Submission to the Select Committee Inquiry into Community Mental Health February 2025

Submission from the Mental Health Action group, representing mental health campaigners in Keep Our NHS Public and the Socialist Health Association

Mental Health Action began as a London-based Keep Our NHS Public group in early 2021. Later that year, the group was approached by the Mental Health sub-group of the Socialist Health Association’s London branch and the two groups decided to collaborate. Many members of MHA are in both organisations.

We now have over 40 members from different parts of the country – Liverpool, Newcastle, Sheffield, Barnsley, Bristol as well as London.Our members are current and retired healthcare workers; service users, their family members and carers; community workers; NHS campaigners. Many of us have been involved in mental health politics and campaigning for many years.

Our submission is motivated by the desperate need for a more humane, properly funded NHS mental health service to transform the landscape of failure and denial of care people with severe mental ill-health are enduring each and every day in this country.

Q 1. What does high-quality care look like for adults with severe mental illness and their families/carers?

Mental health services in the UK are chronically underfunded and understaffed, representing the historic undervaluing of people suffering severe mental ill-health among politicians and Dept of Health policy makers. The priority for any real change towards high quality care ought to be a significant increase in the personal contact between professionals, service users, and their families.

In September 2023, there were 28,600 vacancies in NHS mental health services (19% of the total workforce), including 1,700 medical and 13,300 nursing vacancies. In every region of England, vacancy rates in mental health services are higher than the overall NHS vacancy rate.^[1]

In practice, the government’s priority seems to be the cutting of NHS and other public funding in the name of economic growth, a formula which in the last few decades translates as the redistribution of resources from the care of the majority to the advantage of a small minority.

Like other aspects of the NHS, mental health services continue to be outsourced and privatised.^[2]

There is a chronic shortage of beds in the public sector and increasing dependence on private hospitals, often isolating people from their friends and families and local support network by moving them out of their local area – either outside or within ICB catchment areas. The NHS spent £2 billion on private psychiatric units in 2023.^[3] Local inpatient capacity underlies the safety of community mental health services.

“I recently met some inspiring young people from the Just Treatment group. They told me that 90 per cent of the Priory’s funding was from the NHS. Some had experience of being incarcerated there both as private patients and NHS, and said that as adult inpatients, those paid for privately were given therapy of sorts alongside medication whereas NHS patients were more or less incarcerated with only medication. They have published The Mad Youth Manifesto which contains lots of useful information and personal testimonies of experiences in our mental health system.”

Digitalisation is a major platform of innovation and improvement planning for mental health.^[4] This will be increasingly reliant on private provision of tech development, software, data harvesting and algorithm building.^[5] Private provision of talking therapies is on the increase.^[6] Wasting money on private profit and preventing transparency and collaborations of support is working against the aspirations of an improved public service.

All community mental health services need more fully resourced and fully trained professional staff – psychiatrists, psychologists, counsellors and psychotherapists, nurses, clinical support staff, midwives, health visitors. We cannot have high quality care without a significant increase in a fully resourced, fully trained workforce and adequate human relationships between mental health professionals and service users.

Q 1.2 How could the service user journey be improved both within community mental health services and in accessing support provided by other services/agencies?

Again, the priority for improvement is more resources. In the current economy of shortages of funding, infrastructure and staffing, the service user journey will remain inadequate, unreliable and precarious. Without many more mental health professionals in the community across the diversity of specialisations, service user journeys are likely to be frustrating, caught in never-ending limbo and dominated by medication. Early intervention and triage, crisis response services, frequency and continuity of psychiatric and Community Mental Health Team,^[7] the availability of ongoing counselling and psychotherapy all suffer the geographical variabilities of limited resources and practice. Section 135 and 136 procedures, the implementation of Community Treatment Orders, the reliance on long A&E attendance in the face of shortages of beds can be devastatingly damaging experiences.^[8] In so many ICB areas, the care of people with severe and enduring mental health issues amounts to continuing denial of care. In this context, the strategy proposals of the recent Adult Community Mental Health Framework are unfortunately desperate rhetoric. More detail on this later.

A psychiatrist tells us: “In various mental health teams the composition of the multidisciplinary team members is so variable, that if under-resourced it can sometimes negatively influence the outcome of the patient journey.”

NHS Talking Therapies are failing to meet their access targets, two-thirds of their referrals drop out and only one sixth finish a course of treatment and recover. This has been the story of IAPT/TT since at least 2012. The monopoly of behavioural therapies needs to end, longer treatment and therapeutic support need to be available and the alienating rigidity of its tick box target regime needs to be reformed.^[9]

Q 1.3 How could this be measured/monitored locally and nationally?

