Recite Me

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Community transformation


South West London and St George’s NHS Mental Health Trust (SWLSTG) are in the process of transforming their mental health services and changing the way they operate in Kingston and Richmond. This is in line with the NHS England Community Mental Health Framework for Adults and Older Adults, which describes how the Long Term Plan’s vision for a place-based community mental health model can be realised, and how community services should modernise to offer whole-person, whole-population health approaches.

The transformation programme runs over three years, with the first year taking place in Sutton, as the pilot. Over the last 12 months, teams in Kingston and Richmond have worked closely with local stakeholders – GPs, Voluntary, Social and Community Enterprises (VCSEs), the South West London Integrated Care Board (SWL ICB), local authorities, service users and carers – using learning from the Sutton pilot to design and implement this change.

SWLSTG has worked with service users and carers to design a new model of care, centralised around the core principles of community transformation:

  • Improved integration with VCSE partners
  • A placed based holistic support offer
  • A “no wrong door” approach to referrals
  • Introduction of new roles and skillsets
  • Single, trusted assessments
  • Removing barriers between primary and secondary care.

These core principles underpin the work to achieve the four key outcomes of transformation:

  • Access – increased timely access to a wider range of mental health interventions
  • Recovery – increase in the number of people reaching and maintaining recovery
  • Crisis – reducing the risk of service users relapsing into crisis
  • Experience – improved experience of care and treatment in mental health services for service users, their carers, family and friends.


As part of Community Transformation, each borough has established a Single Point of Access (SPA) team, offering holistic mental health and wellbeing assessments with a focus on service user and carers’ needs.

Following assessment, a multidisciplinary team collaborate at daily referrals meetings to establish the most appropriate interventions based on identified needs and goals. This exciting new service development helps to speed up the referral process and achieves greater integration between primary care, secondary care and VCSE partners.

Through attendance from a range of professionals, service users and carers can access a wide range of mental health, physical health, wellbeing and socio-economic interventions within newly developed integrated Recovery Hubs (formerly Recovery Support Teams (RSTs) or Community Mental Health Teams (CMHTs).

The holistic services provided in Kingston and Richmond now include:

  • Tailored mental health care and treatment, which may include dedicated support for Complex Emotional Needs, support through an expansion of psychological interventions, increased pharmacological treatments and the introduction of further support for co-occurring mental health, alcohol and drugs
  • Employment Support to help individuals to retain and obtain employment
  • Newly commissioned peer support services provided by VCSE partners, which provide peer support from individuals with lived experience of mental health conditions, offering support, guidance and sharing experiences to help individuals with their recovery goals and needs.
  • A forthcoming newly commissioned welfare advice service provided by VCSE partners, offering assistance with issues such as welfare benefits, housing and finances
  • For our partners in General Practices, the SPAs also offer specialist Advice and Guidance without the need for referral through the e-referrals (eRS) system.

In line with our new integrated model, the following teams will change to Integrated Recovery Hubs (IRHs):

  • North Kingston CMHT will become North Kingston IRH
  • South Kingston CMHT will become South Kingston IRH
  • Richmond RST will become Richmond IRH
  • Twickenham RST will become Twickenham IRH

The SPAs and IRHs are not crisis services. If the service user is having pervasive thoughts of ending their life which they feel they will act upon, then this should be treated as an emergency. They can telephone the 24h Mental Health Crisis Line on 0800 028 8000, attend their local Accident & Emergency (A&E) department, telephone the emergency service on 999, or telephone the Samaritans on 116123.