A new framework for community mental health services
By Andy Bell
Earlier this year, the NHS Long Term Plan pledged to bring £2.3 billion of extra funding to mental health services in England by 2023/24 and to establish a new model of primary and secondary mental health care. The model was to be built around a new framework that would set out what people could expect from community mental health services and that would close the gap between primary and secondary care.
That model for has now been published by NHS England. It presents an outline for how an extra £1 billion will be spent over the next five years to expand community mental health services for adults and what changes it expects local services to make to meet people’s needs better.
While successive national mental health policies and strategies have left community mental health teams (CMHTs) untouched, the new framework calls for their “transformation and modernisation”. Existing CMHTs in most areas of the country are based entirely in secondary (specialist) care and they operate with thresholds that require someone to have a level of severity of mental health need to qualify for support.
The framework says this should be replaced by a new “core” community mental health service that will incorporate existing CMHTs with primary care mental health services (for people who need more than Improving Access to Psychological Therapies, IAPT, services can offer but currently fall below CMHT thresholds) and “residential care” services such as supported housing and care homes. These, it says, should be organised around the new Primary Care Networks, of which there are now about 1,000 with average populations of 30,000 to 50,000.
While successive national mental health policies and strategies have left community mental health teams untouched, the new framework calls for their “transformation and modernisation”
These will be expected to meet a wide range of people’s needs, including those with a severe and enduring mental health condition (as now) but also those with co-occurring drug or alcohol difficulties – a group whose needs have consistently been poorly met – and those with common mental health problems. And they will be expected to offer a wide range of interventions, including care coordination, advocacy, psychological therapies, employment, housing and benefits support, and physical health care.
For people with more complex needs, the framework suggests services should be organised at a higher geographical level and should offer specialist advice and consultation to core services, crisis and inpatient care and more specialist services – for example for people leaving the criminal justice system, rough sleepers and those with personality disorder diagnoses.
The framework goes on to make further recommendations about the way the proposed new system is organised. These include a ‘no wrong door’ policy to make support more accessible and an assessment system that replaces the current Care Programme Approach with a new “personalised care and support plan”. On an organisational level, it sets out expectations about the governance of the new services, with a bigger role for local government and the voluntary sector, and suggests the use of ‘alliance contracting’ to bring a wider range of providers together to meet people’s needs.
For the first two years, twelve areas will receive extra funding to enable them to pilot the new framework and learn lessons for others to draw on. This will be an important opportunity to test the theory in practice: for which robust and independent evaluation will be essential.
With significant extra funding, a genuinely “whole person, whole population” service could help to ensure no one falls through the gaps in a system that currently leaves too many people with little or nothing.
The principles set out in the framework offer an opportunity to reform community mental health support. With significant extra funding, a genuinely “whole person, whole population” service could help to ensure no one falls through the gaps in a system that currently leaves too many people with little or nothing. To do that, it will need to be grounded in communities, working with and alongside those who have the poorest experiences of help and support for their mental health to redesign the system. And it will need to recruit, support and retain a diverse workforce with a wide mix of backgrounds, skills and knowledge.
Community mental health teams have been ignored and taken for granted in successive mental health policies in England. The new framework should change that. In so doing, it will present a major challenge to a system (and the people who work in it) that is currently under intense pressure every day. The ways this gets done will matter almost as much as what gets done if it is to achieve the ultimate goal of bringing about better support for our mental health where and when we need it.
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