Top tips and key actions for successful collaborative partnership working across mental health services

Mental Health Social Care: What it is, why and how it matters for Integrated Care describes the distinctive nature and features of mental health social care and its practice base in local government and the Voluntary, Community and Social Enterprise (VCSE) mental health sector. The report highlights the role of councils, and the Integrated Care Systems (ICSs) in which they sit, in supporting and improving outcomes for people with mental illness or experiencing mental distress and their unpaid carers by modernising and personalising mental health care.

These top tips, and key actions, have been co-developed to support effective collaborative partnership working in the planning and delivery of community mental health services. They recognise that every heath and care system will experience challenges in relation to partnership working given the statutory and cultural differences of organisations working across the mental health pathways and that there will be different arrangements to frame local partnership working, including for example a Section 75 agreement.

The top tips and key actions provide a starting point for collaborative problem solving and working, moving away from a focus solely on organisational boundaries. They have been developed through extensive discussion and engagement, drawing on research from the Centre of Mental Health,’ It Feels Like Being Seen and ‘No Wrong Door ensuring that the voice of people with lived experience and their carers is central to the design and ongoing review of mental health partnership arrangements.

The top tips and key actions also seek to promote the six key aims of the NHS Community Mental Health Framework which cannot be achieved by one organisation on their own and requires the buy in from social care, health and the voluntary and community sector. The Top Tips therefore focus on ensuring that those who require mental health services have ease of access to services (no wrong door) that meet both their social and psychological wellbeing needs without layers of complexity or organisational disagreements.

Each top tip is considered in terms of:

1. why it is important
2. how to achieve it and 
3. what it would look like (linked to the relevant Care Quality Commission’s (CQC) Quality Statements for Local Authority Adult Social Care and Integrated Care Systems).

Tools and resources are also identified for each top tip.

Whilst it is acknowledged that social care and health systems are under immense pressure, and that that there is no simple solution to creating an effective and efficient collaborative mental health system, working together using these Top Tips as a guide provides a signal of commitment by partners to improve current ways of working and improve both the experience of those accessing mental health services and those who work in them.

A Word version of the top tips and key actions for collaborative partnership across mental health services is also available to download.

Begin building honest and open relationships that focus on the voices of people with lived experience and carers and that consider each organisations priorities and areas on which they cannot compromise.

Why is it important to develop honest and open relationships?

Defining your partnership priorities is the first step in developing your partnership long-term vision for mental health services. Your partnership priorities will serve as the foundation of the long-term shared vision. To effectively define shared priorities that are collectively owned and focused on the voices of people with lived experience and carers it is essential to have:

• priorities that matter to a wide, diverse and representative range of people with lived experience from the local area
• a thorough understanding of each other's organisational, statutory, and local priorities, as well as a deep understanding of the professional roles within each other's workforce.

How to achieve honest and open relationships

• Obtain the views of people who local services and carers of what their top priorities for mental health services would be.
• Consider employing a strategic lived experience partner who can lead on coproduction and make sense of the information. Engage with grassroots local voluntary and community sector organisations who know the mental health needs of the local population well and can support in identifying priorities.
• Create a partnership board where open and honest discussions can take place to define shared partnership priorities that align to the priorities of people who use local services and their carers. These priorities should consider each organisation’s statutory and local priorities and what can and cannot be comprised on. The priorities should consider the specialist skills and knowledge of each organisation’s workforce.

Tools to develop honest and open relationships

• It Feels Like Being Seen: In 2022, Centre for Mental Health conducted research to consider what does it look and feel like when support effectively considers people’s social and psychological wellbeing as part of mainstream assessments and care planning and what does it look and feel like when there is good collaboration in the commissioning and planning of mental health services and support.
• Mental Health Integration Past Present and Future: Using a comprehensive survey of a range of professionals, and interviews with local and national leaders across England involved in both mental health provision and social care, the research explored the context and affecting integration between health and social care in mental health. Although published in 2016 the findings still resonate strongly today.
• Making the Difference Together: This document provides guidance on practical ways to gather and use direct feedback about people’s experiences of social work practice within mental health services.
• Building Community into the Integrated Care System: A practical toolkit for building robust community mental health care at a local level.

