PRISM (Primary Integrated Service for Mental Health) – CPFT – Winners #MHAwards19

PRISM (PRimary Integrated Service for Mental health): an integrated solution providing community-based mental health care and support for people with mental health needs at GP practice population level. Covering all GP surgeries in Cambridgeshire and Peterborough CCG (total population of c 980K) PRISM ensures that all patients with mental health needs can access prompt advice and support in a familiar GP setting.

GPs, specialist mental health practitioners, recovery coaches, social care, peer support and third sector staff work in partnership (within neighbourhood-based PRISM teams) to provide true patient-centred care. The service focuses on patients aged 17-65 with a mental health need/s, rather than diagnosis (can be a barrier), and offers a supported approach to self help and care for patients who do not need specialist treatment but need more help/support than core primary care can provide.

Winners #MHAwards19


  • From start: Yes
  • During process: Yes
  • In evaluation: Yes


  • Peer: Yes
  • Academic: No
  • PP Collaborative: Yes

Find out more

  • Dr Emma Tiffin - GP, Cambridgeshire and Peterborough STP Clinical Mental Health Lead

Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

Our service

PRISM (PRimary Integrated Service for Mental health): an integrated solution providing community-based mental health care and support for people with mental health needs at GP practice population level

Summary of service

Covering all GP surgeries in Cambridgeshire and Peterborough CCG (total population of c 980K) PRISM ensures that all patients with mental health needs can access prompt advice and support in a familiar GP setting.

GPs, specialist mental health practitioners, recovery coaches, social care, peer support and third sector staff work in partnership (within neighbourhood-based PRISM teams) to provide true patient-centred care.

The service focuses on patients aged 17-65 with a mental health need/s, rather than diagnosis (can be a barrier), and offers a supported approach to self help and care for patients who do not need specialist treatment but need more help/support than core primary care can provide, .

PRISM provides early assessment, brief interventions (e.g. building confidence groups) and supports access to other services/resources available in the person’s local community. It also provides intensive support for patients with serious mental illness to access physical health interventions.

The patient record is shared between PRISM and the primary care team. (with patient consent) and the service operates flexibly at individual GP practice level (e.g some practices use Skype, PRISM “drop in” cafes etc.).

To encourage a primary care philosophy language such as “request for help” rather than referral is used.



Overarching aim: seamless pathway of mental health (MH) care for the patient and person-centred holistic approach focusing on the medical, psychological, social determinants of MH.


  1. Intelligent / effective healthcare delivery

In 2015/16 Cambridgeshire had the highest MH referral rate in the country. CMHT work was dominated by assessments and risk management, leaving little time to deliver effective interventions. Re-access rates were high, and 9/10 referrals were returned to primary care with usually minimal advice. This resulted in the GP and patient being left unsupported. In order to ensure that CMHTs had capacity to deliver specialist treatment when the patient needed it, we needed a radical shift in our system. We needed to find other solutions to support patients to prevent them from becoming unwell so that specialist services could treat the patients who needed it. We needed to support people better on discharge to prevent re-access and we needed to make the system more responsive. Making better utilisation of support in the community, social care provision and the third sector has provided some of the answers to this. Integration of the whole system was the final piece of the jigsaw as below.

  1. Close “The Gap”– all patients with a MH need/s should receive help

Thresholds for accessing specialist MH care were increasing as demand exceeded capacity. Therefore there was an increasing gap between specialist MH care and core primary MH care provision. This applied to both patients stepping down from secondary care as well as to those needing to step up.

  1. True integration

The components already existed in our system but the solution to sustainable, effective mental health provision is to bridge the interfaces: physical/mental health, health/social care, primary/secondary care. This would also deliver benefits that our patients highlighted are important to them e.g single trusted assessment and reduction in being bounced around between services.


