Surrey Heartlands Partnership has funded Surrey and Borders Partnership Foundation Trust and three Integrated Care Partnerships (North West Surrey, Guildford and Waverley and Surrey Downs) jointly to develop a new integrated way of working that aims to improve the wellbeing and care of people with mental health conditions in Surrey.

This new model will be piloted in three primary care networks in Guildford, Banstead and Chertsey, starting in early 2019.

A primary care network is a collection of GP practices working together with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas to provide a personalised and coordinated integrated health and social care system. You can see an NHS video explaining the role of Primary Care Networks here.

A multi-disciplinary team, made up of a clinical psychologist, a mental health practitioner and a Community Connections link worker (provided by the lead partners, Catalyst and Mary Frances Trust) will be based in each primary care network. They will carry out assessments and provide brief interventions and care navigation for people with mental ill-health.

The service will also provide advice on mental health to GPs as well as linking closely with a wide network of community services to ensure people are effectively supported to access other services that can help. Liaison with a consultant psychiatrist will be available where needed.

The service will focus on better meeting the mental health needs of people aged 18+ who require more support than primary care can provide or who are transitioning from secondary care (provided by Surrey and Borders) to primary care, including:

  • those with anxiety and depression who don’t meet the access criteria of Improving Access to Psychological Therapy or secondary care services
  • people with stable mental ill-health who can be appropriately managed in a primary care-based service
  • individuals who have recently been diagnosed with dementia
  • those with a serious mental illness who would benefit from an annual physical health check and access to interventions.

The intended benefits will be:

  • More resource for GPs to help people who have mental ill-health
  • Improved quality of care and a reduced reliance on specialist mental health services
  • A more collaborative approach to providing high quality care
  • An improved relationship between primary and secondary care services
  • To ensure that people with a serious mental illness do not fall into the gap between primary and secondary care services, thereby improving both physical and mental health outcomes.