Suffolk & North East Essex Integrated Care System

Mental health in adults

HOW we plan to make a difference 
WHY this is important for people in Suffolk and North East Essex

The best possible mental health and resilience is essential if everyone in Suffolk and North East Essex is to live well and age well.

As an Integrated Care System we will ensure that:
  • People maintain good mental health and physical health and are resilient
  • People live in resilient and inclusive communities
  • People have prompt access to mental health support for themselves and their carers
  • People receive the best quality integrated services to achieve recovery and good mental health, delivered in the right way, in the right place and at the right time
  • People receive the best care and support when experiencing a mental health crisis
  • People who self-harm or are at risk of self-harming are supported to prevent harm


The Five Year Forward View for Mental Health (2016) highlighted:
  • People with severe mental illness are at risk of dying on average 15 to 20 years earlier than other people, two thirds from avoidable physical illnesses.
  • Early Intervention, Prevention and Self Care matter – it’s the only way that lasting change can be achieved. Helping people lead fulfilled, productive lives is a system wide responsibility and all agencies must play their respective part.
  • Stable employment and housing are both factors contributing to someone being able to maintain good mental health and are important outcomes for their recovery.
  • 20% of older people living in the community and 40% of older people living in care homes are affected by depression.
  • People in marginalised groups are at greater risk, including Black and Minority Ethnic, LGBTQIA+ and disabled people, people in the criminal justice system, and survivors of trauma.
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HOW we plan to make a difference 
Adult MH
What do we know about people’s local experiences?
  • People want help to self-care, and understand the mental health benefits of balance and moderation in their lifestyle choices.
  • People want to be involved in care decisions, have the same choices and rights regardless of location, and have access to advocacy.
  • Better signposting is needed to support services including peer support groups, voluntary sector and therapeutic activities including art, singing and exercise.
  • People want mental health support to be better embedded in primary care and the community. Having to disclose mental health problems to a GP receptionist is a barrier to accessing support, and GPs should have mental health and suicide awareness training. Timely advice and guidance on physical and mental health issues together is needed.
  • Access, continuity of care and co-ordination is an issue, better support for finances and social issues is needed on discharge from acute services, and organisations should communicate better and use the same terms for the same things.
  • There is limited out of hours local crisis support. When police are sent out in a crisis, Section 136 can be overwhelming.
  • Follow up support after a crisis episode or assessment in A&E should be improved. Patients should to have a ‘safety net’ to return back into care facilities if needed.
  • Further support is needed following a bereavement.

For further information see and

    1.1 People know how to maintain good mental health and resilience.

  • • We will give people and carers information and support to understand potential risks to their mental health and how to maintain good wellbeing. The right information enables people to identify risks or symptoms early and take action to prevent worsening health or crisis. Involving carers and families enables a whole-family system approach that supports everyone.
  • • Mental health prevention and recovery will help people build personal resilience. Resilience helps people stay well and recover when they are unwell, and enables people to take more control over their lives.
  • • People working in health and care will have support from their employers to be mentally healthy and resilient. Supporting the workforce helps prevent burnout and enables them to help the people they work with more effectively.

    2.1 People have local community services that work together to support their mental health throughout their lives. We will enable this by:

  • Collaboration between providers of health, care, education, and community services to develop integrated lifelong mental health services based around local communities. Resilient communities can provide longer term, consistent support for people and their carers, which has lasting impact. We will integrate statutory and voluntary services; child, adult and older people’s services; and health and social care and wider public services within our localities across our ICS.
  • Mental health public awareness campaigns, including system wide suicide prevention support. Campaigns can address fears and stigma of mental health through positive education.

    3.1 People will have improved access to community based integrated therapies and support, including for people with the most complex needs, people experiencing racial disparities in services, and carers.

  • Access standards will be introduced for adult and older adult community mental health teams by March 2029. Testing different approaches to integrating delivery with primary care and waiting times standards will improve access to integrated care.
  • Clarity on how and where to access services locally, will mean services are joined up locally and avoid service users being refused help.
  • More people with common mental health problems will receive NICE-approved Improved Access to Integrated Therapies (IAPT) treatments. Targets are that 75% of people receive a service within 6 weeks of referral, and 95% within 18 weeks. The current recovery rate of 50% should be at least maintained.
  • Parent and carer support at an early stage. Supporting parents and carers in mental health issues early supports them in their caring role.