With all partners, people who use services and their carers develop a coproduced collectively owned long term shared vision for adult mental health services that is meaningful for your place.

Why is a long-term vision important?

A shared long-term vision that is collectively owned, along with agreed partnership priorities, goals and outcomes, will help develop collaborative working and facilitate with the necessary cultural and behavioural changes needed across partnership organisations to work towards the same goals and outcomes.

How to achieve a long-term vision

• Share the power with those with people who use services and carers to coproduce a long-term vision for mental health services that are place based and have meaningful and achievable goals and outcomes.
• Engage with middle managers, front line staff and multi-disciplinary team leads to gain their views and thinking (what is working well, what are the challenges and solutions).
• Engage with the voluntary and community sector as these local organisations will often hold detailed knowledge of existing infrastructure, assets and support communities’ access, which can help ensure new services are designed in a way that recognises this existing local context. A localised and community focus is invaluable when considering a long-term vision for local mental health services.
• Coordinate roles and responsibilities explicitly, focusing on addressing cultural, operational, and performance obstacles building a shared language and set of achievable goals and outcomes linked to the partnership agreed priorities.
• Develop leadership roles that work across organisational and professional boundaries that are responsible for promoting collaboration at all levels to deliver on partnership priority outcomes/goals.
• Develop short, medium and long-term milestones, ensuring the vision, priorities and goals/outcomes are tangible, well defined and measurable.

Tools to develop a long term vision

• Think Local Act Personal: Provides a wide range of documents and tools to support with effective coproduction.
• A reflective learning framework for partnering, The King's Fund: Rather than prescribing a series of ‘must dos’, the document provides questions for partnerships to use as a preparatory and reflective tool in their work. New partnerships could use the questions to explicitly consider and be better prepared for some of the challenges and opportunities they may encounter in the early stages of partnering. More established partnerships could use the questions on an ongoing and iterative basis, as a reflective learning framework to support their partnership’s development. They could also use their experiences to iterate and develop the framework itself.
• Community-based integrated services, SCIE: Provides a range of useful tools in developing community collaborative partnership services.
• A working partnership: A guide to developing integrated statutory and voluntary sector mental health services.
• The Community Mental Health Framework for Adults and Older Adults: The Community Mental Health Framework describes how the Long-Term Plan’s vision for a place-based community mental health model can be realised, and how community services should modernise to offer whole-person, whole-population health approaches, aligned with the new Primary Care Networks.

Develop a partnership outcomes framework with outcomes that really matter to people with lived experience and carers.

Why a partnership outcomes framework is important

Evidence from health and care systems which have embarked on transformation demonstrates that having a shared vision and partnership outcomes is vital to develop a common language and shared purpose between partner organisations. This in turn supports partners to move past practical impasses that can arise when organisations and teams have different goals.

The aim of the outcome’s framework is to act as a tool for partners to assess how mental health services are progressing towards making the priorities that matter to people with lived experience and their carers a reality. An outcomes framework should support ongoing partnership priority setting in collaboration with those with lived experience and ensure those working across mental health services are clear about the priorities.

An outcomes framework will be unique to each local area; it is not a ‘one size fits all’ approach!

How to develop a partnership outcomes framework

• Provide clarity on the quality, types of service provision and outcomes that should be achieved for those who may require mental health services.
• Provide a common and shared point of reference to empower front line staff to take large and incremental steps to help meet the outcomes articulated.
• Provide clear articulation of shared ambitions to enable smooth joint working.
• Support VCSE partners, providers and the community to drive forward improvements in how mental health services are commissioned, designed, delivered, evaluated and improved.
• Focus on the outcomes of the priorities that matter to local people with lived experience and their carers in addition to ensuring the delivery of partners statutory duties and functions.
• Ensure your outcomes framework explains how outcomes will be achieved, such as through local mental health care pathways, a range of services, local assets and resources, including the voluntary and community sector, and how outcomes will be tracked and monitored.
• Include an implementation and accountability framework that focuses on monitoring progress of outcomes, assuring quality, delivering improved outcomes and value for money for people who may require mental health services.

