Intervention based care

The adult eating disorder service has two teams, one covering Liverpool and the other Knowsley and St Helens.

Liverpool and Sefton

We’re a psychological therapy service and have recently enhanced provision to include a multidisciplinary team comprising: clinical psychologists, psychotherapists, cognitive behavioural therapists, associate psychological practitioners, assistant psychologists, peer support workers, specialist dieticians and a mental health nurse.

Knowsley and St Helens

We’re a multidisciplinary team including: clinical psychologists, assistant psychologists, (trainee) mental health wellbeing practitioners, an occupational therapist, a specialist dietitian, a trainee cognitive behaviour therapist/mental health nurse and a consultant psychiatrist.

What we offer

The service is a psychological therapy service for adults (16+ in Liverpool, 18+ in Knowsley and St Helens). We offer a range of high intensity and low level psychological interventions for clients referred by their GP or other mental health services (in agreement with GPs and with relevant medical monitoring).

Once a referral has been received, clients are assessed within four weeks (Liverpool) to seven weeks (Knowsley and St Helens).

The range of interventions offered are compliant with NICE guidance. Therapies offered include:

• Cognitive Behavioural Therapy (CBT)
• MANTRA
• Cognitive Behavioural Therapy - Enhanced (CBT-E)
• Ten session Cognitive Behavioural Therapy (CBT-T)
• Cognitive Analytic Therapy (CAT) (Liverpool only)
• Dialectical Behavioural Therapy for Binge Eating (DBT)
• Compassion Focussed Therapy (CFT)
• Guided self help
• Eye Movement Desensitization and Reprocessing (EMDR)
• Integrative approaches.

The service routinely offers group based interventions in the first instance and individual sessions as required, based on stepped care and formulation driven care principles. Sessions are offered on a face to face or remote basis (via Attend Anywhere).

Within the Liverpool and Sefton service, clients are offered a range of workshops, psychoeducation group and SHaRON (online peer support) as well as wellbeing calls whilst they’re on the waiting list for therapy.

We offer a monthly Friends and Family support group. Once clients are engaged in therapy this can be accessed by people who provide them support. It’s currently available in Liverpool and Sefton, with plans to expand to St Helens and Knowsley.

Both services can also offer consultation to other professionals and act as gatekeepers to eating disorder inpatient treatment across localities. We provide assessment and referrals to Oaktrees eating disorder inpatient ward at Clatterbridge Hospital.

FREED

The First Episode Rapid Early Intervention for Eating Disorders (FREED) pathway is available for clients aged 16 to 25 (Liverpool) and 18 to 25 (Knowsley and St Helens). This pathway is for people who are experiencing a first episode of their eating disorder (within the first three years).

Within this pathway there’s a strong focus on the FREED principles of engagement, family involvement in care, supporting transitions and tailoring interventions to the specific needs of young people.  

Service transformation plans

We’re moving toward standardisation across Liverpool and Sefton and St Helens and Knowsley services. This includes standardising intervention offers using stepped care model, the launch of new referral forms and standardising the use of outcome measures across both services. We’re working in partnership to establish a range of pathways which will ensure standardised operating procedures, where relevant. 

Medical monitoring is currently provided by clients’ GPs across both services. However, for Liverpool and Sefton, the transformation plan includes a medical monitoring pathway for high risk clients. Once launched, the service will provide medical monitoring for clients in accordance with Medical emergencies in eating disorders (MEED) guidance.

Contact

0151 351 8600 Eating Disorder Service (St Helens and Knowsley)

0151 471 7751 Eating Disorder Service (Liverpool and Sefton)

Addictions offer a fully integrated addiction service addressing all addiction needs to the population of Liverpool. All interventions follow a comprehensive clinical assessment and are delivered as an integrated recovery focused approach. This is achieved by:

• Co produced recovery plans identifying assets and addressing individual need in key outcome assessment domains
• Offering psychosocial interventions according to need to address drug use including club drugs, over the counter medications, stimulants, cannabis, performance and image enhancing drugs (PIEDs) and novel psychoactive substances (NPS)
• Working with our partners delivering structured and meaningful psychosocial interventions and various skills based recovery programmes, some of which can lead to qualifications
• Ensuring health protection is embedded into all aspects of service delivery within addiction services.

In February 2019, Professor Dame Carol Black was appointed to undertake an independent review of drugs. Following the release of the report, £148 million new investment to cut crime and protect people from the devastation of illegal drugs was announced by Government.

