over the course of a few weeks, Fran was in constant contact with me to provide support and to discuss potential voluntary positions. She even offered to meet up with me at a proposed venue, Space Runcorn, which I happily accepted, that eventually led to me volunteering there. 

During my time at Space Runcorn, I was offered the position of Volunteer Co-ordinator which I accepted, this by far exceeded my expectations of myself. I have never felt so stable, content and happy as I now have purpose in my life. Space Runcorn is a community mental wellbeing hub, who prioritise by providing support, workshops and affordable therapy.  

Without the help of Fran and the service, I believe I would still be lying in that bed with no purpose and no reason to leave my flat. Now, I look forward to my life and what it has to offer and what I have to offer to other people. I continue my journey towards a happy and purposeful life, through volunteering, but this would have not been possible without the generous amount of support from Fran, her colleagues and Halton and St Helens Volunteer Centre.

Client 2: I received a referral from Sarah Hunt, Recovery Team, Brooker Centre. The patient/my client is predominantly deaf; throughout the support journey we have been on I feel her quality of life has improved and her mental health has become more positive because of several teams of support working together. These include: mental health clinical staff within the Recovery Team, social services, Mental Health Care Navigator and the Deafness Resource Centre, Halton. This is a detailed account of the journey we have been on to achieve the successful outcome.

Client 2: I would like to share with you the progress of one of my referred clients as a way of demonstrating the success of the Mental Health Care Navigator role, the benefit of Halton and St Helens VCA and the importance of working as a team with other public sectors in the community.

I am currently supporting a predominantly deaf client, referred to me by the Brooker Centre Recovery Team. In addition to her mental health conditions, my client is also very isolated and lonely, as you can imagine due to her communication barrier. I have been accompanying her to an art group, Weaver Arts, based at the Grangeway Community Centre, Runcorn. She truly enjoys herself whilst she is there by just being part of a group.

When I introduced her to the art group, which consists of current and former Brooker Centre patients, I asked them would they help support me in supporting my client. I printed off left and right hand sign language alphabets and distributed them to the group and asked if they would like to take them home and try to learn basic words. I had a hidden agenda. By asking them to help me support her, it gave them pride in being involved. The group now greet her in BSL and throughout the session attempt to sign and are corrected and taught by my client the correct signing. 

During the process of supporting my client, I established that the mental health clinical team at the Brooker Centre was unable to get access to her flat, her intercom system for her seventh floor flat was not appropriate as if someone presses the external buzzer she has to use a phone intercom - she is deaf! I contacted Halton Sensory Services, Deafness Resource Centre to inspect and install a working buzzer, a specialist alarm clock and a smoke alert alarm that is specifically designed for people who are deaf. I also arranged for Cheshire Fire Safety Team to visit the flat and install any safety equipment needed. 

I was still concerned that my client has had no contact with the deaf community for over 10 years, so I again contacted the Deafness Resource Centre and the manager of Grangeway Community Centre to meet me to look at the possibility of a Predominantly Deaf Peer/Social Group as I had identified the gap in services within the Halton area. I am delighted to tell you that by working as a team with the other agencies, the first Predominantly Deaf Peer/Social Group was launched on 22 October, held in the Grangeway Community Centre.

We have four to six deaf people in the Halton community that will be attending, which may seem small but give it time I am confident numbers will grow. I arranged an informal launch to open the club on the day - a great opportunity for those involved to represent their organisations and showcase the importance of working as a team which includes Halton and St Helens VCA, Mersey Care, Deafness Resource Centre and Halton Borough Council.

Throughout the above journey my client had also disclosed a safeguarding incident. I shared this with the Duty Team in the Brooker Centre who logged it as a safeguarding incident. I worked with several agencies including: Brooker Centre, police, HBC, social services and Deaf Resource Centre. As you can imagine this sudden input of people and authorities caused my client to become very stressed and anxious, keeping her mentally well was my priority.

As part of my vigilance to keep her mentally and physically well I felt her current accommodation was inappropriate based on her disability, social isolation and safety. I requested my client be uploaded onto Property Pool and given a priority status. I’m working towards her being accepted for a bungalow or ground floor accommodation. This involved working as a team with the clinical staff and HBC.

I have arranged for a personal assistant (PA) who can also BSL sign and is in the process of being finalised through Direct Payment. At present the journey to provide a safe, healthy and wellbeing outcome for my client continues, but I am confident of a positive outcome for her.

Imagine Independence by Carmel Garrigos

Referral received from Claire Holder, Arundel CMHT, Community Hub, Baird House.

Reason for referral - BC would like to become more socially included, he is isolated, lives with sisters, used to have a support worker who would take him swimming etc. BC gets very anxious around new people. Would like to have some meaningful activity in his life.

Staff member John Gardner met BC in June 2024. BC has Leukaemia as well as mental health issues. He is 47 years old. Due to Leukaemia, he must take a lot of medication that can often leave him feeling exhausted and can affect his cognitive abilities, leaving him confused with short term memory issues. There is no cure for BC’s condition, and it is about managing it for the time BC has left.

BC is originally from Bangladesh; he lives with his two sisters and nephew in Toxteth Liverpool. They are a close and supportive family and BC feels well cared for.

Initially when JG met BC, he just wanted to go out for a coffee locally as he was in the house all the time with his sisters. He welcomed male company and to talk about cricket and philosophy. BC had a career as a chef before his diagnoses and enjoyed sharing his knowledge of spices and food. BC shared his life story with JG, telling him about his idyllic childhood in the mountains of Bangladesh on his parents’ farm. His parents were very liberal and insisted on a full education for him and all his siblings.

Through becoming close and building trust they discussed the possibility of BC engaging in education again and explained about the Adult Learning Service (ALS) in Liverpool. BC didn’t feel this would be possible due to his conditions. They approached the ALS and discussed BC’s issues with them and that although he would like to study, there may be times when he will miss classes due to illness or medical appointments. The ALS was very helpful and would adjust for BC’s conditions so he could attend.

BC decided that he would like to improve his English, and he had always wanted to learn about computers. Together BC and staff applied for BC to do ESOL English and Basic IT skills with ALS and attended the induction together due to BC being anxious.

During this process they also applied for a disability rail card as BC must travel for specialist treatment. BC started his courses in September and is really enjoying them. BC said, “He feels part of his community and more productive as a person.” He is enjoying the process of learning once again and battles with his conditions to continue with his education.

JG and BC still meet regularly for a coffee and man chat. BC feels this really aids his wellness and JG said it is a privilege to know him and work with him.

Mind Connect by Cathy McSorley

Referrer: Artemis Counihan, Moss House CMHT.

Patient referred with PTSD, trauma, support with any reading/writing. Thinks having some support in relation to his mental health would be beneficial.

Received one to one wellbeing support, both face to face and by phone.

IA has been struggling to find the right place to support him – he wants someone to listen and help him find other places within the community for several issues e.g. housing support, help with physical conditions, legal support. We have helped him talk through the outcomes he would like, researched a few places which could help and supported him to write emails and contact other organisations. We think this has made a positive difference to his mental health as it’s empowering him to act whilst also setting time aside to look after his own wellbeing.

IA feedback: I’m very optimistic about your help. I forgot to say thank you for all your help.

Sean’s Place by Debbie Rogers

N was referred by Stephen Mullen, South Sefton CMHT. He has attended Sean’s Place for a few months and was referred due to struggling with grief and social isolation. N was incredibly shy when he first joined us and would hardly talk. He showed interest in joining one of our bands on a Friday evening, but we were unsure how much he would enjoy it due to being incredibly quiet. N has since made friends with members of the band and has really come out of his shell, jamming with the rest of the group each week and starting to find the joy in music again.

He recently completed our bereavement group on Monday evenings where he opened up about the loss of a loved one and how this affected him and his mental health. This was a huge moment as he had not spoken about this with us, but he felt comfortable enough to let us in to his struggles and understand how he feels about them.

Since then, he has become chattier with staff and has continued to engage well even enquiring about attending the service and our activities a little more. This is a huge step for him and we are delighted to see his confidence grow since joining us.

Sefton CVS by Gina Harvey

We are supporting a client and over the last month we have seen a reduction in the number of times this patient has contacted crisis and emergency services. This person is well known but over the past four weeks has not had any involvement with A&E or the urgent care service. The patient seems happier in herself and has made positive steps to reduce her alcohol consumption.

Our team, adult social care, police and Bootle CMHT have met and been able to monitor her and collectively formulate a plan of action. We have been asked to support with appointments and it was noted that the patient has responded more positively with input from the REDI service.

St Helens VCA by Rebecca Taylor

Patient W was referred to the Care Navigator Service from the Recovery Team at Harry Blackman House, to help with loneliness and isolation. Patient W wanted to learn to swim, therefore I found an adult swim clinic at the local leisure centre. I have now attended this twice with patient W. It has really helped her having someone to get in the water with her and give her that extra bit of confidence.

During the first session, patient W was understandably nervous and needed lots of support and encouragement. She was able to float well on her back, however found it difficult to get back to standing in the water. With guidance from the swimming instructor, we were able to practice techniques which really helped.

During the second session, patient W started to incorporate leg movements whilst floating on her back and started to propel herself in the water, she has made excellent progress in just two sessions. I will be attending the swim clinic with Patient W at least up until Christmas, by this time it is hoped that she will have enough confidence to attend the session independently. Patient W is now keen to join the leisure centre and access exercise classes alongside learning to swim, which is positive.

Patient L was referred to the Care Navigator Service from the Recovery Team at Harry Blackman House. Patient L was very isolated and found it difficult to go out alone. She wanted to try a craft group at the local library. I have been attending with her for a few weeks, she is very talented at craft and produces fantastic work. Although she is very quiet when in the group, slowly she has been talking more to other people in the group which shows that she is growing in confidence.

Alongside the craft group I have also been attending a wellbeing walk with her as she wants to try to get fitter. This has been positive as she is able to walk further than she thought. Patient L is seeing places near where she lives that she didn’t even know were there, such as a lake where you can feed ducks. She said she will take her husband and daughter there to see it.

Patient L mentioned that she has joined Slimming World and has lost a stone in weight. This shows that she is feeling more positive and motivated to make changes. Patient L has started to talk more when we are out, the conversation is flowing better and although progress is slow, it is having a very positive impact.