Tools to support a partnership outcomes framework

• Tower Hamlets Shared Outcomes Framework: Tower Hamlets is well recognised for pioneering new work practices and leading the way in new initiatives and projects. Although their shared outcome framework is across the adult social care and health system it provides an excellent example of what can be achieved when partner organisations, people with lived experience and carers, the VCS and providers come together to develop outcomes that matter to local people.
• Care and Support Statutory Guidance: The Care Act 2014 and care and support statutory guidance is the legal framework for Adult Social Care. It places a duty on councils to support and promote the wellbeing and independence of working age disabled adults and older people, and their unpaid carers and gives them more control of their care and support.
• Stepping Up to the Place: Thua NHS Confederation document provides an accompanying integration self-assessment tool, designed to support local health and care leaders through health and wellbeing boards to critically assess their ambitions, capabilities and capacities to integrate services to improve the health and wellbeing of local citizens and communities.

In partnership develop robust shared governance, quality assurance and reporting frameworks.

Why is a governance and quality assurance framework important?

As part of their public governance responsibility, statutory partners should routinely assess progress and evaluate outcomes against partnership priorities, which includes delivery of their statutory duties. Robust partnership governance and quality assurance measures should determine whether collaborative mental health services are effective and local community assets are being used effectively and efficiently, and if people in need of mental health services have equitable access.

Provision of assurance through a robust shared governance framework is critical to the sustainability of a delegated partnership arrangement or, at a minimum for a healthy enduring collaboration.

How to develop a governance and quality assurance framework

As a partnership you should regularly evaluate current governance and quality assurance arrangements to ensure they support alignment of partnership and professional service activities, statutory roles and responsibilities and provide clear roles in quality assurance and accountability. Performance management frameworks should consider not only activity and quality of individual services but also the extent to which people experience more integrated care based on what local people say matters most to them.

When reviewing current arrangements consider the following:

• Are current governance and quality assurance arrangements transparent and not overly burdensome or bureaucratic?
• Do quality assurance measures focus on the delivery of partners statutory duties and whether value for money is being achieved? Are there shared metrics/ dashboards in place that have been coproduced with people with lived experience?
• Is there clarity about where decision making, and resource allocations powers lie and how decision makers will be held accountable and to whom?
• Does the current accountability plan (if in place) focus on monitoring progress of outcomes, assuring quality, and delivery of improved outcomes for local people who may require mental health services?
• Are there agreed ways of working for overcoming barriers to collaborative partnership working such as joint workforce planning and sharing/pooling of resources?
• Is there clarity about how people with lived experience will be involved in governance, decision making and quality
•  assurance processes?

Tools to support the development of a governance and quality assurance framework

• Rethink Mental Health self- assessment assurance framework: Rethink Mental Illness has launched a new Self-Assessment Assurance Framework for mental health systems. The interactive self-assessment tool is now available and free to use to assess the progress your organisation, partnership, or system has made in transforming community mental health care across five areas: resources, purpose, method, partners, and context with a focus on working with the voluntary, community and social enterprise sector. The framework is a companion to the Rethink Mental Illness report, ‘Building community into the Integrated Care System. You can read the full report on their website here.
• The governance risk and resilience framework: Although this material is designed to support individual council officers and councillors to play their part in identifying, understanding, and acting on, risks to good governance it can be effectively used to support the development of a partnership mental health governance framework utilising the guidelines.
• Good governance handbook provides ten key elements to ensure effective governance arrangements.
• Diverse by Design: 15 key elements: This LGA guide will help you to turn the caring into doing, to make well-meaning into impactful, and will provide you with a range of steps to positively influence a culture of equality and embed the practice of inclusion in your workplaces.
• Guidance about the appointment of Caldicott Guardians, their role and responsibilities issued by the National Data Guardian for Health and Social Care in England (the “NDG”) under section 1(2) of the Health and Social Care (National Data Guardian) Act 2018 (the “Act”) regarding the roles and responsibilities of Caldicott Guardians.

