The Community Framework makes clear that one of its purposes is to enable services to shift away from an inequitable, rigid and arbitrary Care Programme Approach (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.

This is explained in our animation.

To move away from CPA to Community Mental Health Framework (CMHF), a phased approach was introduced in April 2024. New service users entering secondary services will no longer be under rigid CPA but will enter the CMHF recommendations of personalised care based on need. During the next 12 months, more service users will enter this new individualised care based approach. Following this, all community mental health teams will be under the new CMHF.

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: Andrew.williams@merseycare.nhs.uk

Question

Answer

What paperwork will the key worker complete?

The key worker will ensure that PROMs (ReQOL-10, DIALOG and GBO) are completed, alongside a comprehensive biopsychosocial assessment, risk assessment/formulation, care plan and safety plan.

They will also ensure carers demographics are correct and up to date and reasonable adjustments are reviewed.

Documentation section of the SOP is to be circulated w/c 3 Feb for comments.  

What is the expectation for how often GBOs are reviewed?

GBOs are expected to be reviewed every three months, where possible and appropriate. However, if there are cases where a service user is only reviewed yearly i.e. Lithium pathway, GBOs would likely only be reviewed yearly.   

Will medics be asked to create a new GBO/care plan?

No. It has been agreed with Dr Martinez that medics will use the statement of care as the template for their session/clinical letter. However, medics will review any GBOs within their session and describe these in the statement of care.

How will we allocate non-CPA caseload?

This is open to suggestions (tests for change) by teams.

Some teams may have smaller caseloads and adopt an approach where nurses increase their caseloads. For other areas, this won’t be possible, and they’ll adopt an approach where the keyworker is spread across those with a professional registration. Some teams have suggested they’ll test, separating the non-CPA caseload into pathways i.e. Lithium/Clozaril and allocating a keyworker aligned to this pathway.

How will we change key worker?

 

There will need to be a verbal transfer of key worker within teams to ensure that all practitioners are aware of the plan and are working towards the same goals.

New Q&As added from January 2025

Are there concerns that requiring patients to complete DIALOG and ReQoL forms at the initial appointment may act as a barrier?

There will be examples where completing PROMs in the early sessions is not appropriate i.e. where a service user is in crisis or experiencing acute psychosis. In these situations, required interventions should be accelerated and PROMs can be utilised, when appropriate.

GBO should be collaborative, where possible, but can be completed on behalf of the service user in situations as above.  

What procedures are in place to ensure patients complete DIALOG and ReQoL forms during follow up appointments?

These are to be devised locally and will vary dependent upon the person completing the intervention/review.

Why is Rio still referring to CPA instead of key worker in updated correspondence?

CPA will remain an option in RiO as some divisions will continue to use CPA. Key worker/lead professional is an option in RiO and under CPA status, CMHF should be selected.

What happens if no key worker is recorded on a patient’s record?

This will be flagged within a performance report as a safety measure, which will prompt review of the case.

How can we ensure that patients’ voices are heard more holistically rather than just following a process?

The assessment and formulation process should be collaborative, helping the service user to make sense of their symptoms and agree shared goals for their treatment plan. Service user feedback will be collected regularly by each team, over the next six months, to help us understand the impact and effectiveness of the changes.  

How can we make the experience for new patients more welcoming, rather than overwhelming them with forms?

As above and open to ideas!

Can the term “Recovery Team” be removed, and what terminology should replace it?

Yes, Ed is working on standardising one team name and this is progressing.

What level of input is needed from medics in this process?

Medics will be instrumental in the move away from CPA and each place will consider who they may be key worker for, dependent on local workforce, skill mix, caseloads sizes etc. Analysis of caseloads should be completed to review the treatment plan for all service users and who is the most appropriate person to be key worker.

Will the use of HCP diaries be simplified and how will associated risks be managed?

There are no planned changes to HCP diaries, what are the risks?

What will trigger medical reviews under the new approach?

Medic reviews will be agreed by the MDT and can be instigated for a variety of reasons, not least to prescribe and monitor medication as per NICE guidance.

Are care plans structured as Goal Based Outcomes?

Yes. The idea was for the GBO to pull through to the care plan but this was not possible. Our next option is to try to develop the care plan language in such a way that it could identify and measure progress against goals, so staff aren’t asked to duplicate.   

How do the different operational models in Liverpool, Sefton and Mid Mersey (with its dementia service) align?

There are significant differences in older persons models across CMH. An older person’s paper was drafted and presented to OMG, with a proposed model but is being updated before resubmission.

How do we address service user fears about losing support?

The move away from CPA and utilisation of GBOs should ensure that the treatment plan is collaborative.

How do we balance the need for service provision with concerns that some individuals may remain in service primarily for PIP benefits?

The MDT will decide if the agreed treatment plan requires continued intervention by the CMHT or if step down can be achieved successfully.

How can we manage capacity effectively when responding to urgent matters takes priority?