Approach to development and/or delivery

Given the large size of our CCG (980K) and financial challenges (we only had an additional 500K parity of esteem monies to spend on the transformation) – we decided to use a phased implementation approach:

Clear leadership

  • Individual GP practice mental health leads support PRISM teams – these leadership roles are funded via local primary care Quality Engagement Framework – primary care monies
  • Consultant psychiatrists lead on specialist mental health provision for their PRISM populations (including CMHTs which map onto PRISM teams i.e neighbourhood model)
  • STP Clinical Mental Health Lead and Programme Manager


Staff training

Primary care teams upskilled via joint working with PRISM teams / case discussion: MDT meetings, virtual meetings e.g. Skype, email, telephone

PRISM team- monthly training sessions – includes presentations from local statutory, non statutory services, consultant psychiatrists (clinical topics), LGBT, IT


Effective team working

PRISM is based on commitment to teamwork at multiple levels: between individual PRISM teams, PRISM and CMHTs, multidisciplinary staff members within individual PRISM teams.

A shared culture and vision underpin the service. Good relationships are vital, and we invest a lot of time to maintain those factors on an ongoing basis. Our key enablers are shared IT systems and trusted assessments.

We are appointing a PRISM Organisational Development Lead who will further focus on integration/teamwork.

Coproduction – throughout the PRISM development/implementation process and ongoing – see coproduction question


What makes your service stand out from others? Please provide an example of this.

  • Population based service – all patients with a mental health need receive proactive help and support from a multidisciplinary team which is different from the traditional transactional mental health service model with thresholds for accessing help. This allows us to truly deliver on parity of esteem
  • Focus on community assets and supporting people to access these, enabling people that would not benefit from secondary care interventions to achieve their full potential – this is a change from the specialist focused treatment model. This is concordant with our local authority agenda for social care delivery and in line with social prescribing initiatives.
  • New roles – recovery coaches, peer support workers – supporting people to access third sector /community resources, making best use of the patients strengths to improve resilience and reduce re-access to secondary care.
  • Flexible – model is bespoke to practices enabling different innovations at individual practice level e.g. Skype consultations, drop in “PRISM cafes”. This allows/encourages primary care to be more involved in the concept of PRISM and nurtures the engagement between primary care and PRISM.
  • Co-production at all stages of PRISM development (including KPIs), and ongoing. Quarterly patient evaluations are undertaken by our SUN (Service User Network – independent social enterprise) –based on SUN 5 values framework – and delivery board action plans ensure changes are made based on these evaluations/patient feedback.
  • System solutions – working across the PC, CCG and Local Authority agendas to deliver the best outcomes for our community’s wellbeing. Our vision is for a seamless system delivering better access of care for all, a reduction in healthcare utilisation, greater service efficiency and improved patient experience and outcomes. We are now starting to work with the emerging Primary Care Networks to ensure that mental health has a strong voice and that we maximise the opportunities that the PCNs offer (leadership, workforce, finance, training, population health/data).
  • Trusted assessment – an assessment which is transferrable across all parts of the system to ensure reduction of story telling for the patient (this was highlighted as a big issue by our service users/carers). This is also being developed within our IAPT services.


In summary

PRISM is working towards a whole system change in the way in which we work with people in their community. We are have aligned primary care, secondary care mental health services, third sector organisations and the community around the patient, and although there are pockets of this kind of working happening around the country, we are doing this at scale.


How do you ensure an effective, safe, compassionate and sustainable workforce?

Staff working in Primary Care Mental Health Service report feeling valued and heard, their views, ideas and thoughts have contributed to the PRISM vision. The team is diverse with staff from different backgrounds – professionally and personally. We offer our staff a new and innovative way of working supported by a comprehensive training package that includes both in-house training for team members and access to the Trust’s learning and development services. Each team member is encouraged and supported to develop their understanding of all mental health service provision, with shadowing opportunities taking place and guest speakers often headlining in team meetings.

Our recruitment strategy focuses on having the right people in each post, and we are now almost fully recruited despite the workforce challenges in the current climate .

We recognise that supervision is key to staff’s health and wellbeing. Each team member attends monthly operational management supervision. Clinicians also receive monthly clinical supervision (one-to-ones provided by senior mental health clinicians and consultant psychiatrists). The teams also meet monthly for reflective practice sessions.