In partnership develop collaborative early intervention, prevention and wellbeing strategic and operational plans that harness the skills, resources and assets of local voluntary and community sector organisations. 

Why is early intervention and prevention important?

To support people to maintain their independence and prevent unnecessary hospital or institutional care, it is vital that there is capacity within local community-based services to support prevention, early intervention and enablement. Research has shown that early intervention can prevent more serious symptoms from developing and enable people to live well and independently with mental health conditions.

Partners will need to refocus the way mental health services are delivered, giving greater priority to prevention and early intervention, rather than waiting for people to reach crisis point. This will mean developing a wide range of preventative, therapeutic, early intervention and enablement services in the local community.

How to achieve early intervention and prevention

Think broadly about how to partner with the VCSE sector to develop community-based services, support and interventions that focus on prevention, early intervention, self-care, enablement and wellbeing.

Reframe the narrative by focusing on strengths and assets instead of needs and deficits to foster an environment for community engagement.

Promote a culture of co-production, taking a co-design approach that shares the power with people with lived experience, to develop services people want to keep them well.

Include voluntary-led services in local service directories to support personalised care planning and connect people to the wealth of local community resources and initiatives through clear and intuitive signposting, social prescribing, peer mentors, link workers and care navigators.

Support and encourage the full offer of schemes and programmes run by the voluntary sector, including Shared Lives, community circles, time banks, etc.

Tools to support early intervention and prevention

• Building community into the integrated care system is a practical toolkit for building robust community mental health care, Rethink, 2023
• Realising everyone’s access to community help: Voluntary, Community, Faith, and Social Enterprise Mental Health (VCFSE MH) Alliance is a consortium of seventy providers operating in Coventry and Warwickshire. They have been successful in working together to develop a new coproduced, peer support service REACH that facilitates early intervention and prevention services.
• Getting my life back: occupational therapy promoting mental health and wellbeing provides a range of innovative occupational therapy services that focus on prevention and early intervention in mental health services. The report shows that occupational therapy has life-changing effects on people with mental health conditions, from stress and anxiety to depression, psychosis and self-harm.

Develop an assessment framework to ensure all assessments, care and support plans and reviews are co-produced, personalised and Care Act compliant.

Why is a care and support assessment framework important?

Assessment, care and support planning that directly involves individuals and those who care for them is more likely to produce care and support plans that build on the person’s own strengths and assets, as well as achieve shared decision-making, understanding that they know best regarding what their care and support goals are.

How to achieve a care and support assessment framework

• The starting point should be the person’s own strengths, assets and goals, with care and support planning directly involving the person in the process. Whoever is assessing and developing care and support plans must adopt this guiding principle.
• Recognise that strengths-based and personalised assessment and care and support planning is best facilitated by an effective and accessible system of shared care records (as identified in top tip 13) and one that incorporates standardised shared documentation practices that incorporate Care Act eligibility and focus on strengths-based conversations.
• Ensure that there are systems in place that ensure care and support plans are reviewed on a regular basis regonisng that people’s needs and goals will change over time as their mental health, psychosocial and or physical health conditions and personal circumstances change.
• Focus on realising the ambition of personalised and strengths-based assessment, care and support planning may require a cultural shift and therefore require training of multi-disciplinary teams and other assessors to ensure that the expected standards and practices become adopted across all partner organisations and become second nature.
• Actively promote best practices for involving people in assessment, care and support planning, setting of goals and how to plan for early intervention when early relapse indicators are identified.
• Actively identifying when an advocate is required.
• Provide regular training and support on how to work in a strengths-based, recovery and enablement and asset-based approach, harnessing community and voluntary assets.
• Ensure that there is a priority given to effectively involve people’s families, caregivers in the assessment and care and support planning process and how to indefinity when a carers assessment is required.

