man_shirt_smiling_community_thumb.jpegThe way that care is planned and delivered within our adult community mental health teams will begin to change in the next few months.

Over the last few years, we’ve been committed to transforming community mental health services as part of the NHS Long Term Plan. Investment has seen expansion in services and the implementation of new integrated models of care between primary care and community mental health teams.

As part of this continued transformation, we will be replacing the old ‘Care Programme Approach’ (CPA) in line with guidance from NHS England and the national Community Mental Health Framework, which has been co-produced with service users, carers and professionals.

Like all mental health providers across the country, we have been using the CPA to plan and deliver care for almost 30 years. Service users on the CPA receive a care plan and a care co-ordinator to organise their care.

The new approach aims to make sure that everyone receives the same level of high-quality care planning – including a named key worker – no matter if they have or have not been on the CPA in the past.

Why are the changes taking place?

Community mental health policy and practice have evolved significantly over time and new legislation such as the Care Act 2014 has been introduced. Coupled with investment and changes to community mental health services, it is time for a fresh approach.

What is the new approach and what will it be called?

The new approach is based on the following principles:

  • A shift from generic care co-ordination to meaningful intervention-based care planned between the service user and their care team.
  • A named key worker for all service users but with a multi-disciplinary team approach. This means the right people from a number of different services — including social care and the voluntary sector — can provide the right care at the right time based on an individual’s need. This can help to address people’s social need as well as clinical need. And reduce potential gaps in service provision.
  • High-quality, co-produced, holistic and personalised care and support planning with service users actively co-producing and reviewing their care plan with staff. This includes input from non-NHS partners where appropriate, such as social care, housing, public health and the voluntary, community and social enterprise sector.
  • Better support for, and involvement of, carers to provide safer and more effective care. This includes encouraging carers and family members to input into care and support planning.​ Because the role of family and friends in a person’s life is important.
  • A more accessible, responsive and flexible system in which approaches are tailored to the health, care and life needs, and circumstances of an individual, their carer(s) and family members.

The new approach will involve five stages of care:

  • Assessment
  • Care planning
  • Intervention
  • Care review
  • Recovery

The new approach hasn’t been given a new name yet and we would like service users, carers and their family and friends to be involved in considering a new name for the new approach. Further information on how you can be involved is detailed below.

As part of the care planning, the move away from CPA will embrace the newly introduced Patient Reported Outcome Measures (PROMs).

What are PROMs?

PROMs is an acronym that stands for Patient Reported Outcome Measures.

Outcomes refer to the result of any care or treatment provided. It could be that our support has helped someone lead a more fulfilling life, reduced or stopped any symptoms they may have had, or helped them back into employment or education.

Completing these outcome measures helps us to understand a person’s needs and develop meaningful relationships and interventions based more entirely on their goals.

The outcome measures have been developed based on research evidence and recommended for us to use by NHS England and the Royal College of Psychiatrists. 

To support the move away from the CPA, we’ll be using three PROMs. These are:

  • DIALOG: This is a simple set of 11 questions that help plan care around what truly matters to the service user
  • Goal Based Outcomes (GBO)These focus on what the service user wants to achieve and get out of their care and support. And measures their progress towards these identified goals.
  • Recovering Quality of Life (ReQol-10)This has ten questions about quality of life, and how this is linked to the service user’s recovery.

You can read more about PROMs here.

What will the new plans include?

The new plans will:

  • Be personalised. Because we’re all different and one size does not fit all.
  • Share key information.
  • Be developed by the service user with their health care professional.
  • Welcome the views of carers, loved ones and family members.
  • Consider physical, mental and social needs.
  • State what actions people need to improve their health and wellbeing. This includes actions that the service user agrees to take, things that carers might undertake and the actions services will undertake.
  • Include care provided by partner agencies.
  • Make sure that people don’t need to repeat information to several different agencies.

The plans will also provide detail on a named key worker.

What is a key worker? And what will happen to my care co-ordinator when I move from the CPA?

All service users will have a named key worker they can contact. This will be the most suitable person from the multi-disciplinary team. In a lot of cases, this will be their existing care co-ordinator.

But because we’re adopting a multi-disciplinary team approach, service users and carers will be supported by members of the wider care team, too. This means the right people will be able to provide the right care at the right time based on an individual’s need.

Who will the care plan be shared with?

The service user will have control of who their care plan is shared with. This will be discussed and agreed.

How will carers be supported?

There will be proactive support for carers. Their thoughts, comments and ideas will be welcomed and supported.

Service users will be encouraged to share information with them and to include them in care planning and delivery.

Who do the changes affect?

This change affects all community adult functional service users. This includes community mental health teams, specialist teams like Early Intervention in Psychosis, rehabilitation, crisis, hospital liaison and the home treatment team

Other services who use the CPA, such as memory services, will continue to use them. This might mean that some service users will continue to receive care plans for other services they receive.

If you’re currently receiving services from us and are on the CPA, you do not need to do anything. No service user will have any changes made to the way their care and treatment is delivered through CPA without a review in which they will be included.

When we are ready to launch the new approach, we will work with you to transfer you from the CPA to the new approach. This will happen in line with a care review which you will be fully included in.

But if you have any questions then please contact us.

Can I be involved in developing the new approach?

Yes — if you’re a current service user, a carer of a service user or an individual who has been discharged from the CPA within the last five years, we’d like to hear your views on the new approach.

We are holding three focus sessions:

  • Monday 10 June 2024 | 10am-11.30am | Business Hive, Dudley Street, Grimsby DN31 2AW
  • Thursday 13 June 2024 | 1.30pm-3pm | Business Hive, Dudley Street, Grimsby DN31 2AW
  • Tuesday 18 June 2024 | 1.30pm-3pm | Business Hive, Dudley Street, Grimsby DN31 2AW

If you’d like to attend either session, please book your place by emailing the team on or calling (01472) 252366 (ext 14161).

If you can’t make these sessions but would still like to contribute, just let us know — we’d really welcome your views.