Community Treatment Team – Sunderland (CTT)

The aim of the Community Treatment Team, Sunderland (CTT) is to provide specialised evidence based skilled intervention to people with moderate to critical mental health needs that maximises their potential for recovery. The team works with people who have severe and enduring mental illness that often results in complex health and social care needs. CTT have introduced physical health assessments to all new clients referred in to services. The assessment is guided by the Lester Tool which covers Smoking, Lifestyle and Life Skills, BMI, Blood Pressure, Glucose Regulation and Blood Lipids.


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


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

Find out more

What We Did

The aim of the Community Treatment Team, Sunderland (CTT) is to provide specialised evidence based skilled intervention to people with moderate to critical mental health needs that maximises their potential for recovery. The team works with people who have severe and enduring mental illness that often results in complex health and social care needs.

Northumberland, Tyne and Wear NHS Foundation Trust (NTW), in spite of being a specialist mental health trust, is committed to improving the Physical Health and Wellbeing of its service users. The importance of good quality physical healthcare for patients with mental health needs is vital to reducing the incidence of secondary physical health problems and early death. Of the 300,000 people with serious mental illness (SMI) conditions in England many die of the same conditions as the general population, but up to 15-25 years earlier. In 2012 NTW formed a trust-wide Physical Health and Wellbeing group, reporting to the Trust-wide Quality and Performance Group, in order to prioritise the focus on physical healthcare and the health and wellbeing of Service Users, and to ensure that this remains a priority for NTW moving forward.

In response, CTT have introduced physical health assessments to all new clients referred in to services. The assessment is guided by the Lester Tool which covers Smoking, Lifestyle and Life Skills, BMI, Blood Pressure, Glucose Regulation and Blood Lipids. In addition, we provide regular monitoring including physical health parameters, ECG and blood tests as required to clients who are in receipt of antipsychotic medication and mood stabilisers.

Concerns identified are reviewed by a member of the medical team and actioned appropriately including referrals/discussions with GP, Cardiology, Nephrology and Endocrinology. We maintain regular communication with local GP’s regarding the outcome of results along with the treatment plans and progress made in relation to their mental health needs.

We have embedded regular physical health reviews in our standard work and ensure our clients physical health is reviewed on a 6 monthly basis in line with their care plan review. Physical health reviews are facilitated by our Clinical Support Workers who are trained in venepuncture and ECG. We currently have 9 clinics per week for physical health reviews. Staff are also trained in providing advice on smoke cessation and we are currently supporting staff in completing further training in alcohol misuse and sexual health awareness.

We also provide Clozapine Clinics at our team base (Clozapine in prescribed ot clients who have treatment resistant psychosis). Some of this client group experience difficulty with poor veins and it can be difficult obtaining blood required for testing to ensure the client can remain on their medication. In order to ensure our clients remain mentally well, we have arrangements with the local acute hospital for us to take capillary blood samples (as opposed to venous blood) which are then processed in Sunderland Royal Hospital. this ensure clients can remain on medication and thus maintain their mental wellbeing and stability

We have also successfully implemented titration of Clozapine in the community; this allows for the client to remain at home (and is not admitted to a mental health unit, ensuring our inpatient beds are used for those clients who are acutely unwell) and saves our organisation a substantially amount of money.

Northumberland Tyne and Wear NHS Foundation Trust has adopted a positive attitude in engaging service users in physical activity. Following on from government initiatives to increase activity levels and adopt a healthy lifestyle, CTT have access to Exercise Therapy for its client group to promote healthy lifestyle and reduce obesity.

CTT have trained a number of clinicians in smoking cessation treatment and we work in line with Primary Care in ensuring all our clients have access to this service, either via Primary or Secondary Care Services. All new clients being offered an assessment with services will soon be provided with an information leaflet out lining the health implications of smoking.

Wider Support 

We work closely with a number of external agencies including Social Services,  Local Government Smoking Cessation, GP’s, Exercise on Prescription, Sunderland Royal Hospital (Cardiology, Diabetes, Nephrology and Endocrinology), Primary Care Services who offer various courses including Healthy Eating Cookery Courses, , Dietician, Vocational and Voluntary Organisations – Mind, Headlight, Rethink, Arts Studio.