Recent ideology (New Public Management) is obsessed with data and the measurement and monitoring of service outcomes. In the realm of mental health, what exactly is to be measured and monitored? Are we talking about people’s sense of being valued and cared for, their feeling supported in their struggle with experiences of deep psychological pain, marginalisation and difficulties in being able to participate in the mainstream of our society? Or are we talking about more behavioural measures like getting back to work, able to avoid calling on society for support, able to tolerate the disturbance of their struggles and carry on and cope with emotional pain in isolation? We need to pay more attention to the subjective assessment of emotional pain, to service users’ experience, and to a sense of collective responsibility for our fellow citizens.

The quality and service provision of any community mental health team can be monitored nationally and locally only if they are consistent. However, teams are constantly changing in their names, their protocols, their operating procedures and this is happening both locally and nationally.

A mental health care worker puts it like this: “A GP may refer a patient to a local mental health team who may be seen by an assessment team in West London, by a core team in North London, by a “first point of access”, by a “single point of access”, and so on in other places. All these are fancy names given to a single team whose basic role is to assess, diagnose and to assign a pathway to the patient. However, these names are so confusing that sometimes even the GPs and patients can’t get their heads around it. Similarly follow up teams can be known as Recovery teams, Rehab teams, MINT (Mental health integrated network) teams etc. How can data ever be compared if names and operating procedures are so different?”

Q 2. What is the current state of access for adults with severe mental illness to community mental health services?

The process of getting access to community mental health services is via one of six ways.

The first is via a GP referral letter. This referral is then triaged by the Single Point of Access and if the patient sounds like they meet the bar for secondary mental health services, they will be referred by the Single Point of Access to the CMHT. The CMHT Triage Team then triages them again. If they decide that the patient meets the bar, the patient will be informed that they will receive a phone call. There is pressure on the triage team not to allow patients in through the front door, and preferably to “signpost” them to charities or community groups, if there are any. There is also pressure on the CMHT to discharge patients as quickly as possible “through the back door”. If the patient is thought to require psychological services in the CMHT, the Triage Team will inform the patient that a psychologist will also triage the patient. They will be informed that someone will call them with an assessment appointment – with no time line. So there could be 3 triages the patient needs to go through before getting care, in addition to the GP appointment.

The second route into CMHTs is if the patient is in a mental hospital and about to be discharged. The CMHT Triage Team again will triage the patient and see if they meet the bar for secondary mental health services. If not the patient will be abandoned on discharge.

The third route is via the Crisis and Home Treatment Team. They may refer the patient to the CMHT or back to the CMHT after they are discharged from their care.

The fourth route is via A&E. If the patient presents to A&E and is not going to be hospitalised into a mental health hospital, they could either be abandoned or the CMHT might be contacted, especially if the patient is “known to services” previously.

The fifth route is if the patient is in crisis and phones the Single Point of Access or 111, press 2 for Mental Health (not always possible to get through to a professional), they might be referred to the CMHT if they meet the bar for secondary services. Similarly if they are currently under the CMHT but have experienced a crisis, for example at night or at the weekend, and phone 111, a message will be sent to the CMHT that a patient has been in contact. This may be because the CMHT has been too busy to work with the patient, whose mental health has been deteriorating, or the family or neighbours can’t cope.

The sixth route is via the police or ambulance service.

A CAMHS psychotherapist tells us: “Child and Adolescent Mental Health Services (CAMHS) are underfunded, understaffed and failing to deliver the help that children, adolescents, and parents urgently need. The threshold for treatment is equally high, with only the most severe cases such as psychosis, suicidality, or violence being accepted. It has also become almost fashionable for parents to diagnose their children as autistic or ADHD- so no need for therapy – a quick fix of medication will do. These are the most important years of a person’s life, where in-depth therapy (real early intervention) might help avoid serious mental illness later in life. Yet in most CAMHS services there is no real Team of child psychiatrists, educational psychologists, qualified child psychotherapists, parent or family therapists, and social workers, which has regular communication and co-operation with midwives, health visitors, schools and other public services.”

A mental health campaigner reports: “On the transfer of young people from CAMHS to adult Community Mental Health Teams. In my experience, many young people were rejected by CMHTS after CAMHS because the thresholds were so high, i.e. unless they had a diagnosis of a major mental illness they would not be taken on at that very vulnerable stage of young adulthood when they might be struggling with work or study.”

