Rethink Mental Illness logo

Background and aims

Open Mental Health is a multi-agency alliance of local voluntary organisations, NHS and social care services in Somerset. They work in partnership to ensure that residents of Somerset get the mental health support they need, when they need it.

The shared ambition for the Open Mental Health Alliance is to reduce waiting times for clinical services and ensure that people have access to housing, jobs or volunteering opportunities, community activities and physical exercise. The aim of providing this support is to improve people’s wellbeing and mental health, enabling them to live happy and fulfilling lives in the community.

Primary care is often the place people first seek help but may not be able to provide the care that is really needed. While it may not be possible to prevent crisis escalation in every situation, this redesign of community mental health can ensure people’s mental health needs are met in a timely way.


Open Mental Health uses the collective strengths of partner organisations to transform lives and support the mental health of communities in Somerset. They do this by breaking down long existing barriers to support, enabling prevention, early intervention and the provision of holistic support.

People with lived experience of using services have been at the heart of the design, development and delivery of Open Mental Health from the very beginning.

Aims of the redesign of community mental health:

  • To break down barriers between primary and secondary care.
  • Early access to assessments and interventions within primary care.
  • Improve designs of care pathway for people with eating disorders and personality disorders
  • Reduce entry thresholds to access services and improve smoothness of transitions
  • To establish a partnership with voluntary and community sector partners (VCS) offering a wide scope of support.

Somerset open mental health locality model.png

Open mental health locality model: key building blocks and model of delivery (Rethink Mental Illness, 2020).

Building blocks of the model:  

  • Clinical teams are the key building block in the locality model
  • Wider determinants – it is important recognise that access to support is crucial for patients, even if a patient is a are moderate or severe level of risk, they should still be able to access it.
  • Capacity building – it is important that the voluntary sector is built within Somerset as communities are important in a persons recovery.
  • Place based hub – this hub offers a multi-disciplinary team that provides individualised support to meet people’s needs.
  • Crisis provision – a crucial part of the community model of crisis provision is that help is accessible outside of office hours. A 24/7 helpline is available to offer people clinical support around the clock.
  • Peer volunteers – peer support is one of the most important factors in the model, providing relatable support from people with lived experience.
  • Experts by experience – making changed to service design in co-production with experts by experience is critical to make the service as meaningful and effective as possible.

Open health delivery model:

  • This delivery model uses 13 primary care networks (PCN) which are broken down into 4 locality areas throughout somerset.
  • Offer a multi-organisational team. This uses a one team approach; to make sure that mental health is seen as a critical part of their work and is central to the way services are shaped.
  • Localities need to understand, link and fully integrate with the current provision within each area to enable a truly integrated approach that meets local need.
  • Large focus on engagement with GPs and primary and social care networks.
  • Support is flexible  - stepped up or down depending on the level of complexity of the patient. This means that barriers to accessing care are removed.
  • A move away from the idea of discharging a patient, instead managing them independently in the community, maintaining their access to support.
  • To provide a 24/7 volunteer led helpline which gives patients access to support and access to clinical help.
  • Provides multiple entry points, removing barriers to accessing care at traditional single access points (e.g. GPs).
  • Provide black pear system. This enables the use of one shared digital plan that can be accessed across the localities, reducing the need and challenge that comes with using multiple care plans.
  • To change language and dialogue e.g. Refer to ‘warm’ transfers between the community care system rather than ‘referrals’, breaking down barriers between services.
  • To support grassroot organisations which support people that don’t traditionally access services.
  • Encourage a move away from having to reach thresholds in eligibility criteria used in triage and assessment to open the door to people that could be turned away.


This model of integrated care offers high-quality support to those in need in Somerset.  People in somerset can be supported quicker, overcoming barriers to support in traditional models. Other key outcomes are:

  • People feel like they are listened
  • Tailored care provided on the basis of individual needs.
  • Consistent, streamlined care - using one care plan means that patients needs are understood across services.
  • Improved transitions between services.
  • Reduced waiting times for clinical services.

“Open Mental Health really has been a whole system effort, focused on real transformative change of mental health services and support in Somerset.  All of the Open Mental Health partners, voluntary sector and statutory sector alike, have worked incredibly hard.”

Beccy Wardle, Rethink’s Head of NHS Collaboration

Additional information

For more information on Somersets open health redesign of community mental health, visit the Rethink webpage.


Rethink Mental Illness. (2020). Webinar: Somerset’s trailblazing redesign of community mental health. Available at: 

The aim of the ZSA Case Studies is to introduce users to a range of examples of new and innovative practice, with the broad aim of working to support people with their mental health, bring awareness to and help prevent incidence of suicide. Please seek further information by contacting the ZSA and appropriate professional input prior to making a decision over its use.

This content was developed based on information within the public domain. If you would like to update this content, please contact us

For more information on ZSA case studies, please refer to ZSA Policies.

If you have an example of innovative work and / or good practice that you would like to share with us, please e-mail: