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title: "Mental Health Teams"
canonical: "https://wiki.patientsknowbest.com/space/DEPLOY/3573285074/Mental%20Health%20Teams"
format: markdown
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> Macro (toc)
# Introduction
PKB is providing mental health teams and service users a secure platform to view their health and care records, access information about their treatment plans, review medication details, and communicate with their care team, all of which can be made accessible via the NHS App (more information available [here](https://manual.patientsknowbest.com/patient/nhsapp)). Greater visibility and control over a person's health and care information enable individuals to participate actively in decision-making and self-management through enhanced engagement. To read more about how PKB is the solution for many teams and organisations, scroll down the page.
# Core Capabilities
Some of the core features teams use in PKB to support mental health service delivery include:
# Use Cases
## Kent and Medway Mental Health (KMMH)
Celebrating its one-month anniversary, KMMH has achieved a 48% registration rate, smashing its initial target by 8%. Alongside this rapid onboarding, all appointments are available in PKB and the NHS App with notifications and messaging (N&M) turned on. Within the first month of the Trust wide go live, they sent just over 63,000 appointments to 20,700 patients.
Their Mental Health Together team also saw a staggering 300% increase in Patient Reported Experience Measure (PREM) completions in just 4 weeks.
### How they did it
- Appointments are sent directly to PKB and the NHS App Wayfinder via N&M, allowing patients to view their appointments and register with PKB if an email is attached to their record.
- Implemented a workflow where unregistered patients are invited to register and view their appointment in PKB and/or to complete questionnaires by verifying their identity using only their date of birth
- Once the questionnaire is submitted, the patients are immediately prompted to register for PKB, capturing them at high engagement.
Supported by a trust-wide go-live across 22 clinical teams, utilising a resource library and digital care plans.
## Nottinghamshire Healthcare NHS Foundation Trust
Nottinghamshire Healthcare NHS Foundation Trust implemented PKB for Patient-Reported Outcome Measures (PROMs) after being required by NHS England, following low compliance (1–2%) with paper-based systems and a CQC-identified gap.
### Impact
- Completion Rate: The completion rate for the Dialog+ has increased 15-fold, rising from a historical low of 1% to 30% in the initial 3 months (rising to 34% by time of publication), for an initial 13 mental health teams.
To read the full use case, [click here.](https://patientsknowbest.com/2026/03/19/nottinghamshire-healthcare-nhs-foundation-trust-digital-rollout-of-dialog-proms/)
## Waiting List Management + Waiting Well
Mental health services face significant challenges with long waiting lists, but PKB empowers service users to take an active role in their care while waiting.
With PKB, mental health organisations can:
- Support teams in triaging patients effectively using digital tools.
- Keep service users informed by sending updates on referral acknowledgements and waitlist status changes.
- Provide a library of waiting well resources and generic care plans, such as goal-setting care plans or generic condition care plans
## Mental Health Organisation Rollout of PKB
In 2021, Sussex Partnership NHS Foundation Trust started using PKB to enable their service users to access their mental and physical health records whenever they needed them in one place. Importantly, it also allowed them to choose to share parts of their records with others involved in their care, including their GP, other hospitals, care workers, friends, and family carers.
### Clinical Input
- Care Notes integration with PKB gives service users access to their 'My care and safety care plan'
- The Care plan is created, completed and published in Care Notes and sent to PKB
- Care Notes do a demographic update
- Sharing data within the network
- Appointment letters, appointments, and care plans are all under the mental health privacy label
- Giving patients access to their data was the driving force
- Recall questionnaire through an API
### Features
- Care plans are created, completed and published in Care Notes and sent to PKB
- Care Notes do a demographic update
- Sharing data within the network
- Appointment letters, appointments, and care plans are under the mental health privacy label
- Giving patients access to their data was the driving force
- Recall questionnaire through an API
### Outcomes
## Essex Partnership University NHS Foundation Trust (EPUT)
EPUT vave successfully transitioned from paper-based to digital Patient-Reported Outcome Measures (PROMs) using the PKB. Launched in early 2025, this shift has modernised how patient recovery is tracked and managed.
### The Shift: From Paper to Digital
Previously, Adult Community Psychology (ACP) teams struggled with manual paper forms that were administratively burdensome and resulted in low engagement. By digitising the Recovering Quality of Life (ReQoL) measure, EPUT transformed a "tick-box" task into a collaborative clinical tool.
### Key Performance Improvements
The impact of the April 2025 pilot is reflected in the significant rise in data quality and efficiency:
| | | |
| --- | --- | --- |
| Metric | Paper-Based (Old) | PKB Digital (New) |
| Return Rate | ~20% | 36% |
| Completed Returns | 34 | 77 |
| Admin Effort | High (Printing/Posting) | Low (Automated) |
### Benefits
- For Patients: Easier access via any device, real-time visibility of their recovery scores, and a greater sense of ownership over their health data.
- For Clinicians: Reduced manual workload, better data consistency, and more meaningful insights to use during consultations.
- For the System: Integration with Electronic Patient Records (EPR) ensures data is accessible and actionable rather than trapped in "silos."
EPUT plans to scale this success by implementing full automation between PKB and the EPR, utilising automated reminders (PKB "Campaigns"), and expanding the digital PROMs model across all Adult Community Psychology pathways. To read more, [click here.](https://wiki.hub.patientsknowbest.com/wiki/spaces/DEPLOY/pages/5100439743)
## The City and Hackney Collaborative is made up of City and Hackney ICP, North East London CCG, East London FT, The Advocacy Project and Core Art & Sports
Mental health personal health budgets: redesigning the recovery pathway
The aim was to use personal health budgets (PHBs) in a redesigned recovery pathway to help overcome barriers to achieving recovery goals, including for people’s physical health.
Core Arts and Sports and the Advocacy Project utilise the PKB platform as their single aggregated record. Professionals treating patients use PKB to view the patient's medical history to make the best clinical decisions on their behalf. For reference, patients with severe mental illness across City and Hackney in North East London are receiving data from primary, secondary, and voluntary care organisations in a single aggregated record. Read more information on their award-winning [work carried out by City & Hackney](https://patientsknowbest.us1.list-manage.com/track/click?u=ed9891035475747f47bab2b10&id=dbb1608874&e=1680b994d7), which showcases the power of bringing services together across a region.
- Each patient is given digital access to their Personal Health Budget (PHB) on PKB
- A shared recovery plan called ‘Me and My Goals’ was developed
- It brings together Primary Care, Secondary Care (mental health hospitals) and voluntary sector organisations to collaborate with people on these shared resources.
- People can track symptoms and measurements
- No duplication or repeating past medication history
- People consider their mental health, physical health and social needs, and identify three goals to stay well and the next steps for each.
### Outcomes
### National Recognition
In September 2021, the team was recognised for its Digital Recovery Platform for Severe Mental Illness, and it picked up three awards for its cross-sector programme of work at the HSJ Value Awards.
The collective walked away with:
- Winner of the Digital Clinical Transformation Award
- Highly commended for the Primary Care or Community Service Redesign Initiative and the IT & Digital Innovation Award
- Finalists for the Mental Health Service Redesign Initiative
Read more about their success [here](https://patientsknowbest.com/2021/09/17/city-and-hackney-collaborative-scoop-up-at-2021-hsj-value-awards/).
To read the full article, click on the link, [Mental health personal health budgets: redesigning the recovery pathway](https://www.england.nhs.uk/long-read/mental-health-personal-health-budgets-redesigning-the-recovery-pathway/)
## Midlands Partnership NHS Foundation Trust
In 2023, Midlands Partnership NHS Foundation Trust (MPFT) embarked on a transformative journey with PKB across Adult Mental Health Services (AMHS) and the Making Every Contact Count (MECC) initiative.
The aim was to give people access to their health records, enabling self-management of care to improve their experience and reduce service demand.
- Support the hospital’s services to share Professional Record Standards Body (PRSB) care plans
- Empower service users to make positive changes to their physical and mental health and wellbeing
- Improve communication between service users, carers and healthcare professionals
- Editable shareable care planning tool.
- Fully integrated with the NHS App, allows service users to receive digital letters
- Greater patient accessibility, especially around language translation.
- Utilises PKB to support the About Me questionnaire as well as PROMs like DIALOG and ReQol for service users
- Enabling meaningful discussion between patients/carers and clinicians / clinical teams to establish dialogue and shared decision-making
- Monitor people's progress towards their goals
Service users receive an email prompting them to register and complete their PROMs. Once completed, service users' responses are fed back into RiO. Clinicians then utilise these PROMs to develop individualised care plans (including the Care and Support Plan and Overcoming Challenging Times), which are sent to the service users’ PKB records. Read more about the projec[t here](https://htn.co.uk/2023/12/21/reflections-from-across-the-nhs-digital-in-2023/).
## Oxford Health NHS Foundation Trust
The Ketamine Clinic team provides treatment for people with depression who have not responded to other treatments. The team utilised PKB as the digital solution for the pilot. They registered patients on PKB, giving them access to pre-appointment care plans and questionnaires, which improved the efficiency of the appointments.
Click on the link to read the full case study on [monitoring the safety of ketamine in treatment-resistant depression.](https://patientsknowbest.com/2019/11/15/monitoring-the-safety-of-ketamine-in-treatment-resistant-depression/)
## St.Patricks Mental Health Service
In 2020, St Patrick’s Mental Health Services (SPMHS) became the first health service in Ireland to choose PKB as its Personal Health Record platform.
Central to their objective of placing service users at the heart of their care journey was offering them PKB, giving them access to health information, digital questionnaires, and the ability to involve and interact with professionals involved in their care.
A two-way data flow from PKB to and from SPMHS clinical system RiO was ensured through integrations and single sign-on. Professionals can send questionnaires to service users on PKB directly from Rio, and get the responses back on it.
