Written evidence submitted by Professor Emily Oliver (Professor of Behavioural Sciences at Newcastle University); Dr Ilaria Pina (Research Associate at Newcastle University); Dan Steward (Research Assistant at Newcastle University); Dr Fiona Duncan (Research Associate at Newcastle University); Sue Webster (Here Researcher at The McPin Foundation); Dr Sophie Picton (Academic Clinical Fellow at University College London) (CMH0082)

Purpose: This evidence briefing responds to the Health and Social Care Committee's Community Mental Health Services Inquiry, with a particular focus on adults living with severe mental health needs.

Authors: Professor Emily Oliver, Professor of Behavioural Sciences, Population Health Sciences Institute, Newcastle University. Dr Ilaria Pina, Research Associate, Population Health Sciences Institute, Newcastle University; Dr Fiona Duncan, Research Associate, Population Health Sciences Institute, Newcastle University; Dr Sophie Picton, GP Academic Clinical Fellow, UCL; Dan Steward, Research Assistant, Population Health Sciences Institute, Newcastle University; Sue Webster, Peer Researcher, the McPin Foundation.

This evidence briefing has been compiled with and on behalf of the WHOLE-SMI Community Advisory Group, a public involvement group of people with lived experience of severe mental ill-health in the North East of England and North Cumbria.

WHOLE-SMI (Wellbeing and Holistic health promotion for those living with Severe Mental Illness) is ongoing research (since 2021) funded by the National Institute of Health and Social Care Research (grant reference: NIHR SPCR 2021-2026 MH002).

We would be happy to be contacted by the committee to discuss any of these issues in further detail and/or to elaborate on the evidence provided below.

Note: the authorship team are responding as a collective representing their individual views and experiences as researchers, not necessarily those of their organisational affiliations. All have expertise concerning, and direct experience of, research and evaluation of services across community-based care and support settings, with a focus on mental health-related services supporting people living with severe mental ill-health.   

1. What does high-quality care look like for adults with severe mental illness and their families/carers?
1. How could the service user journey be improved both within community mental health services and in accessing support provided by other services/agencies?
2. How could this be measured/monitored locally and nationally?

1.1 The WHOLE-SMI community advisory group, (comprising of people with lived experience of severe mental ill-health (SMIH), their family members or carers), and research participants, shared their perspectives both on high-quality care they had experienced and how health support could be improved. High quality care recognised the complexity of people’s lives and did not consider their mental health condition in isolation from their physical health. Unfortunately, it was clear that not everyone is lucky enough to have access to this high-quality care. Health promotion was valued in preference to a focus on treatment or risk-management; people living with SMIH valued co-produced holistic approaches that supported them to live well, live longer and thrive within communities, with a greater focus on preventative support. 

The following image was produced with our lived experience group and summarised the care experienced, and desired holistic approach, highlighted in workshops with people living with SMIH:

1.2 Our research identified that accessing physical health support and/or holistic health promotion services for those living with severe mental ill-health can be improved by:

• Providing timely and easier access to health promotion support in non-clinical settings, and via non-clinical staff. Working with or commissioning community-based organisations to do this had shown successes in terms of promoting earlier and repeated engagement when needed. Examples of valued non-clinical support settings include community art classes and physical activity spaces.

• De-medicalising terminology and technology where appropriate (e.g., offering conversations rather than consultations) can help engagement especially for those with prior negative experiences in medical care settings. The consideration of choice of language should cover all forms of communication, whether they be written or spoken. 

• Providing consistency in terms of support personnel and/or organisations; the inclusion of peer supporters with lived experience of mental health services was seen as valuable in helping to navigate the system and support health change.

• Enabling multiple entry routes to health promotion services (e.g., via referral from community organisations or self-referral), as well as flexible access opportunities. For example, rigid models based on a fixed number of sessions, or the need to attend in consecutive weeks, did not work well for those with fluctuating and severe health needs.

• Actively supporting cross-referrals via facilitated introductions and co-locating staff and/or services where appropriate (e.g., in hubs, community spaces, online spaces). This prevented an additional burden on the individual and supported uptake and engagement (as well as facilitating trust by proxy in the new service).

1.3 Progress towards these models of provision can be captured and monitored via a range of methods and technologies, at a local, regional or national level. Reporting the proportion of those with an SMIH who have engaged in a physical health support service (not just those who have had an annual health check) would be a useful marker of enhanced provision, additionally enabling follow-on analysis of effectiveness at scale. Integrated care systems are well-placed to monitor model/innovation uptake and identify and share good and emerging practices regionally via feedback to PCNs. They are well placed to act as hub to develop collaboration and integration between health, social care and community organisations, and an updated national policy steer for explicit consideration of SMIH by ICSs would be helpful. We identified differentiated practices both between and within regions, providing an opportunity to better understand the effectiveness of different models if a process is stimulated to collate, evaluate and share this at a national level. Supporting a national approach for effective models could help drive consistency and equity.