Q 2.2 What progress has been made in implementing waiting time and access standards for community mental health services?

The waiting time varies but patients are not informed of the length of time they should expect, which often increases the stress.

Q 2.3 How could access be improved across the country?

Access routes need to be audited. The staffing numbers dealing with patients in CMHTs should be increased and social workers be brought into the staff group where they have been removed. Also a professional’s judgement that a patient needs secondary mental health care should be respected, rather than forcing repeated triages upon the patient. If a GP or a Single Point of Access professional writes that a patient needs CMHT care, the CMHT should accept the patient. Similarly with psychology.

Q 3. Has the Community Mental Health Framework been an effective tool for driving the delivery of more integrated, person-centred community mental health services?

The Adult Community Mental Health Framework is an ambitious vision of reframing community mental health towards user-led experience of the care and support they need in the community. Five years on, the continuing lack of funding, adequate staffing and continuity of care has left people with severe and enduring mental health issues as poorly served as ever – if not worse. The plethora and rapid turnover of third party community support leaves provision patchy, unreliable and impossible to assess in terms of value to service users. Social prescribing in many areas of the country is chaotic, ineffective, hit and miss.

A psychiatrist reports: “The psychology services within the committee mental health services are very variable with some on waiting lists of up to one year or even more.

Some teams have assistant practitioners or assistant psychologists; some don’t.

Some teams have Occupational Therapists who organise football groups, cooking groups, walking groups. Others have no such luck. It’s really a hit and miss experience for many service users.”

A service user says: “ICBs are looking around to fund ‘community groups’ to provide care in the community. Charity and private sector organisations are being set up that no one has ever heard of. They provide a very specific “service” e.g. guitar lessons for autistic men for a very short time before the students give up, but the person who set it up has the ongoing contractual money, with no one to monitor them at the NHS. There used to be regular Contract Reviews at NHS England – until Boris Johnson did away with procurement rules.”

A community art course facilitator in London reports: “I have been overwhelmed by social prescriber referrals, many of whom have complex MH needs. I have no training in psychological work and in the class no capacity to respond to many of my students most of the time. My own stress levels have rocketed.”

A service user tells us: “Community Mental Health Teams (CMHTs – now called “Hubs” so that teams can be combined to cover for serious staff shortages) are understaffed, and experience a staff (as well as a patient) churn. This is not the “community” service Wes Streeting is proposing. His model seems to be more about small businesses and voluntary sector organisations and even Step-Downs i.e hotels where seriously ill mental health patients are dumped (by mental health ambulance with a cage at the back) to make room for the next person who needs a bed. The hotel often serves to house asylum seekers too and usually has one person who virtually lives there 24/7 and locks up at night. Otherwise, there may be the Home Treatment Team if you are lucky popping around to medicate the patient once a day, but after a couple of weeks or less they are sent home or into temporary accommodation with nothing, to be assessed by the Triage Service in the CMHT and in all likelihood pronounced “settled” and discharged to their GP.”

A Ward Councillor in East London tells us: “There needs to be an urgent review of mental health assessments and outcomes as thresholds keep increasing to save costs. In my ward we have two residents who are clearly showing signs of either psychosis or another mental health related diagnosis. They both have used hazardous objects such as hammers, knives, thrown burning objects out of their window, smashed their homes punching every wall etc but we have been told as they are under an independent care living arrangement and there’s nothing else to do except increasing medication or telling their carers in their next visit of the issue. No one around these two residents are protected, even when these two residents are clearly a danger to themselves and others. We need to seek definition of “Independent Living” for people with mental health care needs and stop using the ‘exercise’ assessors use e.g. asking the patient to ‘prepare a cup of tea’- the patient is able to do this and for those few minutes of ‘cognitive capacity’ then they are deemed to be capable of living on their own. Saving costs is driving this.”

A psychotherapist working long-term with people suffering SMI says: “I see people regularly over a period of months and years. For many service users, yes they may attend community groups offering knitting, cycling, music, art, financial and social benefits advice, a hearing voices group. But somehow in the middle of all this activity they are on their own with the pain and struggle of their emotional experience, feeling marginalised and alone. They often have no relationships which provide a sense of home in the community. The hub of provision has no real hub – it’s all spokes. Their meds are the one constant.”

The lack of in-patient beds is a vital issue. People experiencing crisis are spending hours in A&E. They are being sent out of their local community often to private beds, breaking the continuity of community care from services, family and friends.

