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Community Living Well


What is it?

Community Living Well offers support with social wellbeing, mental and physical health needs to people aged 16 and over who are registered with a GP in parts of West London, UK.


It is a single, wraparound set of services that can be readily accessed by individuals, GPs and carers. The services provided include talking therapies, support groups and help with employment or housing issues.


Community Living Well was co-produced with service users, carers, NHS and voluntary sector organisations. It brings together mental health and wellbeing services that are delivered by the NHS and voluntary sector organisations, who work together as equal partners.

Living Well system features:

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Are accountable for people centred outcomes that promote choice, recovery and citizenship



Provide timely access to support where
it is needed 



See people as citizens within communities, rather than ‘patients’ or ‘professionals’

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Put the voice of lived experience at the centre of services and the system

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Work holistically, building up and on people’s strengths



Activate supportive

social networks

How does it work?

The service uses a ‘hub and spoke’ model to ensure that people are able to access a wider range of community services and groups in places that are convenient to them. The Community Living Well hubs are located in two Health and Wellbeing Centres, and the spokes are hosted by third sector partners, GP Practices and in community settings.


The model of care brings together six service providers. It integrates primary care mental health services, including psychological therapies, with new well-being services provided by the voluntary sector. Though each agency remains independent and operates more widely than the Community Living Well programme, partners work together as a single seamless integrated team. Each partner signs an Agency Partnership Agreement and shares management resource, administration and a single IT platform, which all help support integration.

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The person is put at the centre along with a GP who has overall responsibility for their care. There is a single Community Living Well wrap around offer.

Key parts of the service

Case Management
and Primary Care Psychiatry:

A team offers short-term therapeutic interventions and case management to people who experience mental health problems whilst under the care of their GP. The maximum waiting time for a face-to-face appointment is 5 working days. 

Integrated Talking Therapies:

Psychologists, therapists and counsellors provide a range of therapies to meet diverse needs, including Improving Access to Psychological Therapies (IAPT) services and a wider range of ‘Step 4’ psychological therapies. There is a 15-day waiting time from referral to treatment.

Integrated Wellbeing Services led by a single, multiagency manager:

  • Navigators:  A team of navigators give practical support on a range of issues and help people access specialist advice, information and services. The team works in partnership with primary care liaison nurses and other members of the MDT.

  • Peer support: The team includes a bank of trained peer support workers that delivers a range of peer support opportunities, including social opportunities, co-facilitated workshops and group, drop-in and one to one peer support.

  • Employment:  A team of specialists gives one to one support to people on the journey back to paid or unpaid employment and those who want to keep an existing job or undertake training. The team also works with other employment providers across the Clinical Commissioning Group (CCG) to ensure there is ‘no wrong door’ for people who need to access support.

  • Self Care: A range of self care activities are also provided, including massage, a theatre group, volunteering support, and mindfulness.

The difference it makes

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Lower use of secondary health care, emergency admissions, community mental health teams, physical health care and inpatient admissions

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People are better able
to manage their own
mental health needs in
the community

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GP time and capacity
is freed up

“To be honest words can’t really describe how valuable Hannah’s  [Navigator] input has been. She helped me change my life around. I met her at a time when I was low and she really went beyond my expectations. She helped with benefits as I was having a hard time applying and filling forms. She helped me navigate a turbulent time in my life where the world caved in and illness took hold of me. I can't thank her enough.”


- Service User

Find out more


  • Contact: Fiona Sutcliffe
    Head of the Community Living Well Service Network
    NHS West London Clinical Commissioning Group

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