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

5.1 Resource scarcity: there is an ongoing and worsening issue of limited resources in the mental health care and wider health promotion/support system, which impacts its ability to deliver comprehensive person-centred care. This includes financial constraints, staff retention challenges, and under-staffing, all at considerable cost to the service-user. There remains uneven distribution of resources and access to service provision for those living with severe mental illness across the UK, with unmet need exacerbated in rural, remote and coastal regions requiring some service-users being expected to travel vast distances to access services. Delivery variation in regions is also highly impacted by differences in knowledge and skillsets of delivery workforces.

5.2 Commissioning arrangements for community-based mental health care still struggle with a reliance on short-term funding agreements, an issue that additionally permeates that community-based sector. We identified that where commissioners were able to offer consistency and continuity in funding, and therefore also working relationships, this enabled higher quality services to develop. Creating opportunities for longer-term funding of health support services for those living with severe mental illness is key to develop provision trusted by, and serving the needs of, the community. Some service providers face financial pressures or restructuring, which can hinder the innovation expansion. Ensuring adequate funding and resources are available, particularly for voluntary and community organisations, is crucial.

5.3 Difficulties in information sharing: although work is being done to streamline processes and improve communication links across healthcare settings, this coverage is sparse and still in its infancy. Different communication systems and the inability to directly access service users’ information across service providers and between services within the same setting hinder coordination and collaboration. Specifically, mental health support services not communicating with physical health support services and vice versa. Policy interventions should focus on addressing the fragmentation of services and the lack of coordination between mental and physical health, social care, and community support.

5.4 Cultural and hierarchical barriers: power dynamics and hierarchies between service providers, particularly with NHS staff and voluntary and community providers, limit effective collaboration and engagement. There is a need to challenge these power structures and promote equality in service delivery. Encouraging peer support, staff shadowing, and collaborative work across different organisations has been proposed to help improve relationships and enhance the quality of care. More structured support for staff across different levels of service delivery would also facilitate better engagement with service users.

5.5 Inconsistent practices: while some service providers benefit from shadowing clinical staff to facilitate relationship-building, not all services have this practice in place, resulting in inconsistent engagement across services. Policies should prioritise improving workforce capacity, offer innovative practices aligned to local contextual needs across regions, and aligning funding with integrated care priorities. Establishing a formal, structured approach for knowledge sharing and staff training (such as a community of practice) could help implementation of successful practices across different localities.

6. What are the examples of good or innovative practice in community mental health services? What needs to happen to scale up the adoption of these practices across the country?

6.1 Personalised and flexible engagement and re-engagement pathways: the focus on “what matters to the person” ensures that services work collaboratively to tailor provision to an individual’s needs and preferences. Service providers should create tailored engagement pathways that are flexible and person-centred, holistically supporting diverse needs beyond mental health, such as wider social support, especially for individuals experiencing loneliness and/or isolation, or physical health issues1 with less focus on predetermined outcomes and access to a limited number of sessions.

6.2 Collaborative and creative partnerships, or “alliances”: innovative practice should promote collaboration between various service providers, including voluntary and community organisations, alongside resourcing of system navigators (e.g., social prescribing link workers, peer coaches), to support engagement with people living with severe mental ill-health. These “alliances” help overcome the hierarchical dynamics often seen in NHS settings and can also provide support that can be tailored to hyper-local needs, promoting a more inclusive and collaborative approach to care2.

6.3 Use of innovative language: example of innovative practice avoids traditional medical terminology like "referrals" and instead uses "conversations" to help reduce or remove perceived barriers, encourage accessible communication and engage service users. This reflects a shift away from the medicalised model, focusing instead on human equality and personal choice2.

6.4 Co-production: innovative practice should use a co-production approach and two-way conversations to involve service users in defining their needs, tailored treatment options and ensuring that the support provided aligns with their own priorities. However, it is important that resource is not wasted by ‘starting from scratch’. There are a number of evidence-based models in practice in some areas (e.g., physical health support); tailoring and refinement with the community is important here. Service users’ feedback is integral to improving and evolving services, allowing for continuous adaptation, or “prototyping” of delivery models (as opposed to on/off piloting), to meet changing needs over time.

6.5 Creative commissioning leadership and adaptability: local commissioner leadership and innovation is crucial in driving the continuous adaptation and prototyping of innovative practice required to meet the needs for people with SMIH. Unless explicitly prioritised at national and regional level, there will be too much reliance on individual leaders and increasing differences in service provision by area.

REFERENCES

1 Steward, D., Pina, I., Webster, S., & Oliver, E.J. (2024). Transforming systems that address health inequalities and engagement with those living with severe mental ill-health (SMI) in the Northeast and North Cumbria (NENC). North East Public Health Conference 2024.

2Baskin, C., Duncan, F., Adams, E.A., Oliver E.J., Samuel G, & Gnani S. (2023). How co-locating public mental health interventions in community settings impacts mental health and health inequalities: a multi-site realist evaluation.  BMC Public Health 23, 2445.              

3 Pina, I., Gilfellon, L., Webster, S., Henderson, E. J., & Oliver, E.J. (2024). ‘Severe mental illness’: Uses of this term in physical health support policy, primary care practice, and academic discourses in the United Kingdom. SSM-Mental Health, 5, 100314.

For wider resources, blogs, and a project summary please see the WHOLE-SMI webpage or contact Professor Emily Oliver

February 2025