We have a clear reporting structure for both the teams and service. We hold monthly governance meetings which all the team are expected to attend. The Mental Health Liaison Practitioners (MHLPs) have a monthly reporting meeting to provide an understanding and narrative around the team’s data; understanding hot spots or pressures that the teams are experiencing and jointly developing solutions to address the issues when needed. This information is then shared in the Service Line reporting meeting, which in turn reports into the PRISM Steering Group to enable challenges and solutions to be discussed and shared.

We have listened to the clinicians and understand that their roles can sometimes feel isolated. We also know that our staff make better decisions when they can talk these through with peers. As a result, we are using technology such as Skype to help to connect the teams. Each clinician has been set up with an “agile kit”, meaning that they are able to work flexibly to suit the team and their individual needs.

We are fortunate to have close links to the Positive Practice award-winning Wearing2Hats forum, which we joined to seek their advice on how they would like mental health referrals for Trust staff members to be managed. We are also lucky in that the Trust hosts Recovery College East – again we have worked closely with the college and have employed many of their graduate Peer Support Workers. Having peers in the team is so very positive, and the work that they do is highly valued by our service users.


Who is in your team?

The core PRISM team consists of:

1 WTE B8a Service Manager

2.6 WTE B7 Team Managers

11 WTE B7 Mental Health Liaison Practitioners

27.5 WTE B6 Prism Workers

3 WTE B5 Recovery Coaches

3 WTE B4 Physical Health Workers

16 WTE B4 Peer Support Workers

Consultant Psychiatrist – works across PRISM/Community MH secondary care team

We also have an administration team working alongside us. This consists of:

1 WTE B5 Adminstration Lead

1 WTE B4 Senior administrator

8 WTE B3 Administrators

1 WTE B2 Administrator

It is important to highlight that PRISM is a much wider team than the core service – it works across the interfaces and  includes the following staff: GPs, IAPT, specialist mental health services (e.g. Personality Disorder, Perinatal), medicines management, local third sector providers and social care. And, of course, none of this could have happened without working with our trust leaders, project managers, communications lead, commissioners and public health. Teamwork has been key to the success of PRISM!


How do you work with the wider system?

The PRISM model and principles were designed, implemented and are fully “owned” by the system (following a comprehensive engagement process with all stakeholders including all 102 GP practices at the time). PRISM includes: Primary Care, Mental Health Trust (CPFT) providing specialist mental health services, Local Authority, Public Health, Third Sector. The PRISM service includes both physical health and mental health functions, for example physical health workers support patients with serious mental illness to access physical health interventions and attend physical health checks, they work across primary/secondary care and can access both primary and secondary IT systems.


There is a “hub and spoke” model linking the core PRISM service to our specialist mental health services e.g. personality disorder, perinatal mental health. Named link workers from these specialist services support each PRISM team with advice/guidance and assess people as required, this means people requiring specialist care will transfer into specialist teams for treatment, however people with mild to moderate mental health needs will also receive help and specialist input.


Joint commissioning has taken place to support the shared system-wide vision, for example joint Local Authority/CCG commissioning of third sector/community provision in the form of a new Recovery/Community Inclusion Service, with a particular focus on people with a history of trauma (there was also significant input from our MH trust into development of the service specification). In addition Peer Support Workers and Recovery Coaches based within the PRISM teams support people to access community resources and achieve goals identified within their care plan.

We have included all age commissioning principles and developed operational protocols with the Dual Diagnosis Strategy Board to ensure people with co-occurring substance/alcohol and mental health needs are included.

PRISM is also being linked to the developments around Mental Health Accommodation and reasonable adjustments for people with a Learning Disability and/or Autism.

The system has co-commissioned a website which offers self-help advice, support and information on local services – for service users, carers and professionals of all ages.

We have created a whole system governance structure/process to support system-wide working, this includes a multi-agency Community Mental Health Delivery Board which reports into our all age STP Mental Health Strategy Delivery Board. PRISM is a key indicator on the performance dashboards of both these Delivery Boards with an associated action plan and named leads accountable for delivery of each action. In addition the STP Delivery Board monitors mental health outcomes (health and social care outcomes) at population level in line with the PRISM concept.


Do you use co-production approaches?