Q 4. How can community mental health services work with social care, the third sector and local government to better address service users’ health and wider social needs that are wider determinants of mental health outcomes?

After 14 years of austerity policies, it is obvious to everyone in the field that central and local government social services of every kind have been devastated. Austerity cuts have impacted community mental health budgets and services on the ground disproportionally. See the 2018 TUC report “Breaking Point” and the 2020 “Marmot Report-10 years on” for the context.^[10]

Without substantial and sustained increases in the funding and staffing of both mental health services, local authority Cultural, Environmental and Planning budgets^[11], and public funding of social care along with significant improvements in the supply of decent affordable housing, reductions in poverty and income inequality and the other social determinants of mental ill-health this question is frankly offensive. Community mental health services are in no position to “work with”. On average they are having to spread inadequate resources best they can; at worst they are beyond any reasonable breaking point and having to manage the gap between public expectations of basic support and the reality of failing services.

From a psychiatrist working in the community: “I do not think funding should go out of the NHS into third sector charities. An integrated community mental health team also means that all services are available in one place, one location rather than many places, with different phone numbers, different forms for patients and referrers to fill in.”

The integration of the NHS, local authorities, social care, private and third sector charity and voluntary services to provide person-centred mental health care is a piece of mythmaking by the Adult CMH Framework policy document – out of the same political stable as the Integrated Care System reorganisation. The current Labour Government has already made it clear that they are committed to ‘fiscal constraint’ and the goal of economic growth over all. Without changes in the financial, social and moral priorities of government, this question is as disconnected from the real needs of real people as ever.

Q 4.2 How could the funding system be reformed to more effectively drive transformation in the delivery of integrated and person-centred community mental health services?

A fundamental shift in the political, social and economic priorities of government towards the development of a society that puts people and the care of their mental health before the interests of corporate and elite wealth.

Q 5. What blockers or enablers should policy interventions prioritise addressing to improve the integration of person-centred community mental health care?

We should replace the growing phenomenon of either zero or fake consultation of patients, service users and the electorate generally on national and local changes in health provision and policy with meaningful participation by citizens in their health care.

So much current policymaking around mental health is driven by the conundrum of selling the story of progress to ordinary people while defunding services and denying care.

Q 6. What are the examples of good or innovative practice in community mental health services?

A psychiatrist reports: “Overall, when a well-resourced community mental health team can provide an effective service for keeping patients out of the hospital and deliver integrated person centred care. I had observed this in a small town near Oxford where they had a very well-staffed team who had been working for more than a decade, who knew patients like the back of their hands and were also able to work with sector charities by integrating them into their own regular mental health multidisciplinary team meetings.”

From a member working with asylum seekers/refugees: “ Our model is distinct from the norm in using “Befrienders” who often are a life-saving service which is turned to in preference to statutory ones because of the patient having the befriender’s phone number & regular weekly assignations in a cafe. There’s a big difference with that informal approach which is cost saving and flexible to the user & befriender alike.”

Q 6.2 What needs to happen to scale up the adoption of these practices across the country?

Adequate well-trained mental health professional staffing, premises to encourage a variety of supportive and creative meetings between all sorts of people in a local community. Relationships between people come first – not last because it’s “too expensive”.

Releasing ourselves from the mantra of economic growth, the work ethic, consumerism, and alienation from each other.

^[1] https://digital.nhs.uk/data-and-information/publications/statistical/nhs-vacancies-survey

^[2] See https://www.nhsforsale.info/sector/mental-health-2/#:~:text=Companies-,Privatisation,people%20to%20go%20private%20%2D%20rationing.

^[3] https://www.independent.co.uk/news/health/nhs-private-mental-health-uk-b2667431.html

^[4] https://topol.hee.nhs.uk/wp-content/uploads/HEE-Topol-Review-Mental-health-paper.pdf

^[5] https://keepournhspublic.com/wp-content/uploads/2024/09/Clouds-part-1v-final-to-send__-15.8.24.pdf

^[6] https://mentalhealthaction.uk/wp-content/uploads/2025/01/ai-part-1-p-atkinson.pdf

^[7] https://pubmed.ncbi.nlm.nih.gov/38311574/

^[8] https://www.healthwatchhackney.co.uk/wp-content/uploads/2023/02/MENTAL-HEALTH-EMERGENCY-1.pdf

^[9] https://mentalhealthaction.uk/nhs-talking-therapies/

^[10] https://www.tuc.org.uk/sites/default/files/Mentalhealthfundingreport2_0.pdf