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Community mental health transformation charter

Our community mental health transformation charter sets out five key strands for our undertaking of this transformational work and our desired achievements.

These five strands encompass:

  • Why change?
  • Where are we now?
  • What do we want to see?
  • Key steps/milestones
  • What success will look like

The charter also highlights:

  • Accountability and reporting
  • Programme scope of work
  • Success and risk factors
  • Improvements we will see
  • What we will create for our communities, as well as colleagues working in health and care, voluntary and community sector organisations, and primary care networks
  • Sustainability impact

Healthy Minds Community Mental Health Transformation (CMHT) Programme Charter


Better lives, brighter futures – promote, respect and improve the mental health of everyone to live happy, healthy at home.

Programme objectives

As one of four Healthy Minds programmes, CMHT will establish new, integrated models of primary and community mental health care to support adults and older adults with severe mental illnesses (SMI), so they have greater choice and control over their care and are supported to live well in their communities.

Why change?

Our Healthy Minds ambition is to make it easier for people in Bradford District and Craven to access information, advice, support and care based on their needs. 

To achieve this, we need to move away from siloed services based on thresholds and tiers towards an integrated multiagency, multidisciplinary, place-based service, underpinned by a focus on public health to address inequalities and maintain mental wellbeing through effective community-based prevention and protection strategies.

We have an historic, funded opportunity to redesign community mental health care, making better use of collective resources by bringing together local authorities, NHS services, PCNs and the VCS to deliver proactive, personalised and preventive mental health care, aligned with the national Community Mental Health Framework (Sept 2019) and Government White Paper ‘Integration and innovation: working together to improve health and social care for all’ (Feb 2021).

Where are we now?

CMHT strategy in place and work to move from siloed ways of working to an integrated, place-based service being planned, and coproduced.
Investment secured and recruitment underway for PCN-based mental health specialists to improve proactive, personalised care.

Work underway will address:

  • long waits for specialist mental health support. 
  • the under-recognition of the VCS contribution to supporting people’s SMI
  • lack of system-wide integrated care for SMI
  • lack of evidence-based interventions, often with long waits for psychological therapy, for people with complex and longer-term mental health problems.
  • staff recruitment, retention and sickness levels
  • outcome measures to tell us how health inequalities are being addressed.

What do we want?

One programme of work appropriately resourced and coproduced with experts by experience to deliver:

Core model –  integrated social, physical and mental health care to support people’s needs, with no wrong door.

Care provision – coproduced, easy access, patient centred support. Input and equality of voice across services.

Workforce – trauma-informed approach, new roles, clarity on responsibilities, competency driven, training and career pathways; improved wellbeing, recruitment and retention.

Data and outcomes – shared records, interoperability and reporting; Healthy Minds website signposts to services

Focussed support – community-based eating disorders offer; review of local rehab pathway; develop and embed trauma informed approach.

Key steps /milestones

Establish a resourced, integrated programme office.

Develop and agree:

  • streamlined governance arrangements  
  • integrated delivery plan inclusive of specialist pathway priorities and enablers  
  • system-wide carers and involvement strategy and delivery plan, engaging with experts by experience 
  • communications strategy and outline tactical plan 

Ensure all mental health PCNs additional resources universal offer is in place by 2024.

What shows success?

Programme in place with resources secured and clear roles and responsibilities with governance, standard reporting of cross cutting themes and the delivery of  five workstreams that will enable: 

  • Effective, integrated partnership working 
  • Better transition between services
  • Co-location of services
  • Easier access to high quality services
  • Reduced waiting times with the right care at the right time
  • Community Partnership model in place supporting care close to home  

Leads, accountability and reporting

Senior responsible officer: Deputy Director of Integration & Transformation, Sasha Bhat
Each workstream has a named lead who will report to the CMHTx Oversight Group.
The programme will report into the Mental Health Leadership Group, the Healthy Minds Partnership Board, and the Partnership Leadership Executive which provides formal leadership for the Bradford District and Craven Health and Care partnership.
Updates will be reported to the Health and Social Care Scrutiny Committee as required.

Programme scope


  • Adults and older adults community mental health services both  statutory and non statutory
  • Social care for community mental health
  • Primary care psychological and counselling support
  • Employment and housing support 
  • Early Intervention in Psychosis / intensive outreach team


  • Crisis provision
  • Liaison psychiatry 
  • Inpatient services
  • Dementia and care home liaison  
  • Perinatal 
  • Learning disability and neurodiversity 
  • Under 18s 

Critical success factors and risks

  • Enhanced, integrated social, physical and mental health support within Healthy Communities Locality Hubs with flexible ‘stepping up’ / ‘stepping down’ of care based on intensity of input required and enablement principles
  • An end to blanket discharges that leave people with SMI feeling unsupported
  • Shorter waiting times *4 weeks by 2023,  meeting the nationally-mandated week waiting time
  • Removal of arbitrary exclusion criteria; proactive and inclusive care including for co-existing needs
  • Single, coherent integrated model with seamless, clear offer and a named key worker
  • Improved timely access to the full range of primary and secondary care psychological therapies
  • A personalised approach that addresses needs, offers hope and helps someone to live as healthy a life as possible
  • Joined up, accessible support as the norm
  • Integrated teams who are confident, skilled and feel supported at work.

​What improvements will we see?

  • Holistic oversight and evidence of referrals and patient reported outcomes
  • Prescribing is appropriate
  • Manageable caseloads
  • Wider range of support and interventions available
  • Percentage of accepted  referrals for all services are increased
  • Reduced  demand for crisis mental health care
  • Primary care colleagues experience and report improved access and support in their place.

What will we create

  • One trusted assessment process​
  • Directory of resources with understanding  of resources available to support mental health needs
  • Patient information system which can share data between providers​
  • Place-based system of care and support, tailored around local population needs reflecting health inequalities ​and enshrined in ‘happy, healthy at home’
  • Opportunities for collective system person-centred  support for people and their carers.

Sustainability impact

Environmental impact assessment

Increased use of a wider range of roles, linked to improved system career opportunities​
Improved recruitment and retention​
Improved staff satisfaction/morale​

Better access and use of funding to develop new and existing services