Tools to support a care and support assessment framework

• Determination of eligibility under the Care Act 2014: The Care Act 2014 sets out local authorities' duties when assessing people's care and support needs. This resource from SCIE supports care practitioners and answers their questions about assessment and determination of eligibility under the Care Act. It also provides practical guidance over what they should do when applying the letter and spirit of this law.
• Making it Real: how to do personalised care and support provides a range of resources from Think Local Act Personal to ensure assessment, care and support planning is strengths-based and personalised.
• Strengths-based approach practice framework and handbook is a practice framework for strengths based social work with adults with case studies and resources.
• Wellness Recovery Action Plan: WRAP was developed by people who were living with a variety of mental health challenges and were working hard to feel better and get on with their lives. In the last 20+ years, WRAP has been recognised as an evidence-based practice and adapted for use with all kinds of life issues. The WRAP process supports individuals to identify the tools that keep them well and create action plans to put them into practice in everyday life. Lots of resources and tools available to support with developing a WRAP.
• No wrong doors for young carers: Partners in Care and Health commissioned Carers Trust to undertake a refresh and updating of 2015’s “ No Wrong Doors for Young carers: a template memorandum of understanding (MOU) between Directors of Adults and Children’s services.” 
• Mental Capacity Act Code of Practice

Develop a partnership workforce plan which draws on the skills and knowledge of the mental health social care workforce.

Why is a workforce plan important?

A system-wide mental health workforce strategy will ensure there is appropriate capacity and capability across all local settings to meet the priorities and outcomes and goals of the mental health partnership.

Using a whole-system approach to workforce planning will ensure partner organisations are working together to address workforce shortages across the mental health system. This should include developing innovative and shared opportunities for recruitment and retention, whilst avoiding competition for staff and recognising the specific skill set of mental health social workers to ensure dilution of social worker identify does not take place.

The strategy should reflect the need to develop a collaborative workforce by creating opportunities for mental health social work/care and health professionals from multiple mental health settings and agencies to learn from each other, and plan solutions and interventions together. This is likely to produce integrated training programmes and rotational placements across different mental health services.

It should recognise that dedicated social work capacity with sufficient seniority is required to ensure credibility across partnerships, together with a clearly defined set of objectives that are owned by partners. Greater attention must be given to strategic leadership and change management capacity to support both new partnerships and drive a strong social model of mental health forward.

How to achieve a workforce plan

Partner and voluntary and community sector organisations should undertake workforce planning in partnership and not in isolation, working closely with local provider organisations.

Ensure that Local workforce strategies are cross-sectoral in nature, including public, independent and voluntary sectors. They should address:

• existing and future recruitment needs and retention challenges.
• the state of the local workforce market
• the skills and training required to work in new mental health settings and in new ways.
• the advent and roll-out of new roles, such as mental health link workers or care navigators
• the availability of local resources for workforce development and training.

Tools to support the development of a workforce plan

• National workforce plan for approved mental health professionals provides workforce plans and standards for AMHP services.
• Thematic review of the social work role in mental health in the southeast identifies the lessons from experiences of integration, good practice and areas for improvement and innovation; the need to develop a shared view on what the core Social Work offer is to mental health from a Council perspective; the need to need to consider how to strengthen the performance and quality assurance mechanisms of Mental Health Social Work.; the importance of building regional and national connections and strengthen system leadership and identify collaborative goals and solutions.
• Guidance on the support of mental health social workers working in NHS, independent or integrated services is designed to support all agencies that employ social workers. It has been produced to sit alongside the Local Government Association’s employers’ guidance, and to give detailed advice and support to develop the social work role across all mental health settings and organisations. It is based on the learning from the ‘social work for better mental health’ programme, working across over seventy organisations, assessing and developing their integrated arrangements.
• Forensic social work report: This scoping exercise examined forensic social work (FSW) in relation to the three areas of: continuing professional development (CPD), the role of the social supervisor, and recruitment and retention issues. The paper provides recommendations and further information and tools.
• Mental health casework section: conditionally discharged patients: supervision and reporting

Develop multi-disciplinary training that includes the VCSE sector and people with lived experience and their carers.