We are partners with Sunderland Care and Support in providing a Recovery College for our community. it provides psycho educational groups, activity and support around mental health problems and courses are facilitated by trainers who have a lived experience of mental health problems.

The Service User and Carer Reference Group meets Bi-Monthly. This is a high level Assurance Group and has involvement and information around the Transformation Process and its implementation within the community teams within NTW.



NTW has recently undergone significant change in how we deliver mental health care with Sunderland locality taking the lead in its roll out. Service Users and Carers were actively involved throughout the whole process, from workshops to consultation to implementation. The new model will significantly improve the quality and effectiveness of community services for our patients and carers: create highly efficient, new ways of working which will make better use of resources.

The initial findings from “Is there a Pathway to Recovery through Care Coordination were fed in to the Transformation Workshops and Pathway Design. The project will also form part of the evaluating the model. Service user and carer researchers will interview service users and carers about their experience and views on our new model of working.

Our pathways have been designed to put the service user at the centre of everything we do, with a focus on prevention and recovery.

New documentation has been developed to help service users and carers prepare for their appointments: this is owned by the service user and captures the needs, wishes and treatment of the service user that they can keep with them a reference tool.

On a more local level, Sunderland locality is actively involved with Sunderland Service User Involvement Steering Group and Carer Involvement Steering Group which aims to ensure that both carers and service users are involved with the continued development of our community services.

Our Trust values of Care and Compassion, Respect and Transparency ensures we put the needs of our Services Users and Clients at the centre of our work. We have appointed a number of Peer Support Workers who  support and enhance our Service Users on their journey of recovery by reflecting and sharing (when appropriate) their own lived experiences.

Sunderland Recovery College offers an opportunity to provide support and hope to service users. It is designed and led by service users and their carers to enable people to support themselves and each other on their personal road to recovery. The idea behind the Recovery College has taken off and is becoming a key part of the supporting Sunderland Service users.

NTW completes a Trust wide Service User audit every year and results from this are become part of local action plans, with the aim of improving Service Users experiences of mental health services.

Looking Back/Challenges Faced

Cost implication – as with all new ways of working, there was a cost implication in ensuring we could provide a service to meet the physical and mental health needs of our client group. However, the cost was more about time resources as opposed to financial implications: the time to complete training, attend workshops, mentoring etc.

Although the team have always been passionate about the mental health needs of  service users, initially there was some resistance to assessment and reviewing of physical health as “not being our business”. This has resulted in training being delivered to teams with a rationale around mental health and how this can impact on physical health and mortality rates. Introducing the role of phlebotomy, ECG/BP and lifestyle assessments has empowered our Clinical Support workers and the model of assessment and review of physical health is now embedded within the delivery of training. we also introduced Physical Health Champions whose role is to support and educate colleagues around physical health and provide a resource of information which will have a positive impact on health lifestyles.


The physical health needs of our clients are now core business and provide part of our framework in assessment, treatment and evaluation of our client group.

We need to ensure our staff are trained in assessing and delivering treatment: we have developed an internal training package which includes “Train the Trainers” ensuring we have a consistent resource across the team. as staff progress through their careers, we will have a team who will be able to train new team members.



Evaluation of the model is facilitated by Service User and Carer researchers interviewing both Service User and Carer in their subjective and objective views on this. The research will also include the interviewing of NTW employees. We are currently evaluation the new model of care with clients, carers and staff.

We have clinical effectiveness targets set by both CCG and our own organisation in ensuring we assess and review physical health on a 6 monthly basis. This has been supported by embedding this approach in to our day to day delivery of care.

We have completed based line audits on Community Clozapine titration and Smoke Cessation which identified action plans. These are reviewed on a regular basis and contribute towards our internal targets Long term we aim to see a reduction in early mortality and improved mental health


We have shared our experiences with other community teams within NTW and this has contributed to local CQUIN targets. NTW has shared this experience with other mental health organisation through the country.



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