In September 2019, NHS England published a new framework document setting out the changes it expects to see in community mental health services over the next five years.

The framework (PDF) accompanies the NHS Long Term Plan. The Long Term Plan was published at the start of 2019 and included a wide range of pledges in relation to mental health, with investment of £2.3 billion over five years. The largest share of that funding was earmarked for community mental health services, with a promise to deliver a comprehensive “new community-based offer [that] will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use…” 

The Framework sets out how that ambition will be achieved in practice and what is expected of local areas in implementing it.

The NHS Long Term Plan included a wide range of pledges in relation to mental health with investment of £2.3 billion over five years.

Methods

The Framework was developed by the National Collaborating Centre for Mental Health, based at the Royal College of Psychiatrists. Commissioned in 2017, the Framework was produced “with a large Expert Reference Group drawn from a range of disciplines and professions across health, social care, the VCSE sector, community groups, and users and carers”.

The purpose of the Framework is described as being to set out “the vision for a new place-based community mental health model…to shift to whole person, whole population approaches”. In taking this approach, the Framework is clear that its coverage should be seen as including both people with “a range of long-term severe mental illnesses” and “people whose needs are deemed too severe for Improving Access to Psychological Therapies (IAPT) services but not severe enough to meet secondary care ‘thresholds’.” This is an important recognition that the existing ‘stepped care’ system that separates primary and secondary care services for mental health has left out a significant (and arguably growing) group of people.

From the perspectives of people using community services, the stated aims of the Framework are to be able to “access mental health care where and when they need it”, to “manage their condition or move towards individualised recovery on their own terms”, and to “contribute to and be participants in” their communities.

Results

The Framework sets out how it envisages community mental health services will develop to provide a ‘whole person, whole population’ approach. This will be organised on two levels. At the ‘neighbourhood’ level of the emerging Primary Care Networks, serving populations of between 30,000 and 50,000, will be ‘core’ community mental health services. These will offer a range of services, including assessments and interventions such as psychological therapies, physical health care, employment support and financial advice. 

At a higher ‘place’ level, serving populations of between 250,000 and 500,000, will be ‘specialist’ services. These will provide “more targeted, intensive and longer-term input for people with more complex needs”. They will include crisis and inpatient services as well as help for people with eating disorders, rough sleepers and those leaving the criminal justice system.

Alongside this structural shift in the system, the Framework marks the end of the Care Programme Approach, a system which has been in use for almost 30 years. In its place, the Framework states that anyone requiring support in the community “should have a co-produced and personalised care plan”, including their Care Act and Mental Health Act Section 117 aftercare rights. It notes that the complexity of the care plan will depend on each person’s needs and it encourages the use of the Triangle of Care to include carers and families.

The Framework also sets out important details about how this vision will be realised. Recognising that the success of the vision will depend on building partnerships widely in localities, it states that each area will need to develop a governance structure that includes primary care, local government, physical as well as mental health services, voluntary sector bodies and service users and carers. It notes that multiple different organisations will need to provide support under the new Framework and recommends ‘alliance contracting’ as a means of getting different organisations working together to meet the same objectives. It finishes with a note about the diverse workforce that will be required; a theme which is discussed in greater detail in NHS England’s implementation plan for mental health.

As the Framework is part of a five-year implementation process for the NHS Long Term Plan, it will begin for its first two years with a test phase in twelve areas of the country, with implementation support provided by NHS England. It will then be expanded nationwide, with funding provided to Integrated Care Systems to put the Framework into practice.

Conclusions

The Framework argues that community mental health teams (CMHTs) “have long taken a central role in the delivery of mental health services, but their development has stagnated over many years”. As policy attention (and funding) have shifted to newer, specialised teams, CMHTs have been sidelined, leading to “fragmentation and discontinuity of care”. It aspires to change that by reforming the whole system of care – rather than adding extra pieces (and often in the process taken staff and money from CMHTs to resource them). In doing so, it represents a bold step with a scope considerably greater than was evident in the Five Year Forward View for Mental Health. In seeking to meet the needs of people who current systems often serve poorly, and to develop a comprehensive ‘whole population’ offer at the same time as changing the way care planning takes place, it implies change at multiple levels, all at the same time.

