Space for Professionals - Community Mental Health Hubs

GPs are part of a place based, integrated health and care model following the Community Mental Health Transformation. This model includes an integration of working between GPs and Adult Community Mental Health Hubs. You can read more about the transformation in the Community Mental Health Framework here –  NHS England » The community mental health framework for adults and older adults 

Community Mental Hubs want to work collaboratively with GPs, as per the transformed model. This includes:  

• Creating an easy flow of patients between primary and secondary care to meet patients needs 

• Using the role of the Mental Health Link Workers (ARRS Workers where they are in post), to develop interfaces between hubs and GPs 

• Easy access to MH advice and case discussion for GPs from the Hubs  

• Easy access to MH pharmacy advice 

• Shared care of depot patients with link to antipsychotic guidance 

• Working to meet patient needs and ensuring positive outcomes following their care – patients can be stepped down into primary care following the support from their Community Mental Health Hub with easy access back into the team when needed

Complete the SystmOne or EMIS referral form and send it to the appropriate borough hub. Following referral to a Community Mental Health Hub, the patient will be seen within 4 weeks OR signposted on to a more appropriate service. You will then be informed if they are taken on by the hub or signposted to a different service. 

1. Triage by the hub MDT Discussion including the psychological therapies hub where appropriate
2. Care plan developed with the patient and their carers using the DIALOG+ needs assessment tool  
3. Signpost to appropriate resources and services as required based on their identified needs
4. Or alternatively, work directly with the team and receive appropriate interventions. The patient is regularly reviewed using DIALOG+ to monitor their progress 
5. Discharge back to the GP with letter and ongoing DIALOG+ care plan 

• If a patient who is under a Community Hub is in crisis, please contact the hub directly and ask to speak to the Duty Clinician.  

• If for any reason you cannot get through to the team, please email your concerns to SPA on cnw-tr.spa@nhs.net and we will ensure they are picked up by the team urgently  

Kooth - a digital mental health support for young adults

COVE - in-person support

Hub of Hope - mental health charity

• Please contact the SPA via telephone on 08000234650 to discuss your concern and agree the urgency of the referral 

• SPA will then speak to the patient over the phone and where required arrange crisis support via the Home Treatment Teams, through attendance at the Mental Health Crisis Assessment Service or with The Coves within the 4hr or 24hr timeframes that will be agreed with you during the initial call 

• Following triage with the patient and where crisis intervention is not needed, we will ask the community hub to follow up with their patient on the next working day