Capacity and demand will be mapped and planned for by each team. Functions in teams i.e. ‘duty’ should have enough capacity to manage predicted demand, with contingency plans, should demand exceed.

Person centred care approach: Is there future planning to include neurodiversity and ways to develop that area? This is a particular issue with Step Forward and definite training is required.

ASC quality improvement will not be a focus of the move away from CPA but ASC task and finish groups will continue to consider the ASC challenges and opportunities for improvement.

Paperwork: Why doesn’t the BPS paperwork flow smoothly and why is it set up in a disjointed manner?

The BPS was drafted and shared many times during its development. We can organise a review of the document, where any improvements can be suggested.

 

Assessment tools: Why are old tools still being used for copying and pasting into assessments? How can we ensure that Statement and Core maintain their natural flow when meeting patients?

The BPS should be a holistic assessment, with a curious and open approach adopted by the assessing practitioner. It should not be robotic or rigid. If practitioners are finding this, they should role play until they have become comfortable in gathering the information in a conversational style.

 

New assessment practitioner: How does this role fit within the CMH Framework, and why is it different in Mid and North Mersey?

Updated guidance around the referrals pathway will be shared w/c 3 Feb for comments.

Low intensity: Will a key worker be allocated to patients who are open to low intensity only, given that this sits between primary and secondary care?

Yes, a key worker will need to be allocated. However, this is an important question that will be shared with Claire, who is reviewing the current psychological offer/model. One of the main challenges is capacity.

Will Clozaril nurses be required to take on key worker roles?

A meeting is planned to discuss this but there should not be a ‘one size fits all’ approach, as recommended by the CMHF. For some patients, the Clozaril nurse may be the best person to key work but for others, this may not be appropriate. There needs to be a clear process where Clozaril nurses and the wider recovery team regularly communicate goals, progress, challenges, and risks.

Do we need to assess the goals of everyone currently waiting on the RESP pathway?

Yes, for all patients on a waiting list, the respective team (RESP or Psychology) should provide an initial session to review goals, treatment plans and risks. However, a key challenge remains capacity. Additionally, with line management changes, maintaining communication and close working within the team may become more difficult.

Can we clarify whether the key worker role will include medics and psychologists, or if it is strictly for registered staff as advised in a previous meeting?

Key workers in this phase can be anybody with a professional registration i.e. nurse, OT, medic or psychologist

Given current caseload numbers, how will RTT targets be met with existing capacity?

Although RTT and move away from CPA overlap, RTT performance, including capacity and demand and challenges is reviewed each month in the waits meeting.

While the new service model is beneficial for new service users, how will it accommodate clients on Clozapine and depot medication who require longer term care?

It’s important a ‘one size fits all’ approach is not adopted for all service users under one function/intervention. For example, there may be service users open to Clozaril who do not wish to engage in a wider treatment plan and who will only see the Clozaril nurse, alongside a yearly scheduled review.

Alternatively, there may be service users open to Clozaril who have complex needs and are engaging in multiple interventions, with the key worker assigned to another practitioner within the CMHT.

How will the increase in demand from GPs be managed, particularly in areas without PCNs, for RTT and routine assessments?

As above regarding RTT and waits.

What are we moving towards? Even with a scoring system, some people still decline.

There is an opportunity to ask the person in service what they want, leading to intervention based approaches. For well known service users, we can direct them toward their needs. It is important to highlight small changes in progress and find a better way to engage those declining support, such as offering an appointment.

How can PROMS be used effectively?

PROMS is great for new referrals who may struggle to articulate their needs. It is also useful for engaging carers.

How do we ensure care plans are routinely reviewed?

It is the responsibility of the key worker to ensure the care plan/GBOs are being regularly updated by the practitioner’s delivering interventions, if not them. As a minimum, the care plan should be reviewed once a year.

How can we improve care planning between different teams?

CMH are working with inpatient and urgent care to develop one care plan, using the most up to date national guidance.

Should we remove the care plan audit?

There will be measures built into the CMHF dashboard and AMAT to review patient experience and outcomes.

Why are some staff unable to access MAST?

MAST is being rolled out. If your team has access but an individual practitioner does not, please escalate.

Why isn’t the clock stopping when patients DNA?

This is a national directive.

How do we understand why some patients disengage?

Team should be analysing their local data to understand case specifics and also themes.

How do we ensure informed discharge decisions?

It is legitimate to document decisions. GP contact can be part of this process and Jason will follow up on DNAs to try to engage patients. The system should allow us to interrogate data effectively to make informed discharge decisions.

Can Rio be linked to incident reporting with a tick box to ‘Add to care plan’?

This would be a useful function to ensure key information is recorded efficiently. We can discuss with Rio.

How can a Band 3 be a key worker when there are Band 6 staff?

Key workers must hold a professional registration during this phase.

At what point should patients be moved to VCSFE?

Engagement with VCSFE/Care Navigators will begin early in the service users CMHT journey, considering how the wider system can help to meet their needs.