The Access and Egress from service workstream focuses on the points where primary and secondary care services connect and the services that work within this space, such as Step Forward. The efficiency of the interface is vital to creating smooth transitions between services, easy and accessible step up and down to secondary care and processes that enable us to meet service user need at the earliest opportunity in order to support in the most appropriate way.

This part of the transformation programme involves improving how our patient’s access services. Relationships with place based primary care networks (PCNs), GPs, local authority (LA), integrated care board (ICB) and voluntary, community, faith and social enterprise (VCFSE) organisations are key for this workstream, helping us to build place based support systems for our communities to access. The ARRs practitioners and step forward mental health leads work locally in this space building relationships and understanding place based need in order to deliver the most effective patient journey possible for our service users.

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

Evolving Mindset

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. 

Evolving Mindset 

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.

Sean’s Place


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 

Sefton Council for Voluntary Service (CVS)


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.