Shared working

Understanding roles & responsibilities, utilising connections & building relationships to better respond to the physical health needs of people who have a serious mental illness (SMI).

We need to develop systems and working relationships that promote joint-accountability. There is a lack of a joined-up care across mental health, primary care and social care to deliver coherent physical health measures for people living with serious mental illness (SMI). Lack of clarity across these services contributes to poor outcomes of those living with SMI.

The national guidance for Clinical Commissioning Groups states that the “secondary care team is responsible for SMI patients under care of a mental health team for less than 12 months and/or their condition has not yet stabilised, and inpatients”. Primary care is otherwise responsible for SMI patients.

Recommended actions to take

  • Deliver the Five Year Forward View for Mental Health (FYFVMH) target of delivering annual physical health checks to people with an SMI (see national guidance). This represents an opportunity to develop more integrated, co-ordinated and enhanced models of primary mental health care, responsive to a range of needs.
  • Develop and deliver (with mental health and acute providers) shared care pathways and models to support transitions between sectors that support recovery, deliver improved physical health outcomes and embed patient reported outcome measures (PROMs) in evaluation.
  • Develop strong and cohesive relationships and systems with mental health and acute providers to develop joint accountability and effective and efficient mechanisms to support information transfer and shared working.

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