Transformation of Community Mental Health Services

We're transforming the way we provide mental health support in the community for adults and older adults in Sussex.

As part of the NHS Long-Term Plan, which tasked health and social care systems across the country to develop new, more joined-up, ways of delivering care in the community for people with severe mental illnesses, the community mental health transformation will bring local services in Sussex together, including mental health, partners from social care, primary care, local authority, and voluntary community and social enterprise services (VCSE).

The new services will be designed around the needs of the local community and developed in collaboration with the people who will use and work in them.

  • Patient outcomes and experience will improve; patients will be in charge of their own care and will be offered a personalised package of support based on what they need at that time, which could include psychological therapies, physical health checks, peer support, social activities, or support for employment, housing, or finance. 
  • Staff satisfaction and retention will increase; staff will be empowered to work with more autonomy, will have access to additional resources, a more manageable workload, as well as clearer opportunities for training and development.
  • There will be efficiencies and collaborative working across the system; patients will be treated in the right place at the right time, and supported to stay well in their own homes, and pressure and reliance on crisis and acute services will be reduced. 

What is the community mental health transformation?

Understanding new roles: what does a Mental Health Practitioner do?


Latest news

Our progress

On Wednesday 27 September, over 40 Sussex Partnership Trust colleagues, as well as representatives of NHS Sussex, primary care, and Voluntary, Community and Social Enterprise (VCSE), came together to focus on the next steps needed to start to align the current specialist community mental health service for adults and older adults provided by Sussex Partnership Trust (Assessment and Treatment Services) and the Emotional Wellbeing Service in GP surgeries.

The aim of the day was to focus on the contribution of Sussex Partnership Trust (SPFT) in delivering the core model of the transformed service, and the SPFT leadership and internal structures required to deliver this. Partner representatives were present to ensure place-based groups continue to be co-led, and ensure pre-existing plans are incorporated.

The discussions throughout the day were supported by facilitators and structured in to three exercises:

  1. What is the final destination we need to get to? What does "good" look like?
  2. The ‘core’ service on paper. Who is in the core team?
  3. What do we need to do in our ‘place’ to take that next step? Who is going to do what?

Themes of discussion and agreement:

Structure of the service

Together we tried to conceptualise and imagine what the new service could look like, and the broad agreement was that there should be a 'core team' that works closely with a 'wider network' of services, teams and organisations. The core multidisciplinary team (MDT) would include community mental health teams (currently Assessment and Treatment Service/ Specialist Older Adults Mental Health Services (SOAMHS), Emotional Wellbeing Service, VCSE colleagues and peer support. The core team would work closely alongside a wider-network, to include GP practices, NHS Talking Therapies, Drug and Alcohol services, Early Intervention in Psychosis, Perinatal, and other relevant stakeholders.

Service implications

There was a lot of discussion about how multiagency triage could further develop, and the meetings that would be required to support this to work effectively, with examples being shared by colleagues of where this is happening and working well in areas already.

A working group has already been established to explore a consistent approach to this work, and using learnings from previous work already started by the pilot areas. A part of this will be to look at the viability of GPs and other clinicians being able to make a referral directly into the core team, which could be advantageous as it would create a shared accountability for that person's care from the start. Multiagency triage meetings will also support decision making of the best options for a person's care from the core team and the wider network, and an immediate allocation of the available resource within the system, reducing delays for support to start.

The following meeting structures have been suggested:

  • Daily huddle, led by the core team but open to all in the network. To be used to manage triage and allocations, and also include space to raise urgent queries and concerns
  • Weekly network meeting for case discussion
  • Weekly multidisciplinary team meeting to manage and plan caseload work

Cultural principles

There was discussion about how the envisaged core team needs to be much more than simply an aligning of ATS and EWS, but instead creating a new supportive structure that will enable genuine change to happen, to include:

  • Patient centred care - by providing choice of options and a joined-up approach to care, by ensuring all support needs are considered as a system from the start
  • Supporting practice and the building of relationships, to provide continuity of care for patients and decision making by those responsible for delivery
  • Collegiate approach with network partners through shared care practices and direct clinician-to-clinician referrals and regular multidisciplinary discussion
  • Improved recognition of specialist skills by individual disciplines and modernising the lead practitioner role.

