Recite Me

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Community Transformation

Over the coming years, the Trust’s Integrated Programme is bringing forward new investment and innovations.

Improving our services to provide high quality care for people across South West London is a key part of our overall mission Making Life Better Together.

We embarked on a transformation programme for adult community mental health services in September 2019; in line with the NHS Long Term Plan,  recognising that a new integrated and flexible delivery model is required to help meet current and future service user needs.

The NHS Long Term Plan (LTP) prioritises community-based care and recently transformation funding was announced to support the transformation of adult community mental health services over three years (2021/22 – 2023/24).

Why do we need Community Transformation?

We know that our current clinical pathways can be inconsistent and fragmented in the way they deliver services.

The overarching purpose of this programme is to make both community and inpatient services work together so that patients get the right care and support as they need it. By ensuring everyone is offered core care and treatment options, choice and flexibility, we can really make life better for our service users and carers.

These ambitions will be supported by investment into mental health under the NHS Long Term Plan.

Making it happen

The Trust has worked closely with colleagues and partner organisations across the South West London Integrated Care System to successfully bid for new funding that was announced to support transformation of adult community mental health services over three years (2021/22 – 2023/24).

For Year one the Trust was successful in receiving £2.8m which will be invested in community adult mental health services in 2021/22 with additional amounts available for future years.

The proposed new model of community adult mental health delivery will:

  • Focus on supporting individuals with serious mental illness and within this group specifically also strengthen support and care for individuals (1) with an eating disorder, (2) with a diagnosis of personality disorder or (3) requiring mental health rehabilitation
  • Be organised around and/ or integrated with wider partners including Primary Care Networks and primary care, voluntary and community sector provision and local authority provision.
  • Be co-produced and include both clinical delivery and provision by voluntary and community sector organisations
  • Remove barriers between primary and secondary care.
  • Optimise data sharing
  • Recognise and impact on the social determinants of health and non-clinical needs
  • Reduce waiting times, addresses inequalities and support transition.

Our next steps

The proposed model will be piloted in Sutton in 2021/22 and then reviewed and adapted as needed.

Placed based design and delivery groups will commence in Kingston, Merton, Richmond, and Wandsworth over the next 18 months and work carried out in each borough to ensure new models of care meet the needs of our local populations.

We look forward to working with partners and organisations across our communities as we bring forward this innovative new programme.

For any questions about Community Transformation at SWLSTG please contact us at


Community Rehabilitation

The Trust’s Clinical Transformation Programme comprises of several workstreams, one of which focusses on Specialist Services Redesign (SSR). There are two current transformational projects within the SSR workstream; rehab services transformation and eating disorders services transformation.

The aims of the rehab services transformation are to:

  • Review SWLSTG current rehabilitation pathway provision
  • Redesign and develop an enhanced SWLSTG rehab pathway to ensure that i) the rehab services are recovery focussed with a clear understanding of what this means and ii) services deliver high quality care, in the least restrictive environment possible, which is integrated with newly developed community rehab services
  • Define elements of admission to rehab inpatient units in collaboration with the South London Partnership Complex Care Programme (SLP CCP) and ensure standardised operational processes are aligned with the redesign of the SWLSTG rehab pathway.

Work will involve learning from other trusts’ pathways, developing a community rehab team and linking this into the Community Transformation Programme, reviewing SWLSTG procedures and ways of working, standardising rehabilitation interventions offered based on service (high dependency unit, community rehab unity, community offer) and ensuring a clear and robust new rehab pathway is put in place.

To date, the rehab transformation team have worked with service line and SLP colleagues to map out the current “as is” pathway, identifying where there are gaps and issues across the pathway and with the pathway processes. Several workshops have been held with the ward consultants, ward managers, and partners from SLP CCP team, with the third and final workshop on 3rd December 2021. The first two workshops have focused on the development of the new community rehab team and the role of the SLP, and how these interface with our inpatient services. There has also been discussion on current issues and how we can work to overcome these challenges.

Work is also continuing on understanding demand and capacity related to rehabilitation provision across SLP and within SWLSTG. Work continues into establishing bed optimisation numbers, skill mix and establishment, and estates. A working group is being set up to continue work on this.