Back in 2009 the CCG (formerly NHS Cambridgeshire) and the Local Authority co-commissioned the SUN Network to support service user engagement as a principle of World Class Commissioning. Since that time the SUN Network, working closely with Rethink Carers Group, has supported our mental health commissioners, providers and service users/carers to co-produce services – the SUN are involved with all stages of the mental health service commissioning cycle/process .

In Cambridgeshire and Peterborough all of our services are routinely evaluated from the perspective of the service user/carer. The SUN Network has developed their own 5 values framework service assessment tool which awards providers a number of stars based on the inclusivity of the 5 values within their services. This follows an in-depth service review which includes service visits, interviews and audits/analysis. The SUN Network evaluates PRISM on a quarterly basis, reporting back to the PRISM steering group (both SUN and Rethink are members of this group also). All issues/feedback then become part of the PRISM action plan to fine tune the model which ensures that it is dynamic, flexible and constantly evolving according to local population needs.

The SUN are a key stakeholder in all our tendering processes, writing and evaluating their own specific tender questions, the most recent example/tender being the commissioning of the Recovery/Community Inclusion service as part of the PRISM service model.

The PRISM model was the result of patient/carer feedback which highlighted 2 main issues; repeated story telling and difficulty navigating the system. All subsequent service specifications have been reviewed by the SUN Network and Rethink Carers group to ensure these issues are addressed.

To ensure a robust and genuine co-production process our STP Mental Health Delivery Board is co- chaired by The Sun Network/Rethink to ensure effective service user/carer oversight of strategic priorities.

We also continuously seek feedback, both formal and informal, from all stakeholders. We communicate regularly with GPs and have put together a PRISM Q&A document which is shared. We use survey monkey to collect GP feedback and this is actioned via the PRISM Steering Group.

Examples of changes that we have made following GP feedback include; offering GP self booking into PRISM appointment slots and piloting a Mental Health Specialist Pharmacist role.

Examples of changes that have been implemented following PRISM team members feedback, include; the use of Skype to help the workers to feel less lonely and more connected, allowing decisions and ideas to be shared with the team.

Examples of changes that we have made following service user feedback include; PRISM prescription pads, to help the person to remember what was discussed and what the agreed plan was. We have changed the name of the CPFT element of the service to  ‘Primary Care Mental Health Service’ based on feedback from patients. The trusted assessment has been a key response to service user/carer frustrations of repeated assessments and being bounced around the system.

Co-production has been integral to making services more accessible, appointing the right staff and ensuring that our patients and their families are getting the best outcomes.


Do you share your work with others? If so, please tell us how.

Yes. We have shared our PRISM model/developments (and continue to do so) at a local, regional, national and international level via presentations, written and electronic media.

  1. Local


The PRISM team regularly share updates with all local stakeholders (CCG, Mental Health Trust, 3rd sector, service users and carers, Local Authority) via workshops and existing forums/meetings including local delivery boards (community mental health, crisis concordat and STP mental health delivery boards). The team have also contributed to local suicide prevention workshops, eating disorder and perinatal mental health workshops – sharing their ideas and plans.


Websites/You Tube

  • PRISM information is also shared via our MH trust website (
  • C&P multiagency mental health website (
  • Service award video



We also have a monthly newsletter which is circulated to primary care providers in the area which includes PRISM development updates.



The PRISM team have also promoted their work/service on local radio (BBC Radio Cambridgeshire).

  1. Regional
  • Regular presentations at East of England Clinical Network events – 18/19
  • PRISM webinar (covering concept, pathway, implementation tips) hosted by EOE Clinical Network – Feb 2019
  1. National
  1. International
  • PRISM was presented at International Mental Health Leaders Conference, Sweden, September 2018



What outcome measures are collected, how do you use them and how do they demonstrate improvement?


Outcome Measures

PROM – collected by our secondary care services which provide evidence based interventions for patients referred by PRISM. We have a new recovery/community inclusion service (third sector) “going live” in Sept 19 which will provide interventions for PRISM patients and PROMS will be collected/monitored. Interesting feedback from our SUN around PROMs within PRISM was that these should be reserved for services providing evidence-based, time limited, specific interventions, preserving PRISM worker time for face to face care in the community.