Next steps:

Using the feedback from the day itself and since, the Community Programme Team will continue to work alongside the three 'places' to continue these conversations, and begin to plot out the key actions, owners/leads, and timelines for delivery. To include:

  • Continue plans to develop a Pan-Sussex approach to triage
  • Review existing plans with place-based leads, and agree next steps with local teams
  • Work with teams to understand what support is required to plan and deliver new ways of working at a local level
  • Continue roll out of EWS across PCNs
  • Develop formal partnership agreements, with clearly defined roles and responsibilities.

If you have any questions or comments about this work, please contact

There have been lots of developments and activity happening across Sussex. See the full list below:

When? What? Details
November 2023 Monthly webinar

A focus on the older adults portion of the community mental health transformation, and the launch of a new suicide prevention campaign for older adults.

Watch webinar

October 2023 Monthly webinar

'Meet the programme team' - a panel discussion about the community mental health transformation programme.

Watch webinar

September 2023 Monthly webinar

Dr Emily Gray and Stina Bormann provide an update on the developments in the community rehabilitation pathway.

August 2023 Monthly webinar

Tasha Barefield, Lived Experience Coordinator, Jonathan Beder, Transformation Director, and Megan Gee, Communications Manager, provide an update on the 'changing the language' project that is being completed as part of the community mental health transformation programme.

July 2023 Monthly webinar

Penny Fenton, Community Pathway Lead, and Martin Dominy, VCSE Transformation Lead for Mental Health, share the proposed integrated model diagram which aims to show how we anticipate community mental health services in Sussex to look post-transformation, which includes how they will better align and work more collaboratively together.

June 2023 Monthly webinar

Oliver Dale, Clinical Lead for Community Mental Health Transformation, Nigel Evason, Interim Director of Programmes for Mental Health Collaborative, and Martin Dominy, VCSE Mental Health Transformation Lead, East Sussex and Brighton & Hove, share examples and learnings of how other parts of the country have approached the community mental health transformation programme, and what we can learn from each of them in Sussex.

May 2023 Crawley community mental health transformation workshop

An in-person workshop which built on the previous event in October 2022, to continue to discuss the community transformation programme in Crawley, West Sussex.

The event was attended by people with lived experience, family and friend carers, health and social care staff, and VCSE representatives. The workshop had a focus on coproducing plans for the development of community hubs.

May 2023 Monthly webinar

Emma Logie, Lead for VCSE Mental Health Transformation Team (West Sussex), and Martin Dominy, Head of VCSE Mental Health Transformation Team (East Sussex and Brighton & Hove), speak about the role of the Voluntary, Community, and Social Enterprise (VCSE) in the community mental health transformation programme.

April 2023 Monthly webinar

Dr Bree Macdonald and Dr Brian Solts discuss the work that has been so far and is ongoing to develop a specialist pathway for adults with complex emotional needs (CEN).

April 2023 Brighton & Hove quarterly webinar The first Brighton & Hove community mental health transformation quarterly webinar, which provided an update on progress made in the city so far, and next steps.
March 2023 Partnership Matters article The community rehabilitation hubs that have been developed as part of the community mental health transformation programme featured in Sussex Partnership's magazine, Partnership Matters. Read the full article on page 5 here.
March 2023 'Changing the Language' workshops Two workshops were held as part of the Changing the Language project.
March 2023 Monthly webinar

The development of an all-age eating disorders pathway for Sussex.

February 2023 'Changing the Language' focus groups Two focus groups were held as part of the Changing the Language project.
February 2023 Monthly webinar

A discussion about the importance of co-production - working together with people with lived experience of mental health difficulties, and family/friend carers.

January 2023 Monthly webinar


Rachel Coffey, Programme Director, provides an update on what has happened in the programme so far and the next steps for 2023.

December 2022 Monthly webinar

Jenny Edge, General Manager for Emotional Wellbeing Service (EWS), and Anne Foster, Head of Mental Health Commissioning, provide an update on the development of the EWS and the next steps

November 2022

Monthly webinar

Rachel Coffey, Programme Director, and Penny Fenton, Community Pathway Lead, provide a background about the transformation of community mental health services for adults and older adults in Sussex

November 2022

Place based workshops

Virtual and in-person workshops took place in East Sussex, with invited guests from the local health and care sectors. Building on the priorities identified in the system model workshops in August, the groups worked together to agree what the local area could start to do to transform their local community mental health services.
October 2022 Place based workshops

Two workshops took place with invited guests from the local health and care sectors in Crawley and Brighton & Hove. Building on the priorities identified in the system model workshops in August, the groups worked together to agree what the local areas could start to do to transform their local community mental health services.