Why is a multi-disciplinary training programme important?

New ways of collaborative and integrated working will require staff to work acquire new skills, adapt their ways of working and facilitate communication. Joint training can facilitate a shared language and culture and promote a shared values-based approach across organisations. In addition, joint training is essential, as it helps foster and secure the practices and protocols that underpin delivery of collaborative/integrated care and improved mental health outcomes.

How to achieve a multi-disciplinary training programme 

The partnership training offer should be co-produced and co-designed by all stakeholders, which includes people with lived experience and unpaid carers.

Topics for joint training include:

• standardised approaches for joint assessment, care and support planning, care management, and crisis response
• Training of roles, responsibilities, skills and knowledge bases of each organisations workforce and what they bring to mental health service provision.
• making the shift from reactive to proactive/early intervention and preventative care
• working with shared care records, and information sharing
• understanding and accessing the resources available for personal care and support plans, including direct payments
• Strengths and asset-based approaches.
• Risk enablement and management approaches
• personalisation and co-production methods, including shared decision-making.
• team development to improve working relationships and behaviours, joint problem- solving and shared accountability across organisations.
• involvement of mental health link workers (mental health care navigators) to support self-care and social prescribing.
• develop case examples and scenarios of what good mental health services look like delivered by people with lived experience and carers.

Tools to support the development of a multi-disciplinary training programme 

• Coproduction: A range of resources from SCIE to support coproduction and development of multi-disciplinary training.
• Multi-disciplinary teams: Range of training tools from SCIE to support multi-disciplinary working.
• Enabling innovation and adoption in health and social care: Developing a shared view: Principles from CQC to support collaborative and integrated working that can be delivered via training.

Develop integrated commissioning capacity to enable ready access to joined-up health and social care resources and transform care.

Why is integrated commissioning capacity important?

Integrated/joint commissioning is crucial to address and meet local need and should share a strategic vision. The experience of care is more likely to be seamless where organisations and practitioners share accountability for care and support outcomes, the best use of joint resources and the joint management of risks. Integrated or joint commissioning enables shared accountabilities and practices to work effectively. Commissioning collaboratively as a system enables benefits to be realised for the whole system, however, this needs to deliver for all organisations in terms of improved outcomes and experiences for people, cost avoidance, financial savings, and better access to services.

How to achieve integrated commissioning capacity

Consider how you use the Better Care Fund or other mechanisms to pool mental health budgets and move towards integrated commissioning.

Ensure that commissioning for mental health is informed by active Joint Strategic Need Assessments, capable of identifying shared populations that need support to ensure less fragmentation of mental health systems and services and the effective implementation of community mental health transformation.

Develop a single team of joint commissioners, ideally co-located, to better leverage the co-ordination, pooling or alignment of local resources to create improved outcomes and experiences that is underpinned by locally agreed community mental health transformation plans.

Recognise that commissioners cannot work solely in a transactional way and ensure strong and proactive dialogue with local providers, VCS, social care and clinical professionals and people who use services to shape the delivery of the service model and full range of joint care and support services, from early intervention and prevention to urgent care in the community.

Invest in the skills needed for effective commissioning to include new models for contracting, including lead providers, risk-reward incentives and clear person-centred outcomes and performance metrics.

Tools to support the development of integrated commissioning capacity

• Joint commissioning for integrated care: Tools and resources from SCIE to support in the development of joint commissioning arrangements.
• Mental health social care: what it is, why and how it matters for integrated care: This report considers the appropriate footprint(s) for the commissioning of mental health services and related support, to ensure that they are both coterminous with place and aligned with the mental health and wellbeing priorities of the people and communities therein.
• Thinking differently about commissioning: Findings from research on how commissioning practices across the country are changing. The research provides a number of innovative commissioning approaches.
• Local Government Association Stepping up to the place Part B: Evidence review.
• Part B - Evidence Review October 2018 WEB.pdf (brookes.ac.uk): Stepping up to the place. Part B Evidence review (IPC, 2018) highlights barriers and enablers of integrated care practice, including financial arrangements, shifting money across the system and budget sharing mechanisms

Develop partnership rapid response with shared escalation processes and pathways to respond to serious incidents and near misses that link into the local Safeguarding Adults Board/s.

Why are rapid response and shared escalation processes important?

A partnership crisis response in the community that supports early intervention can support in stabilising a person’s deteriorating mental health, keep them at a place they call at home whilst avoiding unnecessary assessments under the Mental Health Act and admission to hospital.

Nationally, numerous Safeguarding Adults Review have identified the need for shared crisis response services and shared escalation plans/processes in responding to serious incidents. Having a shared partnership escalation process helps to ensure that risk can be collectively shared, managed and reduced. Where a serious incident takes place escalation plans ensure that senior management are notified, and that shared learning is achieved and embedded across the system to reduce the likelihood of reoccurrence.

How to achieve rapid response and shared escalation processes

• Partnership Crisis Response
• Focus on ensuring that you have an effective single point of access with 24/7-hour coverage that enables an effective rapid response system to be deployed for people whose mental health needs require urgent attention. This should include:
  • a fully integrated rapid response team, ideally available 24/7. Delivered by a range of health and social care professionals with access to specialist psychosocial and medical expertise, as needed, who can triage and attend to the individual’s urgent mental health needs that has robust pathways to AMHP service.
  • a single point of access, usually telephone triage in a physical hub, from which to coordinate the rapid response, and which is linked to a shared care record system.
• Work with VCS organisations in the early intervention and hospital avoidance space such as crisis cafes and crisis safe spaces that run 24/7
• Serious Incident Escalation, Review and Learning
• Develop a partnership serious incident escalation process
• Develop a serious incident review and learning framework that links to the local Safeguarding Adults Board to ensure that system themes are captured, and lessons learned shared amongst all partner’s ensuring learning is embedded across the local adult social care and health system.

Tools to help develop rapid response and shared escalation processes

• Building community into the Integrated Care System: Provides case examples and innovative ways from Rethink; VSC organisations can provide invaluable capacity in the early intervention and crisis space.
• Safeguarding Adults Reviews under the Care Act: implementation support: Information on legal duties of local Safeguarding Adults Board with useful examples on how to promote a learning culture and move away from a blame culture.
• Making Safeguarding Personal provides useful insights on how organisations can promote a person-centred approach when at adult is deemed to be at risk of harm and or abuse.
• Patient safety incident response framework and supporting guidance provides information and guidance for NHS staff on how to respond to serious incidents.
• Care and Support Statutory Guidance: Chapter 14 provides guidance on sections 42 to 46 of the Care Act 2014 and covers adult safeguarding, what it is and why it matters.

Introduce access guidance rather than allow arbitrary thresholds.

Why is access guidance important?

The national agenda for mental health promotes health and social care agencies working together in partnership to ensure that those who require mental health services have ease of access to services that meet their needs without layers of complexity or organisational disagreements. Access guidance should ensure that people are seen by the right professional at the right time and at the right place; that there is no duplication of process and there is parity for all people referred.

How to achieve access guidance

Develop guidance that is based on the principle that there is no wrong front door and a person who is presenting with mental health needs will be supported to access the right bit of the service through a warm handover rather than a passive hand off.

Ensure that all preventative and enablement services are inclusive of people with mental health needs and not solely focused on physical or age-related considerations.

Work with housing services to providing training on working with people with mental health and develop good strategic and operational links with mental health social work/care and community support offers.

Ensure legal frameworks of mental health social care are understood and clearly recorded, along with Care Act eligibility, including wellbeing and principles of prevent, reduce and delay and statutory assessment requirements.

Ensure workforce roles across each organisation are clearly articulated, covering the skills/knowledge they bring and their areas of responsibility such that the social work contribution is clear, captured, and communicated, so that there is a good understanding of its necessity and when it should be accessed.

Ensure that younger people with mental health conditions are given parity of esteem as children with disabilities and children in care as part of the preparing for adulthood pathway.

