Delivering Neighbourhood Mental Health at Scale: How Sheffield’s PCMH Model, Powered by SystmOne, is Delivering National Ambitions
About the PCMH Programme
Sheffield’s Primary and Community Mental Health (PCMH) service is a trailblazing example of how neighbourhood-based models can transform mental health care. Operating across all 16 Primary Care Networks (PCNs) and embedded in general practice, the PCMH service brings together Secondary care, Primary care, VCSE, and community partners to deliver integrated, proactive, and personalised care for people with severe mental illness (SMI).
The service is designed to fill the critical space between primary and secondary care, enabling earlier, more flexible intervention for those with complex mental health needs – close to where they live.
How PCMH Aligns with the NHS Long Term Plan and Community Mental Health Framework
The PCMH model directly delivers on the ambitions of the NHS Long Term Plan and the Community Mental Health Framework, by:
- Delivering neighbourhood health
- Integrating primary care, VCSE, and NHS services
- Tackling inequalities and improving access
- Using data and digital tools to shape population-level delivery
- Protecting time for personalised, therapeutic interventions
Learning from Early Challenges: Why Access Alone Wasn’t Enough
An initial open-access model with a strict “no wrong door” policy led to significant strain:
- Caseloads exceeded 200+ per clinician, prioritising quantity over quality
- Staff burnout and turnover increased, leading to pauses in referral acceptance
- A lack of outcomes – clinicians were assessing and holding, not treating
- High volume of inappropriate referrals meant time wasted on redirection (double-handling)
The Shift: From Holding to Healing
In response, PCMH reoriented its approach to become a treatment-first service, supported by system-wide redesign:
- Every patient is spoken to or seen to determine their care path based on strengths, not just paperwork
- “Huddles” between teams allow safe and timely transfers, not rejections
- Moved culturally to sit between primary and secondary care, with better control of activity and caseloads
- Consistent booking through direct integration with SystmOne enables timely, equitable access
SystmOne: The Digital Infrastructure That Made It Work
The digital transformation that underpinned PCMH’s success was enabled by SystmOne, which provided the foundation for real-time, coordinated, data-driven care.
Key Benefits of SystmOne in the PCMH Model:
- Direct booking from general practice to PCMH team’s rota – no delays, no duplication.
- Shared access to records: Physical and mental health information is unified, reducing risk and fragmentation.
- Outcome tracking is integrated directly into the platform using ReQoL.
- Reporting dashboards support 8-weekly data reviews with PCNs, helping them identify trends and refine local delivery.
- First of type in Sheffield: Enabled Electronic Transfer of Prescriptions (ETP) for Psychiatry.
- Standardised documentation: Templates with embedded coding ensure consistent, best-practice recording for personalised care and support planning.
- Data-driven appointment management: Clinical ledger tracks bookings and adherence to clinical models, linking service delivery to ReQoL outcomes.
- Custom reporting: Tailored reports meet the specific needs of services and stakeholders.
- Flexible by design: SystmOne supports neighbourhood-specific service models while maintaining standardised governance.
Key Achievements (March 24 – April 25): Real Impact at Scale
| Metric | Value |
| Total referrals | 9,979 |
| Screening appointments | 6,865 |
| Treatment appointments delivered | 42,857 |
| ReQoL measures sent and completed | 4,359 |
| Average ReQoL improvement | +8.29 points |
| Total discharges | 7,973 |
| % of patients remaining well post-discharge (6 months) | ~79% |
| % of discharged patients re-presenting to PCMH (not secondary care) | 56% |
ReQoL (Recovering Quality of Life) is a nationally recognised patient-reported outcome measure used in mental health services. It focuses on wellbeing, functioning, and recovery. An average improvement of +8.29 points represents a meaningful clinical gain for service users.
What Else Has Been Achieved?
- Improved access: Over 5,000 people actively supported
- Digital transformation: First-ever unification of physical and mental health records in Sheffield
- Strengthened partnerships: Sheffield Health and Social Care FT, Primary Care Sheffield and Sheffield Mind partners now co-deliver the model with PCN engagement
- Improved equity: 40% of users from Black, Asian and Minority Ethnic communities
- Workforce innovation: New roles introduced (e.g. Community Connectors, Mental Health Wellbeing Practitioners, Clinical Associate Psychologists) with new templates created for the new roles
- Protected treatment time: Clearer triage, reduced admin, more therapeutic delivery
- Improved accessibility: Care delivered remotely, in primary care and community settings, reducing stigma and travel
- Tailored, data-informed delivery: Population health approaches unique to each PCN
A Blueprint for the Future
Sheffield’s PCMH programme shows what’s possible when local services are empowered, digitally enabled, and purposefully designed around people – not systems.
But the model only works when the infrastructure supports it – and SystmOne has been a fundamental enabler of safe, proactive, and joined-up mental health care.
As systems across England scale up their 10-year plans, SystmOne offers a proven, scalable solution for delivering truly integrated neighbourhood mental health care.