‘Mind the Gaps’
Can the Community Mental Health Framework improve care for people who have traditionally fallen through the gaps between services?
About the author
Hi, my name is Andy Bell. I am the deputy chief executive at Centre for Mental Health, an independent not-for-profit organisation that seeks to eradicate inequality in mental health through research, analysis and advocacy. The Centre hosts the Children and Young People’s Mental Health Coalition and the Equally Well UK collaborative.
The Community Mental Health Framework acknowledges that the current system of mental health support excludes a number of groups of people for whom there is little or no service to meet their needs.
One of the biggest gaps that people fall into is between IAPT and secondary mental health care services. People whose needs are deemed ‘too complex’ for IAPT but who do not meet thresholds for community mental health services too often find themselves fitting into neither and simply getting rejected by every local service.
We have seen this happening to many different groups of people, of all age groups and with a diverse range of needs (Naylor et al., 2020). The one thing they have in common is that they don’t fall readily into the limited boxes that health and care services have created to demarcate who they help and who they don’t. They include people diagnosed with personality disorders and those coping with complex traumas. People discharged from community mental health services may also need some ongoing support and speedy access to help if they experience future crises.
People with co-occurring mental health and substance misuse problems (often labelled ‘dual diagnosis’) still repeatedly report being ‘bounced’ between services and getting help from none. Men and women who find themselves in the criminal justice system have very high levels of need yet very few people who leave prison get accepted by community mental health services, even when they have been receiving help from their equivalents inside (Durcan et al., 2018). And people living with overlapping mental and physical health problems, particularly in later life, when access to mental health support is especially poor, continue to fall into gaps between the two systems.
In promising a ‘whole person, whole population’ approach to mental health support, the Framework makes an important pledge that must not be forgotten during the implementation phase of the Long Term Plan. It must now become a founding principle for Integrated Care Systems as they take up responsibility for health services in their areas: not a hollow slogan that gets shelved quietly in the aftermath of a pandemic which is projected to increase demand for mental health care very substantially (O’Shea, 2021).
Many local areas have already started taking steps to close these gaps. Some have found innovative ways of meeting people’s needs by developing new services or adapting existing ones. In Nottingham, for example, the Primary Care Psychological Medicine service works in GP surgeries to provide support to people experiencing persistent physical symptoms and other complex needs. It has been found to produce improved outcomes and to reduce costs (O’Shea, 2019). Similar services in Bradford and in Hackney have also been evaluated and found to produce good outcomes for people who have been repeatedly failed by existing services.
Elsewhere, primary and secondary care services have come together to provide a more collaborative service, to close the gaps between them – for example by locating mental health specialists within primary care. This has been done at a large scale, such as the LIFT service in Swindon, which includes its IAPT service but also a wide range of other offers, and also at a much smaller scale – for example where a single psychologist works within a
GP surgery providing open access appointments to patients and advice to GP colleagues (Newbigging et al, 2018; Durcan, 2020). In some areas, voluntary and community organisations have been brought into the picture to provide a wider range of support than can be offered by clinical services alone: including care navigation, welfare advice and social prescribing.
All of the local innovations we have seen have managed to bridge some of the biggest gaps in the system and offer help to people who would otherwise get very little, or sometimes very ineffective, support. None yet offer a comprehensive blueprint for a genuinely ‘whole person, whole population’ approach, however. Most focus on meeting specific needs, or they work at a small scale so their benefits do not spread widely. And some groups of people – perhaps most notably those living with ‘dual diagnosis’ – have been left out almost everywhere.
Gaps in the mental health system are not new: but that does not make them any more acceptable. As the Community Mental Health Framework moves from paper to practice, local systems should be able to learn from the areas that have tried new approaches to closing the gaps.
There are opportunities now to make this a reality. Primary Care Networks now have the opportunity to use additional funding from the Additional Roles Reimbursement Scheme to bring in mental health practitioners, who will be employed by their local NHS mental health trusts (NHS England, 2021). This adds to an existing scheme that enabled Primary Care Networks to employ physiotherapists, pharmacists and other staff, but not in mental health. The recent extension is an opportunity to address this disparity and provide more consistent mental health support in primary care.
The NHS was founded on values of offering universal health care, free at the point of use, leaving no one behind. For many people with a range of mental health difficulties, that promise has been a long time coming. The days of ‘inappropriate referrals’, ‘primary diagnoses’ and ‘sub-threshold needs’ must come to an end. With promises of investment and redesign on the way, we need to rebuild the system so that no one is left out or left behind.
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References
Durcan G, 2020. Clinical psychology in primary care www.centreformentalhealth.org.uk/publications/clinical-psychology-primary-care
Durcan G et al., 2018 From prison to work www.centreformentalhealth.org.uk/publications/prison-work
Naylor C, et al., 2020 Mental health and primary care networks www.centreformentalhealth.org.uk/publications/mental-health-and-primary-care-networks
Newbigging K et al., 2018. Filling the chasm www.centreformentalhealth.org.uk/publications/filling-chasm
NHS England, 2021. Supporting General Practice in 2021/22 www.bma.org.uk/media/3730/bma-c1054-supporting-general-practice-in-202122-21-january-2021.pdf [Accessed 1 April 2021]
O’Shea N, 2019. A new approach to complex needs www.centreformentalhealth.org.uk/publications/new-approach-complex-needs
O’Shea N, 2021. Covid-19 and the nation’s mental health, May 2021 www.centreformentalhealth.org.uk/publications/covid-19-and-nations-mental-health-may-2021