September 2022

Partnership Matters article

The community transformation was featured in Sussex Partnership's magazine, Partnership Matters. Read the full article on page 22 here.

August 2022

System model workshops

People from across the health and care system, including senior leads from across the primary, statutory and VCSE health and care system, people with lived experience and experts by experience of accessing mental health services, and carers, attended workshops at University of Sussex in August, to establish what needs to happen for community mental health services to be transformed, future models, improved ways of working together and local priorities. The workshops were a significant milestone in the programme so far, which initiated a collaboration of people who will use and work in the services. 


Specialist pathways

The Enhanced Community Rehabilitation Service provides intensive community treatment and the ability to intervene earlier than current Assessment and Treatment Services. For example, they are able to monitor adherence and work more intensively with housing providers to maintain tenancies.

The Enhanced Community Rehabilitation Service works closely with community inpatient rehabilitation services to reduce length of stay and improve patient outcomes in the community regarding recovery, and social and occupational functioning.

Offering an alternative pathway to this cohort of complex high-need service users will also reduce demand on Assessment and Treatment Services, allowing them to focus on and be more responsive to other high need service user groups.


The transformation aspires to develop an all-age service for eating disorders, increasing capacity, shortening waiting times for support, and removing the barriers that are currently in place to access services. 

Eating disorder services nationally have seen a large increase in demand, especially during the Covid-19 pandemic, and specialist services in Sussex have been facing unprecedented service pressures. We have been working to improve services and meet this demand, including through:

  • Expansion of specialist services to reduce waiting lists (adults and children and young people (CYP))
  • Alignment of specialist service provision across Sussex to reduce unwarranted variation (adult)
  • Expansion of early help provision via VCSE organisation, Beat (CYP)

To further improve outcomes and experience for people of all ages experiencing eating difficulties and disorders, health and care organisations are working together to look at the current care pathway (the whole system offer for each stage of support from prevention/early identification through to specialist and more intensive care) and thinking together about what we would want this to look like in Sussex. This has highlighted gaps and opportunities for more joined up, integrated working and for developing a seamless pathway of care with a focus on early intervention.

We are now moving into implementation of the new pathway within available resources, and we will be working with people, professionals and organisations across Sussex to make that happen.

Please check back for further updates.

The community transformation will give a renewed focus to people living with a range of long-term severe mental illnesses, including complex emotional needs associated with a diagnosis of personality disorder. 

Getting involved

Want to get involved, share your views and ideas, and be part of this exciting transformation?



Event / workshop / webinar


Sign up

Wednesday 13 December 2023 12-1pm Monthly webinar - topic: Neighbourhood mental health teams: a model for Sussex, and our current roadmap Virtual Click here
Wednesday 17 January 2024 12-1pm Monthly webinar - topic: Improving communication and signposting for people seeking support for their mental health in Sussex: sharing the insights project completed, the recommendations, and identified workstreams Virtual Click here
Wednesday 21 February 2024 12-1pm Monthly webinar - topic: Place-based updates and progress: an update from Crawley, High Weald Lewes and Havens, and Brighton & Hove Virtual Click here
Wednesday 20 March 2024 12-1pm Monthly webinar - topic: TBC Virtual Click here

Within the transformation programme there are co-production leads, who help bring people together and support them to be able to contribute and make a difference to mental health care services. There is also the SCALE Network, which stands for Sussex Coproduction And Lived/Living Experience.

Get in touch to find out more about how you can get involved.

Natasha Barefield (East Sussex and Brighton & Hove):

If you are a voluntary, community or social enterprise organisation working in mental health, you may be interested in joining the network for your area, to help influence and shape the future provision of community mental health.

West Sussex:

Brighton & Hove / East Sussex:

If you have any questions or comments about the community transformation, or want to get involved, please email

And you can also follow us on social media to stay up to date with all the latest news and updates:

Facebook: @SussexCMHT
Twitter: @SussexCMHT
Instagram: @SussexCMHT