Tools to support the development of access guidance

• It feels like being seen: In 2022, Centre for Mental Health conducted research to inform the work of the Care and Health Improvement Programme. They focused on two core questions relating to the role of local authorities that commission and provide adult social services in assessing and meeting people’s mental health needs: What does it look and feel like when support effectively considers people’s social and psychological wellbeing as part of mainstream assessments and care planning? What does it look and feel like when there is good collaboration in the commissioning and planning of mental health services and support?
• No wrong door: Commissioned by the NHS Confederation and written by Centre for Mental Health, the report brings together research and engagement with a wide range of stakeholders, as well as people who bring personal and professional experience about what these vital services should be like in 2032.
• Transforming mental health social work report: The report brings together a varied and diverse collection of experts from a range of social and health care agencies to develop new approaches to mental health social work, forensic social work, trauma and family-based social work, leadership and continuous professional development.

Develop a partnership mental health hospital discharge model that has parity with acute hospital discharges.

Why a partnership mental health hospital discharge model is important

To ensure a safe transition from hospital to community settings a robust partnership mental health discharge model is required. The transition from acute mental hea partnership mental health hospital discharge model alth inpatient to community care can often be a vulnerable period where people can experience additional risks to their mental health and psychological wellbeing. Previous research with people who use services has found discharge to be a chaotic, stressful and emotionally charged time. The term “revolving door” is widely used to describe how individuals can repeatedly transition between hospital and community care, and then back into hospital within a very short timeframe.

How to achieve a partnership mental health hospital discharge model 

Establish Board level reporting and executive Senior Responsible Officer (SRO) level ownership with delegated responsibility of the discharge process at organisational and system level, ideally coordinated by a single person on behalf of the system at Director Level (like the single coordinator role in hospital discharge).

Focus on outcomes for the person not organisational boundaries, for example:

• locally agreed protocols setting out, roles and responsibilities and timescales for responding, arrangements for funding (117 and CHC), partnership strengths –based risk management.
• Joint commissioning arrangements that provide high quality rehabilitation, recovery and enablement support for positive mental health
• Access to housing and supported living to support timely discharge
• Clear focusing of existing services to support prevention, rehabilitation, recovery and enablement.
• Ensure alignment with transfer of care hubs to enable people with physical health needs (as well as mental health needs) to access local discharge to assess services.
• Focus on work that reduce time in hospital through focused interventions based on personalised care planning where there is agreed purpose of admission and estimated date of discharge supported by strengths based care and discharge planning e.g. Ward round / daily multi-disciplinary meetings are focused on plans, making sure people have the right interventions (e.g. therapy, medication reviews etc) to move their care on every day (green days) rather than wasted days in hospital waiting for interventions (red days).

Tools to support the development of partnership mental health hospital discharge models

• From admission to discharge in mental health services: a qualitative analysis of service user involvement: Wright,  2016, Health Expectations, Wiley Online Library 
• Discharge challenge for mental health and community services providers: NHS England provides a number of discharge initiatives than can be implemented to promote safe and timely discharge from mental health acute settings.
• London’s Mental Health Discharge Top Tips: Provides ten top tips for hospital discharge.

Partners in Care and Health expresses gratitude to the following organisations for their invaluable cooperation in developing these Top Tips.

• ADASS
• Association of Mental Health Providers
• Barnet, Enfield and Haringey Mental Health NHS Trust and Camden and Islington NHS Foundation Trust
• Bracknell Forest Council
• British Association of Social Workers (BASW)
• Cambridge and Peterborough NHS Foundation Trust
• Centre for Mental Health
• Chief Social Workers Office
• East Sussex County Council
• Essex County Council
• Essex Partnership University NHS Foundation Trust
• Department of Health and Social Care, Head of Place Strategy
• Leeds and York Partnership NHS Foundation Trust
• London Borough of Croydon
• London Borough of Islington
• NHS Greater Manchester Integrated Care
• Rethink
• Southampton City Council
• Surrey County Council
• Worcestershire County Council