The Framework also recognises that the extent of changes it sets out “will take time [and] careful joint working” in localities to be successful. The challenge will be to allow a change that takes time to happen in a health and care system that favours short-term and sometimes short-lived initiatives with immediate ‘outcomes’, and where near constant structural change often scuppers long-term developments. Will local organisations, and the people who work in and around them, really be given the time to build the necessary relationships and partnerships to deliver this change process? Or will events overtake it, as has so often happened before?

Strengths and limitations

The Framework sets out what can be seen either as a radical departure from a system that has not changed appreciably for many years or as another of a succession of nationally mandated reorganisations of mental health services. People using and working in mental health services will have heard promises of large-scale change before, only to feel let down when it does not materialise. In a system that is meeting ever-greater demand for community mental health care with a workforce that hasn’t grown to meet it, there may be skepticism about whether it really will be different this time. 

Like the National Service Framework for Mental Health some twenty years ago, the new framework has the benefit (unlike most of the intervening strategies) of coming with a significant sum of money – at least for its NHS funded elements (Bell, 2016). This gives it an important advantage following many years of austerity. For the crucial local government-funded elements, not least social care but also public health (including substance misuse) services, the absence of a generous long-term financial settlement may be significantly more challenging. Without them, the NHS will struggle to create a genuinely ‘whole person, whole population’ mental health service. Yet there is no indication that any of the £1 billion earmarked for this part of the Long Term Plan will be available to local authorities to do their part. This could make the already large gap between NHS and local government spending power bigger still, making partnership working ever more difficult.

The Framework makes frequent reference to some of the most longstanding and stark inequalities in mental health and mental health care: for example the lack of support offered to people diagnosed with personality disorders and the absence of effective help for people with co-occurring alcohol and mental health problems (Centre for Mental Health and Institute of Alcohol Studies, 2018). It seeks to close the gap between IAPT and primary care on the one side and secondary mental health care on the other: a gap that has left a wide range of people with little or no help for their mental health despite often having serious and complex needs. Many local areas have already sought to do this in different ways – for example in Swindon, Nottingham and Bradford (Newbigging et al, 2019; O’Shea, 2019). If it can build on the evidence they have begun to generate and demonstrate that a genuinely whole population approach to community mental health care is possible, it will mark a generational shift in support. If it can generate more evidence about the most effective ways to close the gap, we will have a lot more to learn in the next five years.

There will be a worry, though, that the Framework will replace one set of missing steps with another. The proposed division between core and specialist services should reduce the risk of gaps appearing between services, but it will need careful management to ensure that this really happens. Providing a genuinely comprehensive, stepped care system where no one is left out will require a very different approach to identifying, assessing and meeting people’s needs to the one currently in operation in most local areas. 

Implications for practice

The Framework has the potential to bring about a large-scale and long-lasting change to the way people get support for their mental health in England. With the back-up of new money and a national Long Term Plan with a clearly spelled out implementation process, it has some crucial advantages on its side. To be successful, it will depend on the ability of the system to recruit and retain the workforce it requires to be realised. This may be the biggest challenge of all in a health and care system that can only function well if it has a workforce of the right size, with the right skills in the right places. As the Care Quality Commission (2019) recently observed, poor outcomes often start when someone cannot get help quickly where and when they first need it. Changing this for people seeking help for their mental health will be a mark of success for the new Framework, and it can only happen if people are in place to do it.

For practitioners, the Framework implies some very different ways of working, finally moving away from the Care Programme Approach, closing the gap between primary and secondary care and placing less emphasis on assessments, service thresholds and risk assessments. How this manifests in practice will inevitably be different in different places. The Framework is less a model and more an outline. It sets out some ambitious aspirations that will now need to be interpreted locally by those charged with putting it into practice. Learning from those who go first, and building up evidence about what seems to work and what does not will be crucial to ensure the eventual success of this document in making a major and lasting difference to the support people get for their mental health nationwide.

Conflicts of interest

None

Links

Primary paper

Other references

Bell A (2016) Implementing mental health policy: some lessons from recent history London: Centre for Mental Health

Care Quality Commission (2019) The state of health care and adult social care in England 2018/19 

Centre for Mental Health and Institute for Alcohol Studies (2018) Alcohol and mental health. London: Centre for Mental Health

Newbigging K et al (2018) Filling the chasm: Reimagining primary mental health care. London: Centre for Mental Health

O’Shea N (2019) A new approach to complex needs. London: Centre for Mental Health.

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