PREM – patient reported experience measures – SUN Network periodic quarterly evaluations. Of the evaluation of 51 people in Q2 of 18/19 some of the results are as follows:

  • 98% of people reported that they felt listened to when they saw someone from the PRISM service
  • 76% felt their needs had been met during the appointment
  • 71% of individuals felt that during their appointment there was shared decision making
  • 65% confirmed they felt they had gained some benefit from the appointment,
  • 71% had something positive to comment on the service
  • 91% of participants confirmed they were happy with the service being delivered in their GP surgery.

The process of data collection by the SUN network is that the PRISM practitioner gains consent for contact details to be sent to SUN with preferences for preferred method of consultation i.e. phone, email, post, face to face. SUN then contacts individuals accordingly and presents feedback to PRISM Steering group.


CROMS – clinician reported outcome measures – GP and staff satisfaction surveys are done periodically and sent out electronically.


All data is reported to the CCG via the contract route and is analysed by the PRISM steering group. The PREM and CROM data informs the PRISM action plan going forward


Achievements so far:

The impact PRISM has had for the patient and wider system is as follows:

  • Reduction of waiting times for assessment by a mental health professional.
  • Reduction in caseloads for secondary care mental health services, therefore increasing capacity for staff to work more effectively with their service users and treat more people, more quickly.
  • Reduction in the workload of GPs
  • Better access to social care where needed.
  • Improved access to our IAPT providers, by seeing people in the right place at the right time by the right person:



Has your service been evaluated (by peer or academic review)?

  • Yes, an external evaluation has been carried out by York Consulting.
  • The full evaluation can be viewed @


How will you ensure that your service continues to deliver good mental health care?

PRISM development and delivery is embedded into our local governance structure. It is a key priority on both our all age STP MH Delivery Board and our Community MH Delivery Board and is included within both action plans to ensure ongoing evolution of the integrated PRISM model. Both delivery boards include senior representatives of key organisations across our system (providers/ commissioners, primary/secondary care, health/social care, 3rd sector, service users and carers).

PRISM has involved a step-change in the way that community mental health services are delivered in Cambridgeshire and Peterborough, focusing on integrated services and person-centred care. This has meant that other areas of mental health service provision (e.g. crisis services) that interface with PRISM have also had to adopt changes in practice that are based on the PRISM model (as above). This system-wide impact and culture change will help to embed PRISM in a way that is not dependent simply on individual enthusiastic leaders, ensuring sustainability of the model and principles long term.

The education and upskilling of primary care staff via co-location of the PRISM team will also ensure that PRISM has a wider impact on the mental health of the population (in the community) for the longer term. We are already seeing evidence of this with more appropriate consultant advice being sought by primary care compared to the traditional community mental health service model.

PRISM also creates greater capacity for delivering specialist evidence-based interventions (as per evaluation/outcomes sections), ensuring the best outcomes for the patient and a sustainable service where capacity can cope with demand. This is achieved through true joint working/management of resource and maximising use of community assets to provide care and support in the community.

PRISM is recurrently funded but we have ensured ongoing evaluation from an economic, healthcare utilisation and patient/carer perspective, meaning we can evidence the value of the service (value defined by quality, outcomes (clinical, patient/carer experience) and cost effectiveness). Being able to demonstrate the value/benefits of PRISM to all stakeholders will ensure that there is ongoing system buy-in and engagement which reduces the risk of any reduction in investment. We have also appointed to a PRISM Organisational Development role in order to support the further integration of services – which is fundamental to the PRISM model and will support sustainability of the PRISM service long term.

Robust governance arrangements (as described previously) will ensure ongoing performance management and development of PRISM, focusing on ongoing delivery of good mental health outcomes for our local population including service users, carers and staff.



What aspects of your service would you share with people who want to learn from you?