Dame Black provided detailed analysis of the challenges posed by drug supply and demand, including ways in which drugs fuel serious violence, impact on a person’s mental health, and the support from addiction and mental health services. The second part of her review focused on treatment, recovery and prevention. The overarching aim of the transformation work is to ensure vulnerable people who use substances get appropriate support to recover and fulfil their lives in a number of settings, leading to people remaining in recovery, reduced crime rates associated with substance use and receiving appropriate support for their mental health. A key part of this work is reviewing the dual diagnosis pathway between services ensuring timely, effective treatment. This approach will integrate two model pathways to allow for one model of dual recovery for people with co occurring disorders as a step in moving practice toward the recovery orientation being called for in both fields.

• View the independant review of drugs summary

As part of the transformation process, we are reviewing the functions of a CMHT. We have secondary care teams in our communities that offer similar support to service users but are called different names. In Liverpool and Sefton they are called CMHTs and in Warrington, Halton, St Helens and Knowsley they are called Recovery teams.

We began process mapping sessions to understand the service user journey for both teams from point of referral to discharge. We are reviewing all interventions and processes for a service user and ensuring we are delivering these in the most efficient way alongside patient safety and experience. The transformation is working towards a more fluid journey, offering ease of access and patients will be stepped up and stepped down based on their need. We have representation from all community teams to utilise their expertise to collaboratively model a service that delivers the best possible care for service users.

The NHS Long Term Plan (2019) identifies that people with severe mental illness often have reduced life expectancy due to avoidable physical health conditions. It is well documented that people with severe mental illness on average have 15 to 20 years shorter life expectancy than the general population with two out of three deaths due to physical illness that can be prevented. They often develop chronic physical health conditions at a younger age than people without serious mental illness. These chronic conditions include obesity, asthma, diabetes, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), stroke, heart failure and liver disease.

A more recent Government report published in April 2022 highlighted Liverpool City Region as one of four local authorities with higher rates of deprivation and higher rates of premature deaths for people with a serious mental illness. 

Community physical health team services’ aim to deliver physical health assessments for people and through active engagement both at primary and secondary care level, aim to increase accessibility to these physical health assessments and any interventions that may be recommended as a result. The ability to influence and improve health outcomes through the identification of undiagnosed health conditions is key to improving the physical health of this population. 

Community physical health services are delivered differently across the Mental Health Care Division and engagement with the Community Excellence Transformation Workstream will be focused on the following aims, to ensure that services are standardised, meet the needs of the populations they serve and are data driven to provide the most effective physical health outcomes.

Aims of the physical health workstream:

• To identify national guidance related to health inequalities experienced by people with severe mental illness 
• To review current workforce model of physical health services and propose standardised model of physical health services across community services
• To review current roles and function (including review of SoPs) of physical health teams across community services identifying differences and similarities in practice
• To review training and competency requirements of staff within physical health teams
• To review and standardise use of physical health equipment across the division - to develop standardised operating procedure, ensuring consistent approach
• To align physical health KPI measures across community services and work towards a standardised approach to reporting
• To develop a standardised physical health dashboard within BiT for performance measures (PROMS) across secondary and primary care
• To identify funding arrangements at Place with associated SLA/contracts
• To review digital offer across physical health teams and promote standardised approach to piloting of new initiatives, that is, point of care testing kit
• To work alongside the EBE Service User and Carer Workstream
• To co produce with primary care interface workstream in relation to physical health offer
• Review of internal and external communication strategies working towards a standardised approach across the system.

Getting help early gives someone experiencing psychosis the best chance of getting better more quickly. Our early intervention teams work with people between the ages of 14 and 64. We support people who are thought to be experiencing their first episode of psychosis, and those who appear to be at increased risk of developing psychosis.

Our aim is to support people and their families through the experience and to get people back to where they want to be. We offer a space to talk and understand what is happening to them. We can help manage stress and build confidence. We can advise on medication and practical issues such as education, employment, housing and benefits. 

Our teams include mental health practitioners who are from mental health nursing, social work or occupational therapy backgrounds, psychiatrists, psychologists and pharmacy.

We offer three programmes of treatment: people who have clearly had a psychotic episode are taken on for up to three years; those who appear to be at increased risk of developing psychosis are taken on for up to one year. Where we are uncertain what the presenting problem is after a detailed assessment, the person will be supported for six months, while a more detailed multidisciplinary assessment is carried out.

Following the acquisition of North West Boroughs by Mersey Care in 2021, an exciting opportunity arose for early intervention teams across North and Mid Mersey to come together and share their models of care, best practice, challenges and learning.

Mersey Care now provides EIP services across:

• Liverpool: Subdivided into North and South Liverpool teams and based at Baird House
• Sefton and Kirkby: Geographically subdivided into South Sefton and Kirkby, based at South Sefton Neighbourhood Centre and Hartley Hospital
• St Helens and Knowsley: Based at Peasley Cross
• Warrington and Halton: Based at St Johns Unit, Widnes.

Within the framework of the Community Mental Health, Clinical Excellence Transformational Programme, EIP leads from across Mersey Care engaged EIP services in November and December 2022, beginning to understand the similarities and differences in the delivery of services. This information was used to develop a ‘compare and contrast paper’ which was utilised to promote learning amongst EIP services, benchmark current performance and to support development of systems for best practice and one Mersey Care EIP standard operating procedure.   

This compare and contrast paper was presented to an EIP Transformation event in January 2023, where services reviewed the service variation and recommendations and planned a strategy to support development of one model. From this event, seven task and finish groups were identified to focus on reviewing and standardising the following areas:

• Service pathways
• Physical health
• Assessment process and documentation
• Individual placement support
• Family intervention
• NCAP and digital readiness  
• Outcome measures.

Five of the task and finish groups started in February, with two due to start in March. The physical health task and finish group paused due to the Community Mental Health Physical Health Workstream developing a standardised physical health model. Progress and risks are being monitored monthly via a monthly EIP Transformation meeting named ‘Future Development Group’.

The membership for each task and finish group includes: service users, carers and peer support workers, as identified by the co production workstream, to ensure the right people are helping to design the future model and have a voice in key decisions. 

• The Community Mental Health Framework for Adults and Older Adults 
• NHS Mental Health Implementation Plan 2019/20 – 2023/24  
• A guide to leading large scale change through complex health and social care environments 
• Rehabilitation for adults with complex psychosis
• Psychosis and schizophrenia in adults: prevention and management

Public Health England estimates that “41% of people classed as rough sleepers have long term physical health problems such as heart disease, diabetes and addiction problems compared to 28% of the population” and also that “another 45% have been diagnosed with mental health issues, compared to 25% of the general population”. The transformation work includes standardising approaches across the Mental Health Care Division by an assertive outreach approach of the Homeless Outreach Teams. This will enable engagement and access by taking services out to the individual regardless of where they are, for example, in a night shelter, hostel or in a shop doorway. The transformation work is to bring together all the relevant people and agencies in order to assess, plan and coordinate the best way to meet the needs of people with complex lives. Looking to standardise where possible, and work collaboratively to provide a joined up single plan for service delivery for each person, their family and carers across the Mental Health Care Division. Identify ways to provide best practice and standardise across.

What are Patient Reported Outcome Measures (PROMs)?

PROMs are questionnaires completed by the patient to understand and measure an individual's self reported health and wellbeing. This is opposed to a Clinician Reported Outcome Measure (CROM) which is an outcome measure completed by a clinician.

Over time, scores from these questionnaires can be compared to measure change in someone’s mental health condition, functioning or overall wellbeing, whether they are getting better, staying the same or getting worse. 

PROMs should be considered routinely in clinical sessions to guide and inform individual co produced* care planning, improve person centred care and to ensure the care being delivered is meeting an individual's needs.

There is a national expectation for PROMs to be embedded as part of the new and integrated models of primary and community mental health care for adults and older adults with severe mental illness. Find out more: https://www.rcpsych.ac.uk/improving-care/nccmh/service-design-and-development/proms-cmh-ig

We are working closely with colleagues in community mental health services, as well as Informatics Merseyside and external partners, to identify the necessary changes and enhancements to our digital and information systems to enable transformation.

*Co production refers to patients, and people in their support networks such as carers, and staff in services working together to develop and shape care delivery, rather than staff making decisions alone. Co production suggests that to provide truly effective public services, equal partnerships are needed between users and providers of a service. It encourages transparency about how and why things are done.

Why are PROMs important?

Routine outcome monitoring using PROMs can help practitioners and services understand whether they are meeting the needs of their patients and demonstrate the effectiveness of care being delivered.

Most patients report that routine outcome monitoring using PROMs is personally beneficial. It can help them to feel understood, it allows discussion on issues that are particularly important to them and allows progress towards personal goals to be tracked.

Routine outcome monitoring using PROMs can also allow services to reflect on whether they’re offering value for the NHS and those who access NHS services, and to identify the most effective ways to deliver high quality services.

The recommended PROMs

A national task and finish group, including people with lived experience of using community mental health services, clinicians and service managers have set an expectation that all patients should have PROMs scores recorded using three brief tools: DIALOG, Recovering Quality of Life (ReQoL-10) and Goal Based Outcomes (GBO). These were chosen and recommended because:

• DIALOG asks about a person’s wider health and ​​​​​​social needs to support the development and review of a holistic care plan
• Goal Based Outcomes (GBO) focuses on measuring progress towards personally meaningful goals
• ReQoL-10 provides an understanding of the factors contributing to the patient’s personal recovery.

In addition to the nationally recommended tools, services still have the flexibility to use other PROMs and CROMs that are meaningful and useful to them and the people they work with.

Training packs have been developed for team managers, clinical leads, and PROMs champions to use with staff in their areas to support the implementation of the agreed measures:

Introduction to patient reported outcome measures in adult community mental health services training

Introduction to ROMs and PROMs in early intervention in psychosis services training.

Clinical Outcomes Programme

The clinical outcomes programme is a Trust wide programme to embed the use of routine outcome measures (CROMs and PROMs) in all services where clinically appropriate.

The figure below outlines how the programme’s work is supporting the roll out of PROMs in our community mental health services.

Roll out progress

We have used the learning from our pilot sites (Step Forward Liverpool, St Helens Recovery Team, and Windsor Community Mental Health Team) to inform and support the roll out of the agreed outcome measures across adult community mental health services for people with a serious mental illness in line with the agreed timeframes and scope.

There is ongoing work to look at how the use of PROMs fits with the key worker role and assessment and care planning processes as part of the wider transformation programme.

The table below summarises which teams we have supported to implement the agreed PROMs so far and those yet to go live.

In addition to the above, the clinical outcomes programme team are also working to support the implementation of routine outcome measures within Early Intervention in Psychosis services and Adult Eating Disorder Services.

Engagement with the Complex Care teams in North Mersey has been deferred pending the confirmation of the model of care for older adults.

Want more information?

Wendy Copeland-Blair, Clinical Outcomes Programme Lead: wendy.copeland-blair@merseycare.nhs.uk

Olivia Wooding, Quality Improvement Partner – Clinical Outcomes: olivia.wooding@merseycare.nhs.uk

Systems

Rio: Working with Informatics Merseyside colleagues to add additional functionality to the system to support accurate tracking of clinical pathways, waiting lists etc. and to release new forms and visualisations to enable capture and feedback of the information provided via the agreed PROMs (DIALOG, ReQoL-10 and GBO).

MaST: Together with Holmusk UK we have successfully expanded the Mersey Care Management and Supervision Tool (MaST) to include Warrington, Halton, St Helens and Knowsley Recovery Teams with plans in place to roll the tool out further to all Step Forward psychology, early intervention, older adults/Later Life and Memory Services, eating disorders and addictions teams. We are also adding in functionality to support colleagues to ensure that agreed PROMs are completed in line with minimum frequency standards (as laid out in team process guidance).

Reporting and dashboards: Business Intelligence reports and dashboards are continually being updated to reflect the new Mersey Care operating structure with new dashboards being rolled out to support community mental health services with performance monitoring and to evidence the hard work of teams as they undergo transformation.

Step Forward launched in Liverpool in 2020 and then in Sefton and Kirkby in 2021. The service is a key element of our framework and aims to ensure that we provide an accessible, flexible and responsive service to meet presenting need at the earliest opportunity. The aim is to meet need outside of secondary care, maximising community assets and providing psychologically informed interventions to support recovery. In addition, the service works closely with secondary care teams to support seamless transitions between primary and secondary care.

Step Forward psychology services are community based psychosocial services supporting the alignment of community mental health teams with primary care networks. Each service comprises a range of practitioners: clinical psychologists, psychological practitioners and assistant psychologists, working across Liverpool, Sefton and Kirkby. Pathways are developed with key partners to provide a seamless service user journey.

Step Forward for Early Help service was developed to support with ‘Strengthening the Early Help Adult Mental Health Offer’ project. The aim of this pathway is to deliver an integrated ‘whole family approach’ where parental mental health is a central focus, and which provides an early help response by preventing the escalation of crisis by addressing families’ needs and reducing risk factors.

Step Forward Liverpool, Sefton and Kirkby, and Early Help services are primarily intended to serve people, 18 and over, who present with common mental health problems that have greater chronicity or complexity than would typically be seen in primary care NHS Talking Therapy services, but whose difficulties would not be considered complex enough for secondary care community mental health team input.

People who present with multiple comorbidities are also considered potentially appropriate for the service. Typical presenting issues might include: complex multiple trauma, emotional and behavioural dysregulation, and/or moderate or chronic self-harming behaviours.

Our teams also work closely with underrepresented communities to increase our knowledge and understanding of the challenges people face and we adapt our service to reduce and overcome identified barriers. The support we offer is tailored to individuals, and we aim to provide a responsive service to meet the needs of people from various cultural and religious backgrounds. Through this, we hope to create a therapeutic setting of mutual trust and respect in which everyone feels heard, valued and understood.

Within the framework of the ‘Community Mental Health, Clinical Excellence Transformational Programme’, we are also contributing to the Step Forward workstream, which, following the acquisition of North West Boroughs NHS Foundation Trust by Mersey Care in 2021, aims to align our Step Forward offers across North and Mid Mersey, and includes the sharing of models of care, best practice, challenges, and learning.