### Features
- Central library for support and resources to enhance care and treatment experiences
- Questionnaires for every program and every stage, 'assessment,' 'pre,' 'interim,' and 'post,' tailored to the service users' recovery stage
- Events and Messages receive PDF doc of the keyworker information and support plan, discharge summary and clinician summary review report
### **Outcomes**
- 40 questionnaires are available for professionals to send to service users, covering a wide range of conditions such as Eating Disorders, Bipolar Disorder, and Depression, as well as programmes like Mindfulness and Building Healthy Self-Esteem.
- Single sign-on to Rio
- Two-way data flow
- Integration for appointment details, including video links to join them remotely and clinic letters.
# Key Features
There are key PKB features all mental health services can use with their cohort to capture and view data. A list of them is below.
### NHS App
Information from healthcare providers can be accessible via PKB’s web solution and via [PKB’s jump off points in the NHS App;](https://wiki.hub.patientsknowbest.com/wiki/spaces/MAN/pages/3624075361)
### Questionnaires
Patients can initiate a questionnaire by clicking Start Questionnaire on their homepage or directly within the NHS App. Once completed, the questionnaire can be sent to a professional or team.
Teams using the questionnaire tool can ensure the outcome of clinical reviews is recorded, and the patient has a copy. Teams can also identify patients suitable for virtual appointments or PIFU.
### [PKB's advanced questionnaire functionality](https://wiki.patientsknowbest.com/space/api/3691937900/Complex+Questionnaires)
The features include:
- Scoring and calculations
- Branching, allowing patients to complete the parts of the questionnaire that are relevant to them
- Coded fields questionnaires can be mapped to clinical codes
- Patients can save drafts
- Send questionnaires to patients who aren’t registered or already in your team
PKB’s advanced questionnaire functionality and automated scoring of assessments will be provided, and coded questionnaire responses will be mapped to the patient's graphed measurement section, making it easier for patients and their healthcare collaborators to understand any trends and progress of deterioration as assessments take place over a period of time.
### Care Plan Templates
PKB has a general [care plan toolkit](https://wiki.hub.patientsknowbest.com/wiki/spaces/DEPLOY/pages/3542778062),** **and there are several [mental health-specific care plans](https://wiki.patientsknowbest.com/space/DEPLOY/3573285109) that are already in use by our mental health user base such as:
- [Me and My Goals with Physical Health Check](https://wiki.patientsknowbest.com/space/DEPLOY/3573285244/Me+and+My+Goals+with+Physical+Health+Check)
- [My Care and Safety Plan](https://wiki.patientsknowbest.com/space/DEPLOY/3573285109/Mental+Health+Care+Plan+Template#My-Care-and-Safety-Care-Plan)
- [Depression and Anxiety Monitoring Care Plan](https://wiki.patientsknowbest.com/space/DEPLOY/3573285109/Mental+Health+Care+Plan+Template#Depression-and-Anxiety-Monitoring-Care-Plan)
- [Bipolar Disorder: Is Valproate The Right Treatment For Me?](https://wiki.patientsknowbest.com/space/DEPLOY/3573514902/Decision+Support+Tool+for+Elective+Care+Pathways+Templates#5.-Bipolar-disorder:-Is-Valproate-The-Right-Treatment-For-Me?) (NHSE decision support tools care plan converted into a PKB care plan
### Appointment journey through NHS App
# Comms Examples
The Sussex Partnership NHS Foundation Trust website gives patients information and a link to register with their PKB record via the NHS login. [https://www.sussexpartnership.nhs.uk/my-health-and-care-record](https://www.sussexpartnership.nhs.uk/my-health-and-care-record)
The tri-leaflet below is also sent to the patient alongside clinical or appointment letters.
# Further Information
- [How to capture digital outcome measures in PKB](https://wiki.patientsknowbest.com/space/DEPLOY/3731947525): examples outcome measure questionnaire templates and workflow
- [Severe mental illness: ](https://wiki.hub.patientsknowbest.com/wiki/spaces/DEPLOY/pages/3573514722)using PKB to provide a digital recovery platform
- [Mental Health questionnaire templates:](https://wiki.hub.patientsknowbest.com/wiki/spaces/DEPLOY/pages/3572990091) examples of questionnaires used by mental health teams
- [Mental Health care plan template](https://wiki.hub.patientsknowbest.com/wiki/spaces/DEPLOY/pages/3573285109): example of a care plan used by a mental health team
- [A digital recovery platform for severe mental illness](https://transform.england.nhs.uk/key-tools-and-info/digital-playbooks/mental-health-digital-playbook/a-digital-recovery-platform-for-severe-mental-illness/): NHSX Digital Playbook using PKB as the digital solution for the severely mentally ill
- [Video testimonial of a patient on a waiting list for CBT](https://www.youtube.com/watch?v=MG9ETm1SJAM): given PKB so he could independently act on this advice at home whilst waiting for this therapy to start
- [Video testimonial of a patient with long term mental health and physical health conditions](https://www.youtube.com/watch?v=oHgcVtR8c7Q): didn’t feel in control of their own health and struggled to communicate her background and needs.