Engagement of the local system –  fundamental to the PRISM model is true “sign up” by all stakeholders (health/social care /3rd sector/service users/carers/public health) to the common vision and set of principles – this facilitates the relationships /collaboration/ joint working which underpin the model. We held a series of workshops and met with individual GP practices (with new GP contract primary care engagement could be via Primary Care Networks). It is important to focus on the broader scope of primary care MH (including social determinants of health) and recognition of the long term horizon in terms of gain on investment i.e. prevention is key

Evidence base/data this was important to support the case for change. Ideally you should be able to evidence local MH need/interventions/services. For example in 2015/16 C&P had the highest number of MH referrals in the country (16.5K) of which 9/10 were returned back to primary care, the majority with minimum advice. This led to poor patient and staff experience and an inefficient, ineffective secondary care service which was so busy with assessments that it struggled to deliver any treatments. The referral data therefore supported the need to develop a new MH pathway to achieve intelligent healthcare delivery and good patient and staff experience/outcomes.

Communication – we found that excellent communication was required to ensure that everyone remained engaged with the changes required to implement the PRISM model. We did this via regular meetings, workshops, PRISM teams talking to their GP practices, monthly newsletters and our public C&P MH website (

Governance/robust action plans – our governance structure includes both STP and Community MH delivery boards which was key to the delivery of PRISM, and still is. All stakeholders from our system are represented at senior level (including service users, carers) and jointly own the co-produced action plans.

Leadership again this is key to achieving the change required to implement PRISM. Good leadership is required at all levels (clinical and non-clinical) and includes individual GP Practice Mental Health Leads (funded via primary care budget) who are responsible for supporting/liaising with their PRISM team. As Primary Care Networks develop it would be possible to develop Network MH Leads to provide the primary care leadership function.

Strategic sign up and commitment – again this was key to achieving change. We developed a single multiagency STP MH strategy (previously individual organisations all had their own which were all different!) which identified key aims and approaches focused on prevention, community-based care, tackling inequalities.

Culture shift – from specialist treatment to community-based prevention and care. This continues to be a challenge and we have appointed to a PRISM Organisational Development post to work with primary care, specialist PC MH service and the 3rd sector – to focus on the integration/joint working/supporting the MH of communities and improving population and staff outcomes.

Maximising integration achieved via co-location of PRISM staff in GP surgeries, employing PRISM physical health workers (to support patients with SMI to access interventions e.g. health trainers, smoking cessation service), shared IT, working towards common assessment framework

Flexibility –  operationally at GP practice level, factoring in demography/BME population

Phased implementationbuild on what you already have – operational, financial, ICS/STP – the system. For us PRISM is a dynamic, evolving model focused on sustainability/meeting the MH needs of our population long term.

“Think primary care”/local population   KPIs,  funding options, flexible, use primary care LANGUAGE e.g. request for service, not referral

Clinical responsibility – for the patient remains with the GP although the interventions are delivered by the wider PRISM team , therefore there is a need for a shift to a different way of working and a different way of thinking about responsibility and accountability/joint management of patients. Relationships within PRISM teams (especially between consultant and GP) are therefore key.

Strategic tips

  • Commissioning pathways not ‘services’ – remove gaps and thresholds
  • Funding models supporting population based service models – pooled budgets, weighted capitation, outcomes payments – move away from transactional funding mechanisms
  • Contracting – longer contracts, alliance contracts – for recovery / wellbeing (3rd sector) service
  • Alignment of MH and Primary Care national strategies : MH Forward View, GP FV/now the Long Term Plan
  • Workforce – focus on functions and not titles, training/competencies required, flexible (e.g. staff working across PRISM/CMHTs), workforce planning to ensure sustainability of PRISM long term


Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England): Cambridgeshire and Peterborough CCG, Cambridgeshire and Peterborough Local Authorities

Providers – Cambridgeshire and Peterborough Foundation Trust, MIND and other local 3rd sector organisations.



Brief description of population (e.g. urban, age, socioeconomic status):

Our CCG area includes 2 cities, Cambridge and Peterborough – very different demographics, Cambridge largely high socioeconomic status although pockets of deprivation. Peterborough population is low socioeconomic status. Our rural area (Fenland) also has low socioeconomic status. Huntingdonshire has an older population. Peterborough has a high BME and non-english speaking population – relative to the rest of England.

We have a rapidly increasing population due to new builds e.g. Northstowe

Size of population and localities covered:  Circa 970 K population   Localities – Cambridge, Peterborough, South Cambridgeshire, North Villages Huntingdonshire, Fenland,



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