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Delivering together for ambitious improvements for mental health service users and carers in Newcastle and Gateshead

People, partnerships and practicality is the call to action from health and care partners committed to making tangible improvements for people who need mental health care and support.

Complex and confusing, with public funds, specialist staff and other resources stuck in mental health hospital beds with not enough community provision in the right places to prevent mental health crisis and therefore more people needing hospital care.

This was the consensus view from organisations involved in mental health care in 2016, when a major programme of public consultation ‘deciding together’ paved the way for a range of partners to work together in a new, more integrated way around improving mental health services.

Now health and care organisations, community and voluntary organisations, service users and carers across Newcastle and Gateshead have been working to make things simpler and create meaningful changes to how mental health services work together and evolve – putting people with mental health conditions, their families and carers at the heart of that change.

Recently, this included four different week long workshops, which generated a comprehensive description of the Community Mental Health services to be created in Gateshead and Newcastle, under the following four banner headlines:

  • Getting help when you need it
  • Understanding need and planning support
  • Delivering support
  • Staying well

To ensure the redesign was comprehensive, the scope of the original Deciding Together work was extended to include:

  • Older People’s Mental Health services in Gateshead 
  • Third Sector Mental Health services, and the wider Community and Voluntary Sector 
  • Social Care and other Local Authority services 
  • Interface with GP services 
  • Interface with employment and housing 

All partners are committed in moving on from ‘deciding together’ to ‘delivering together’ and are putting three ‘P’s at the heart of the ‘deciding together and delivering together’ programme.


Those who use mental health services and their families and carers must remain at the forefront of concerted efforts and work.  The mental health workforce, staff, volunteers and carers, are the biggest asset and there is a shared commitment to use their skills and time wisely.

Delivering Together design workshops identified cross cutting priorities and principles which will underpin the service design and modelling as below:

  • ‘Trusted Assessor’ approach across whole system, including respecting and listening to Service Users, Carers and all partners
  • Recovery approach across whole system, including how Peer Support concepts can be delivered
  • Carer involvement in their Service User’s support, care and treatment (including Triangle of Care and Support for Carers)
  • Service User and Carer involvement in service planning/delivery/training including Expert by Experience
  • Common sense confidentiality approaches, including common approach to risk management and sharing of risk information


There is clear and strong commitment from all stakeholders to get on with the job and working differently across the health and care system, and being open about that for some this means a significant cultural changes as well as changes to the way services work together.

Existing budgets and resources will need to be used flexibly and creatively across the system. 


Turning new ideas into reality, recognising that there are some quick wins with some elements being designed and delivered in the next few months and others over the course of a couple of years.  We need to see tangible results. 

Agreement across the mental health and care system is to:

  • Improve and simplify access to mental health support
  • Improve the transitions of care where there is meaningful joined responsibility for the person no matter which organisation is providing the care helping people have easy access into support and easy access out as needed
  • Develop community hubs closer to where people live, providing for improved joint working across organisations and a place for people to access a range of supports
  • Respect service users and carers as able to make judgements about their own needs, and as full partners in care and support
  • Increase the importance placed on the social support required to help people stay well
  • Increase the number of alternatives to hospital admission
  • Ensure well-coordinated, holistic care and support for everybody, and improving the crisis response for Older People with organic and functional mental health issues
  • Deliver integrated training strategy across all staff groups and organisations
  • Reduce organisational barriers between NHS, social care and community and voluntary organisations that currently limit more connected and joined up care and support with the person at the centre, including how information is shared
Work streams focus on delivering the change

A number of different work streams are focusing on how bring the new vision from design into a reality. The model which emerged from the Delivering Together Design Events has been nominally divided into 5 areas around key subject areas – each will work with the others to develop an overarching model for a seamless system of care and support.  All will work in partnership to further develop the model of proposed future state, as part of the Deciding Together Transformation programme.

Getting help work stream

This work stream considers how requests for help are responded to by the whole system, whether that be in person, by telephone or other electronic means.  This work will also consider how Carers are supported to request help for the individual they care for, or for themselves.

The work will consider the skills of those responding to requests for help, and those who will aid individuals in accessing the wider system. 

Finally and importantly, this work will consider how information will be shared across the Access System.

This work stream met initially to outline the scope, what was in scope and what was out of scope based on the reports from the workshops.

This identified some potential issues it may face during this work, and where it may need additional expertise from other enabling support services such as IT, information sharing, consent governance, GDPR etc.

Finally the group have developed and agreed to terms of reference and committed to scope the Getting Help model and present through a ‘check and confirm’ workshop.

Urgent response work stream

This work stream considers how urgent requests for help are responded to, including how individuals presenting in crisis, at liaison services and to emergency services are supported by the whole system.  The work stream is also looking at how carers are supported in such circumstances. 

Finally, this work will consider how individuals are ‘stepped up’ and ‘stepped down’ in terms of the intensity of support offered by the whole system, and how Urgent Response services link to other parts of the pathways.

The group has meet and been looking at how the system can widen access to a timely mental health urgent response for all members of the community and the resources required for this.

In particular focusing on the right services being in place in the right places and skills to provide effective response the various degrees of severity of need.

This work will  also conside how Home Based Treatment options can be extended.

A key area of focus will be ensuring equity of service across Newcastle and Gateshead.

Older people's mental health and dementia services work stream

The work aims to develop a system of support which is designed to specifically meet the needs of older people with both functional illnesses (such as depression and psychosis) and those living with dementia,their families and carers. The work will build on the initial model design from the workshops for:

  • Joined up care which encompasses social care and both physical and mental health in equal measures.
  • Urgent care and home-based treatment which meets the specific needs of older people i.e. a crisis which is often a mixture of physical, mental health and social care needs, giving appropriate options for where that care can be delivered.
  • Co-ordination between services so that the person and their carer doesn’t have to repeat their story over again and so that services are more efficient by limiting duplication.
  • A network of support for people with dementia and their carers (no matter their age) which meets their needs through the different stages of the condition, so that there’s a recognised person or place to turn to.
  • Support for carers (of either dementia or a functional mental health condition) which maximises their resilience and confidence to be able to care, with a ‘trusted assessor’ approach when they tell us that the person they care for is unwell

A team from across a number of different statutory and voluntary sector organisations who are passionate about the care of older people met together with the shared common goal of developing the best possible mental health services for older people.

They discussed that the two areas which would most benefit from development were felt to be urgent care for all older people and support services for people with dementia.

Members also felt it to be important to develop services to reflect the needs combined social, mental and physical health needs of older people to create a holistic system of care, working across organisational barriers.

Community based support work stream

A group has met and there was a strong willingness around the table to work together and equality of views is recognised.

The group have agreed to build on the design from the workshops, findsolutions together and be prepared to challenge each other.  

There has been a useful focus on NTW community services as a starting point, however there was an awareness of the differences between Newcastle and Gateshead services, and a recognition that there was a good possibility of quick wins. In recognition of the cross cutting role of community services there was a need to have a clear efficient mechanism for work streams to draw together model design throughout the process, always reflecting on the initial modelling through workshop reports.

Bed based resource work stream

The group have met and are looking to implement the existing agreed model as detailed through Deciding Together consultation process.

They are also considering the recommendations from the workstreams and implement medium and long term vision, this includes making best use of resources and estates and improving the environments of bed based resource. The group wish to clarify bed based resource to include community resource.

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