City & Hackney has one of the UK’s highest prevalence of Severe Mental Illness (SMI), compounded by high deprivation, digital exclusion, and fragmented mental and physical health support. 

Feedback from dedicated service user groups flagged that many people severely affected by mental illness were unable to achieve their recovery goals and be discharged from secondary services to primary care. Meanwhile, national policy around personalisation and digital transformation in mental health was advancing, creating an opportunity to redesign care around the individual. 

We worked with our service users to redesign the recovery planning process along the whole recovery pathway. As programme lead, I was tasked with designing and delivering a cross-sector pilot that would embed low cost, direct payment Personal Health Budgets (PHBs) in the recovery pathway as a means of achieving individual goals, and also bridging income inequalities. 

I led co-production workshops with service users, clinicians and commissioners, applying a strengths based model to recovery goal setting. I developed the strategy to scale PHBs beyond s117 across the whole pathway, embedding them in digital care plans and designed a tiered authorisation system to ensure equity, governance and support and training materials for staff. I also designed and launched the “Stay Connected” PHB to provide devices and connectivity to those at risk of exclusion.

As a result, we became the first site in England to offer PHBs across the whole SMI recovery pathway, not just 117 aftercare, and where PHBs are integrated into digital personalised care planning, supporting people to self-manage their mental wellbeing and step-down to primary care.