The Community Framework makes clear that one of its purposes is to enable services to shift away from an inequitable, rigid and arbitrary CPA classification and bring up the standard of care towards a minimum universal standard of high quality care for everyone in need of community mental health care. A flexible, responsive and personalised approach following a high quality and comprehensive assessment means that the level of planning and coordination of care can be tailored and amended, depending on:

  • the complexity of an individual’s needs and circumstances at any given time
  • what matters to them and the choices they make
  • the views of carers and family members
  • professional judgment.

The new approach is based on the following five broad principles, some of which are further outlined below:

  1. A shift from generic care coordination to meaningful intervention based care and delivery of high quality, safe and meaningful care which helps people to recover and stay well, with documentation and processes that are proportionate and enable the delivery of high quality care.
  2. A named key worker for all service users with a clearer multidisciplinary team (MDT) approach to both assess and meet the needs of service users, to reduce the reliance on care coordinators and to increase resilience in systems of care, allowing all staff to make the best use of their skills and qualifications, and drawing on new roles including lived experience roles.
  3. High quality coproduced, holistic, personalised care and support planning for people with severe mental health problems living in the community: a live and dynamic process facilitated by the use of digital shared care records and integration with other relevant care planning processes (for example, Section 117 Mental Health Act); with service users actively coproducing brief and relevant care plans with staff, and with active input from non NHS partners where appropriate, including social care (to ensure Care Act compliance), housing, public health and the voluntary, community and social enterprise (VCFSE) sector.
  4. Better support for and involvement of carers as a means to provide safer and more effective care. This includes improved communication, services proactively seeking carers’ and family members’ contributions to care and support planning, and organisational and system commitments to supporting carers in line with national best practice.
  5. A much more accessible, responsive, and flexible system in which approaches are tailored to the health, care and life needs, and circumstances of an individual, their carer(s) and family members, services’ abilities and approaches to engaging an individual, and the complexity and severity of the individual’s condition(s), which may fluctuate over time.

Also part of the transformation focusses on improving the physical health of service users and carers who have severe and enduring mental health issues with an emphasis on eating disorders, addiction and homelessness. More detail is included in the following sections.

The role of the key worker as organisations move from care programme approach to community mental health framework was the discussion topic at a well attended regional event with staff, service user and carer reps, hosted by our community mental health services.

See the presentations from the event in the attached document.

If you’d like further information, contact Deputy Divisional Director, Community Mental Health Services: