To make sure we are strong for the future we're balancing operational and clinical excellence in our services with innovation. This means that we will:
- Blend our expertise so that we can provide more whole person care for people with physical and mental health multi morbidity
- Partner with other organisations to find the best solutions to the big demand, workforce and affordability challenges
- Continue to be an innovator using data and technology, ensuring that modern technology helps our clinicians to do their jobs but also makes it easier for people to access the care they need
- Explore and use the M-RIC research and innovation partnerships which will bring new innovations in treatment for our service users and patients.
We want to use our unique blend of all age services to become more preventative with a focus on people’s total health and wellbeing needs. Across our organisation we have a tremendous foundation to build on – to develop more co-ordinated care which meets people’s mental health, physical health, learning disability and addictions needs.
We call this approach whole person. This means providing support for their physical health, mental health, learning disability and addiction needs in a co-ordinated way, removing the need for so many separate appointments. It also means having a greater focus on prevention and earlier intervention, using data and insight to understand peoples’ needs and take a ‘whole family’ approach across our services.
We use data and technology to make our services more targeted, effective and personalised, giving people greater control of their health and extending the reach of our specialist teams. This includes:
- A new single data platform to strengthen business intelligence
- Undertaking a training needs analysis to inform and build staff skills, confidence and knowledge around digital technology
- Implement digitally enabled care opportunities in our services.
This programme demonstrates a commitment to improving the quality of care, supporting the health and wellbeing of service users and ensuring the best use of our workforce in delivering integrated care. By embedding co-ordinated, proactive physical health support into inpatient services, the Trust is working to achieve measurable improvements in service user outcomes and population health, while reducing pressure on acute hospitals. It should be noted that the full benefits for service users, staff and the wider system will take time to be realised, even after the model is fully implemented and embedded into practice.
The programme also fosters a ‘one team’ approach, providing opportunities for staff to share knowledge, learn from one another and transfer skills across teams, strengthening workforce capability and supporting sustainable, collaborative care models.
The Trust’s approach is likely to serve as an exemplar for other organisations, demonstrating how integrated, whole person physical health support can be embedded effectively into mental health inpatient services.
September 2024
We have started engagement to further understand what ‘whole person’ means in practice, building on our analysis work and have:
- Used shared data from health and care to understand more about the needs of people who present in our services with complex mental health, physical health and social needs
- Identified the scale of opportunity to reduce duplication and provide more joined up care for service users and carers who are seen in both our physical health, mental health services and other services
- Started engagement with clinical teams about what ‘whole person’ means in practice for them and how we will measure that we are providing care for people’s total health needs
- We are continuing to gather and share case studies and examples of great practice in our services in meeting people’s holistic needs.
October 2024
- SRO has transferred to Jenny Hurst, Chief Nurse
- We have reviewed progress against the operational plan priorities and established a new oversight group
- Each of the Operational Transformation Programmes will have a clear whole person objective to ensure that in the transformation of services, a whole person approach is a core principle.
November 2025
We’re rolling out our new model of co-ordinated physical health support into all of our mental health and learning disability wards in Liverpool, Sefton and Knowsley* from October 2025. Full implementation is due by May 2026.
This model focuses on proactive management of long term conditions, preventing deterioration and reducing unnecessary hospital transfers.
Key features include:
- Integrated care pathways for mental and physical health
- Multidisciplinary team working
- Telehealth and remote monitoring
- Joint training for staff.
Service user story
44 year old inpatient with paranoid schizophrenia and bilateral amputations. Pressure sore with infection under prosthetic leg attachment site - escalated to on call doctor - antibiotics and planned wound reviews. Visibly perspiring, NEWS score of 0, no changes during obs but complained of bone pain. Transfer to A&E was recommended, ambulance arrived, refused to leave due to distress about waiting times and wasting people’s time.
Ward escalated to Single Point of Contact for Urgent Community Response assessment via the physical health into mental health inpatient pilot. Assessed within two hours, wound managed, swabbed and had advice on further care. Ward liaised with prosthetics service for support and appointment made.
Distress reduced, timely, effective treatment, staff remained on ward, integrated mental and physical health care!
*Planning in Halton, Warrington and St Helens, where the Trust doesn’t provide community physical health services, will involve collaboration with local partners to ensure equitable provision across the entire Trust footprint.
March 2026
We have now moved into Stage 3 of the Physical Health Into Inpatients Programme, launching the proactive long term condition (LTC) management pilot with community matrons across 11 wards from 17 December 2025.
This marks a major step in supporting earlier intervention, improved long term condition management for inpatients and working to avoid unnecessary transfers to accident and emergency departments.
Additionally, on 4 March 2026, we successfully went live with the UCR Therapies Pathway for five wards across Liverpool and Sefton, enabling enhanced access to AHP led advice, triage and urgent interventions where patients are at risk of deterioration or potential hospital transfer.
Progress to date
Phases 1 and 2: 2 Hour Urgent Community Response (UCR) Pathway
- 11 wards are now part of the UCR pilot
- 24 referrals have been completed, with five progressing to UCR assessment.
Phase 3: Long Term Condition Management
- Went live on 17 December 2025 across 11 wards
- 38 referrals made to community matrons, with 33 patients having their care completed
- A Medical Advice Support Line is offering clinical support and oversight
- Medicines Management In Reach has received four referrals for detailed medication reviews
- A full standard operating procedure (SOP) is in place and being refined as learning grows
- Joint training is being developed for community teams on mental health and medicines management.
Key achievements
- Avoiding unnecessary hospital transfers: UCR has supported five deteriorating patients, preventing avoidable A&E attendance
- Enhanced multidisciplinary team collaboration between inpatient and community teams
- Improved LTC support: community matrons have supported 38 patients across the pilot wards
- New AHP Therapies Pathway live from 4 March 2026 for five Liverpool and Sefton wards
- Standardised admission physical health assessments now in place Trust wide
- Telehealth pathway due to go live in April 2026
- Interoperable system automation improving data flow across clinical systems
- Strong workforce engagement informing ongoing pathway refinement
- Medicines management impact: Four in reach referrals have enabled safer prescribing and clearer discharge planning.
Key achievements for the Physical Health into Mental Health Inpatients pilot
- Expansion of proactive care model: Phase 3 (Proactive Care and Long Term Conditions pathway) expanded to 16 wards from 15 May, progressing into Stage 2 rollout in June
- Strong pathway activity:
- 76 Community Matron referrals and 19 District Nursing referrals received
- 17 Medicines Management referrals completed
- Urgent care pathway in place: UCR pathway live across 16 wards, supporting deteriorating patients (28 referrals to date, with 6 progressing to action)
- Training and workforce development: New combined training programme delivered, with 23 staff trained across 2 sessions
- Working in collaboration: Agreement secured with Mersey and West Lancs Teaching Hospitals NHS Trust and North Cheshire and Mersey NHS Foundation Trust to extend the model to St Helens, Warrington and Halton, with further engagement and planning underway
- Partnership development: Specialist respiratory pathway in development in conjunction with University Hospitals of Liverpool Group
- Positive feedback from staff from both inpatient and community teams in relation to a collaborative care approach, learning from colleagues and gaining a better understanding of each others professional roles. Developing a more multidisciplinary approach to managing patients with complex mental health issues and patients benefitting from physical health input. This is captured regularly through case studies and lessons learned.
Service development
- Medical advice line extended to include pharmacy staff (four week trial)
- Telehealth pathway progressing, with draft processes and care plans in development
- Ongoing work to automate patient documentation across systems (currently manual)
- Updated patient survey to strengthen service user feedback collection.