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PROactive Management of Integrated

Services & Environments



Emma Tiffin

Strategic Adult Mental Health Clinical Leads, Cambridgeshire and Peterbourough CCG

Emma has worked in mental health clinical leadership roles locally for 13 years and also has skills in media and mental health research. Most recently Emma has been involved in redesigning mental health services for older people with the integrated bid and redesigning adult services focusing on a recovery/community-based service model.

Emma trained as a GP in East London and held an academic mental health post at Queen Mary University developing mental health guidelines for primary care. She is a practising GP and has a weekly radio slot “Health Matters” on BBC Radio Cambridgeshire.

Enhanced Primary Care Mental Health Service


There is a currently a gap in mental health service provision between what Primary Care offers and specialist Secondary Care provides.  There is also a need to create a sustainable mental health service model with sufficient capacity for the future and a need to address the parity of esteem agenda.  This project seeks to design and implement a suitable service model for providing enhanced mental health care in the community.

Work to Date

We are currently in the consultation and design phase.  So far we have met and organised engagement events with local commissioning groups and third sector providers.  The local Rethink Carers support group and Service User Engagement (SUN) Network have helped coordinate our Carer and Service User engagement.

A consultant psychiatrist, is helping us to identity the most appropriate patient groups for the service.  We held a workshop on 2 September with all our key stakeholders to help make sure we are identifying the most appropriate patient group(s).

Initial research shows potentially suitable patients for this service are those with a diagnosis of:

o Stable Serious Mental Illness (Schizophrenia, Schizo-affective Disorder, Bi-Polar and Chronic Stable Depression)

o Personality Disorder

However it is acknowledged that the service needs to be based on patient need, not just diagnosis.

A key emerging idea is an MDT team/“One Stop Shop” model covering a geographical area. The team could comprise: a Primary Care professional e.g. HCA, GP support; specialist mental health clinician/support; Third Sector organisations; and Recovery Coach/Peer Support worker.

The potential advantages of the new service would be:

Greater capacity in secondary care, as more stable patients are stepped down into the enhanced service – this would enable to specialist mental health services to focus on patients with the greatest/most complex needs

Providing post discharge support and supporting the recovery model to improve the quality of care for patients and reduce reliance on secondary care services

Greater capacity in Primary Care as patients with more complex needs can be referred into the enhanced service

Facilitating an integrated/collaborative approach to patient care across providers which will also address parity of esteem

Improving the relationship between primary care and secondary mental health services

Ensuring that SMI patients do not fall into gap between primary and secondary care services, thereby improving both physical and mental health outcomes

We are continuing to refine these ideas to include the key themes emerging from our engagement work and also through discussions with CPFT clinicians and the Local Commissioning GP Mental Health Leads as more information/data analysis takes place.  Key elements include arrangements for prompt re-access to Secondary Care when required and how this work links with the on-going work regarding Primary Care at scale which is part of the government’s 5 year forward view.