    4.1 People will receive the best quality community based person-centred care. We will enable this by:

  • We will implement outcomes of the Independent Review of the Mental Health Act 1983. Life expectancy of people with severe mental illnesses can be up to 20 years less than the general population. Increased choice, and less detention, improves quality of care and recovery.
  • We will improve access to physical health checks for people with severe mental illness, by March 2024. Health checks and further identified support will help to close the gap in life expectancy between people with severe mental illness and the general population.
  • Integrated care will be informed by an understanding of trauma. Recognising and supporting the impact of trauma helps recovery and resilience.
  • Care will be focused on the root of mental health issues. Services should listen and identify causes, not just treat ‘symptoms’, or rely solely on medical approaches.
  • Community-based approaches including IAPT, including physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use. Place-based multidisciplinary teams with improved information sharing will provide people with greater choice and control over their care and support them to live well in their communities. The ‘new care model’ approach will allow providers to collaborate more closely in planning specialised mental health services. Improved information sharing underpins the new model of care. To enable delivery we will grow our workforce with a particular focus on the recruitment of psychotherapists, adult community nursing and community support workers.
  • Integrated health, care and voluntary services in both primary and secondary care, including social prescribing, will give people greater choices to access a range of services delivered in a variety of ways.
  • Extending of IAPT services for people with long term conditions provides genuinely integrated care at the point of delivery. Nationally, 1.9million adults and older adults will be accessing IAPT treatment by 2023/24.
  • Delivery of the Early Intervention in Psychosis (EIP) Standard provides for better future outcomes for patients who access timely EIP services. Targets are to achieve and sustain 60% EIP Activity Standard by 2020/21, and to achieve 95% Level 3 EIP NICE concordance.
  • We will extend Individual Placement and Support to help people with severe mental illness into work or meaningful activity, to help improve health outcomes and tackle deprivation. • We will ensure that mental health provision meets the needs of rough sleepers. Services should be accessible and meet the complex needs of rough sleepers.

    4.2 People receive the best quality inpatient care, provided locally.

  • Inpatient care will be person-centred, recovery focused, and minimise use of restrictive practices. People should have maximum choice and control, and their length of stay minimised through effective interventions. Use of segregation and seclusion should be minimised.
  • Inappropriate acute out-of-area placements will be ended by December 2021. In this way people can maintain relationships with family and friends during an inpatient stay.
  • The inpatient physical environment will be improved. People should receive care in good quality clinically appropriate settings.

    4.3 People with gender dysphoria receive high quality services.

  • We will work with NHS Specialised Commissioning to establish a configuration of providers who comply with new service specifications for adult gender dysphoria services by March 2024. The new system will incorporate developing and learning from pilot sites to evaluate new delivery models in primary and community care settings.

    5.1 People in mental health crisis and their carers have access to community-based support to help avoid crisis and acute inpatient admission. We will enable this by

  • Crisis Resolution and Home Treatment Teams (CRHTTs) - 24/7 intensive home treatment service as an alternative to acute inpatient admission, by March 2020. People and their carers will have the support they need to avoid inpatient admission, and be assessed and cared for in their community wherever possible.
  • Increasing options such as sanctuaries, safe havens, crisis cafés, crisis houses and acute day care services for people in crisis and their carers. Alternative, dedicated mental health crisis services, usually delivered by voluntary sector partners, have relatively low costs and high user satisfaction.

    5.2 People who need crisis mental health services will have prompt access.

  • Waiting times targets for emergency mental health services e.g. NHS111, A&E mental health liaison, and community crisis services will be embedded in waiting time standards, beginning in 2020. This will ensure prompt access to care and support.
  • NHS111 will be the single universal point of access for people in mental health crisis, linked to CRHTTs, by March 2024. A single point of access will enable a prompt and more co-ordinated response to people in crisis in the community.

    5.3 People in mental health crisis and their carers receive the best quality emergency first response.

  • Ambulance staff will be trained and equipped to respond to people in mental health crisis. In this way ambulance staff will be skilled in responding to mental health crisis including supporting carers.
  • Mental health transport vehicles and trained staff will reduce inappropriate conveyance by ambulance or police to A&E.
  • Mental health nurses will be situated in ambulance control rooms. Nurses can improve triage and response to mental health calls and increase the competency of ambulance staff through an education and training programme.

