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Community mental health service review

We’re working to improve community mental health services for adults with Severe Mental Illness (SMI) across Herefordshire and Worcestershire.

Our goal is to provide: 

  • Better designed services around the people who use them.
  • Earlier support, so fewer people need intensive treatment.
  • Improved experiences and outcomes for patients and their families.

By March 2027, we aim to make care more joined-up, personalised, and accessible.

Why are we making these changes?

Last year NHS England asked all Integrated Care Boards (ICBs) to look closely at how their community mental health services work. The aim was to review how community mental health services support people with severe mental illness, especially those who find it hard to use standard services and need more regular and focused help in the community.

We were asked to work with our local ICB review current community mental health services and decide whether they meet people’s needs and find where things could be better. A big part of this is the new Personalised Care Framework, which will help make sure people with severe mental illness get consistent, person‑focused, and well‑coordinated care.

This work aims to make community mental health services better, so fewer people need intensive support. 

How are we doing this?

We’ve created five key workstreams to drive improvements:

  1. Legislation and policy – Clear, transparent policies aligned with the Mental Health Act and Capacity Act.
  2. Assertive community offer – Proactive support for those who need it most.
  3. Clinical pathways, multi-agency working and information sharing – Streamlined processes for safe, effective care, and better collaboration with housing, voluntary sector, and other partners.
  4. Working closely with families – Embedding family involvement and recovery-focused care plans.
  5. Personalised care 

What does this mean for patients and their families?

  • More opportunities for patients and carers to shape and design our services.

What are the community mental health services?

We work together with GPs and other local organisations to provide joined-up, person-centred care, helping you to receive the right support, in the right place, at the right time.

Get involved

We’re committed to making sure patients, families, and carers are actively involved in shaping this project. If you’d like to:

  • Learn more about what we’re doing
  • Support the project as an Expert by Experience
  • Share feedback or explore opportunities to get involved

We would love to hear from you!

Contact our Patient Experience and Engagement Team:

  • Email: whcnhs.communityengagement@nhs.net

Project news and updates

February — April 2026

  • We have mapped and analysed our patients (caseloads) across both counties to identify those who need a more assertive and proactive approach.
  • We have reviewed medication clinic processes to make sure they follow best practice guidelines.
  • We have completed a review of the Assertive Outreach team model in Herefordshire. The service has gone through the Royal College of Psychiatrists accreditation process. 
  • New coding has been added to our patient record systems. This helps us quickly identify patients by their diagnosis.
  • New alerts are being created in our record systems. These will tell teams when patients are given high‑risk medications and highlight any side effects.
  • The information on our website has been reviewed and updated. We have checked accessibility and health literacy to improve experiences for patients and families.
  • We are reviewing our referral processes and how patients access support. We want to have similar processes across all services.
  • We are looking at our staffing and structures to make sure they meet the needs of our patients and are fit for the future.
  • We are reviewing the training available for our staff, as well as social care and voluntary care partners.
  • We have improved how we record and review information about our patients (demographics). This helps us to better understand our patients and the support they may need.
  • We are exploring how peer support workers could be part of our services. Peer support workers are people with lived experience who support others in their recovery.
  • Work is underway to make the guidance we provide to staff, including standard operating procedures (SOPs) and policies, easier to read and access. 
  • We are working to ensure all staff have a clear understanding of the definition of Serious Mental Illness (SMI). 

January 2026

  • We have reviewed all the information about our services on our website. We made sure it is up-to-date, easy to understand and follows health literacy guidance.
  • We have also created a new online hub for community mental health services. This will grow over the next few months. It will help patients and families find the information they need in one simple place.
  • We are currently writing a project charter. This will explain our aims, how we plan to work and how we will measure our progress. We will add it to this page when it is ready.
  • We are in regular contact with other NHS community mental health service providers across England. We are learning from their approaches and looking at what could work well here in Herefordshire and Worcestershire.
  • We recently carried out a survey with our carers about their experiences of our services. Thank you to everyone who took part. The results will be available next month and will be shared with the project team.
  • We are looking at ways we identify and record information on carers on our patient record systems. We are also developing guidance for our staff to promote early conversations with patients about their family and/or carer arrangements.  
  • We are looking to improve and increase engagement with experts by experience – these are people who have accessed our services. We are also hoping to introduce a new Peer Support Worker role into our services.
  • We have reviewed our patient letters, developing them in collaboration with patients to ensure they are easy to understand, and contain helpful information and signposting to support services.