    5.4 People in emergency care settings have full access to mental health assessment and support. We will enable this by:

  • All-age mental health liaison service in acute hospitals, at minimum Core 24 standard, that can meet the specific needs of people of all ages, by March 2021. Prompt access to the right support can minimise people’s stay in the Emergency Department and to have the urgent mental health support they need arranged promptly.

    6.1 People know the risk factors for self-harm.

  • Awareness campaigns will improve knowledge of the risks of self-harm, high risk groups and sources of support. Improving awareness helps people to help themselves if they are at risk, and to help others. Campaigns include social media and other ways to reach people.

    6. 2 People who self-harm have high quality care and support. We will enable this by

  • People working in health and care being trained to recognise self-harm and support. Staff and volunteers trained in self-harm can be alert to high risk groups, recognise signs, have difficult conversations, and provide high quality support throughout their organisation and community.
  • People who self-harm having access to evidence based support, delivered in a personalised way.
  • Health and care services sharing information on self-harm to help prevent self-harm continuing and escalating.
  • Supporting focus on the underlying causes of self harm, not solely self-harming behaviours. Tackling the causes of self-harm helps recovery and building resilience

We will know we are making a difference because we will see:

  • Reduction in excess under-75 mortality rate in adults with serious mental illness
  • Fewer emergency hospital admissions for intentional self-harm through improved community support and Crisis Resolution Home Care Teams (CRHT)
  • More people who have completed IAPT treatment having reliable improvement or moving to recovery
  • Fewer hospital admissions for mental health conditions
  • An increase in coverage of 24/7 adult crisis resolution team and service users with crisis plans
  • More people receiving psychological therapies (IAPT), from 20,575 in 2018/19 to 28,428 in 2023/24
  • Increase in proportion of people with severe mental illness receiving a full annual health check and follow-up interventions, from 35.4% in 2018/19 to 82% in 2023/24
  • More people with severe mental illness accessing Individual Placement and Support, from an estimated 559 in 2021/22 to 969 in 2023/24
  • Increase in Early Intervention in Psychosis services reaching NICE standards at Level 3 or above, from 0% in 2018/19 to 100% in 2021/22
  • Increase in proportion of mental health liaison services within general hospitals meeting the ‘core 24’ service standard, from 0% in 2018/19 to 100% in 2021/22
  • Fewer days spent in inappropriate out of area placements by adults needing non-specialist acute mental health inpatient care, from 1,750 ‘bed days’ in 2018/19
  • More people over 18 with severe mental illness receiving care from new models of integrated primary and community mental health services, from 0 in 2018/19 to 6,520 in 2023/24

Adult survivors of childhood sexual abuse have been largely hidden in plain sight in health services foryears. They’ve anecdotally told us how the system has failed them. We have been wanting to educate relevant health professionals about disclosure and support trigger points in health, based on what survivors were telling us - but the traditional meetings weren’t having the desired impact or effecting any change. It wasn’t until we embarked on conducting research with University of Suffolk, which created an evidence base that health professionals could understand sign up to that things started to change – we are engaging health leaders in thinking differently about how (and where) we support survivors, and respond to their individual needs for lasting outcomes.

Having grown up in an abusive home, Frankie, a single mother, moved to Ipswich to a two-bedroom Housing Association flat. Frankie had no friends or family to support her and throughout her life struggled with poor mental health, low moods, stress and anxiety. The death of Mary’s father strained relationships with this side of the family and there was conflict over contact. Frankie’s anxiety levels increased significantly and consequently she often missed appointments and groups with the children. Frankie was worried that she would get stuck in spiralling depression thus deciding to proactively seek help by selfreferring to Home-Start via the MASH team who matched her with volunteer Catherine. The practical and emotional support Catherine gave helped Frankie to access relevant agencies including Cafcass, Children’s Centre’s, Health Visitors, schools and nurseries. With Catherine’s support Frankie is managing her anxieties and behaviours and as a result the children are now attending all required health appointments. Frankie’s mental health has improved dramatically and with encouragement from Catherine, she has successfully applied for a University Access Course. Catherine is also supporting the family during ongoing court proceedings. Frankie feels her volunteer “made a huge impact on her life, having someone to speak to and encourage her made her want to succeed and reach for the stars!”

Last Updated on December 10, 2020

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