Written evidence submitted by Social Interest Group (SIG) (CMH0205)
Community Mental Health Services
Submission of Evidence
About you:
Social Interest Group (SIG) is a national collective of charities supporting people with multiple and complex needs. Our services span mental health (forensic and non-forensic), criminal justice, drug and alcohol addiction, criminal justice, homelessness and domestic abuse. On average we support almost 10,000 people per year in residential, custodial and community services.
Our reason for submitting evidence is that mental health needs are prevalent amongst those we support, creating complex needs and we are specialists in delivering effective care and support. We work collaboratively with sector partners and have expertise on efficient, person centred mental health services in community settings.
High quality care for adults and their families looks like early prevention and support in the community. That is where mental health challenges begin and that is where they ought to be addressed with self-referrals and those by families efficiently processed and actioned by mental health teams in the community.
Assessments must be timely and intervention must be early when needs are identified; therapeutic intervention and medication have to be used in combination and balance to address and manage severe mental illness (SMI). Ongoing access to community mental teams should be seamless and fair.
High quality care looks like the new community-based offer promised in the NHS long term plan and NHS mental health implementation plan 2019/20 – 2023/34 actually being delivered, to ‘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.’
Personalised and trauma informed care help people manage their mental health in the community and enable their families to offer the support they can manage in their capacity as informal care network. Enabling families to support people benefits those with SMI to maintain the psychological safety of being around those they know and trust, in home and community environments.
Physical health care, employment support and community activities and courses elevate care from rudimentary to holistic, efficient and sustainable. This is high quality care and it benefits families as they share skills for independence and wellbeing, enabling continued good health in community settings, avoiding crisis and emergency measures that are often ineffective and aggressive.
The service user journey can be improved at every phase beginning with initial access to support, followed by timely assessments and follow up action by all agencies engaged on the mental health pathway when needs are identified. Cyclical care planning between multidisciplinary and VCSE services to ensure needs and aspirations are being met in a person centred way, will improve the service user journey.
Currently, there is an enormous barrier to access CMHS. Referrals and requests are not being responded to and there is no recourse for service users to seek as teams are not physically accessible in community centres or GP surgeries without appointment.
Once on the pathway for support, perhaps after attending A&E in crisis, service users face barriers to support as community mental health services are disjointed by siloes such as dual diagnosis policy, high staff turnover and lack of service user records and information sharing between community services.
For improvements to the customer journey, partnership working between local services will ensure that service users support and treatment is delivered holistically and seamlessly as all professionals and services are working to an agreed treatment plan for continuity and flexibility.
The government have pledged to recruit to 8,500 new roles into the sector. This is needed alongside increased long term funding so improvements in staff turnover and increased capacity for treatment and support are provided for service users. Continuity and capacity are key to improvements for the service user journey.
All community services need to collate data from service users and feedback needs to be measured according to an agreed national framework for all health and social care delivery. The local picture will then become clear from the point of view of both those receiving and those delivering support.
Both quantitative and qualitive data must be collated and interpreted to ensure cultural sensitivity, to empower service users to share their experience fully and for data to reflect outcomes rather than just outputs.
Currently, mental health trusts are loaded down with many data collating metrics but they often do not correlate departmentally with uniformity. Without uniform metrics and measurements at system, place and neighborhood level, no local or national measuring or monitoring is possible.
Combining qualitive and quantitative data from local level upwards, cross department and with a multi-agency approach that included VCSE, will enable analysis that creates a responsive and responsible Community Mental Health Service (CMHS) in every locality.
The delays of months and even years that are reported in response to treatment requests mean that the service user journey is not beginning at all for many people. Even for those who receive an initial appointment, it is often tokenistic to tick the ‘responded to referral’ box for performance data and meaningful support and treatment are not being offered. The state of access for adults with SMI is alarming and dangerous.
Many adults with SMI are reaching crisis point because CMHS are inaccessible. Our service users report experiences of contacting NHS single point of access by telephone repeatedly over the years to find that phones are not answered and they have come to refer to the service as ‘point of no access’.
Many of our service users face access issues to treatment because vital but infrequent appointments with psychologists are routinely cancelled. Medication reviews are also cancelled frequently or not offered at all to even those service users with SMI on medications which require close monitoring.
Our service users have even sought access directly at local NHS Mental Health hospitals when experiencing crisis but have been not received treatment or support. Access is being denied to many with SMI and people are dying in the community whilst under the care of CMHS. Recently, a major NHS report shared with the Independent revealed 15,000 people died under such circumstances in one year (from March 2023- March 2024).
Targets in place to improve access such as time from referral to assessment to treatment beginning (deemed to be from second contact) are tokenistic and people are dropping out of contact with services. This indicates that poor treatment and barriers presented by institutional approaches are causing people to avoid contact with CMHS despite their severe need.
This is cause and effect reflects the reality of the culture of stigma and institutionalisation that service users experience when trying to access mental health support. NHS Talking Therapies and Early Intervention in Psychosis targets appear to have been met but access is low according to the data, which shows that the access rate is 22% lower expected.
Our residents, and service users of our partner charities confirm the experience of continuing stonewalling at each point of the pathway to support, as one of the causes of these stark access statistics. In moving forward to set targets for CMHS, lessons have to be learned that incorporate quality of treatment and support as measurements of efficiency and success.
The Community Mental Health Framework is a well-informed document that is responsive to the lived experience of those with SMI, their informal network and the expertise of community mental health services and their staff.
Integration, accessibility and holistic support are indeed keys to transforming mental health but the framework is not in practice; statutory organisations are not implementing the changes prescribed and service users are told it is business as usual at every point of access; GP’s, community mental health teams and frontline staff are still presenting barriers to access because they are telling service users that they do not need intervention but can only have anti-depressants for their low mood.
Governance, culture and accountability must be addressed in order bring transformation to institutionalised services. Mentality and methodology amongst statutory organisations stigmatises service users and information barriers are actively applied which withhold information about how to get help, service user rights, and fair assessment and treatment.
To treat people with SMI in this way is discriminatory and denies their autonomy and dignity. People do not get well or stay well when treated this way. For marginalised groups and seldom heard communities, institutionalised attitudes further exacerbate mental health and existing challenges.
Person centred approaches from services and teams that enable service user co-design and autonomy in support and treatment plans are essential to make the Community Mental Health Framework a reality.
Training statutory staff from all bands, developing accountability framework that is measured by responsivity to service user needs, experience and feedback, are all essential to making CMHS effective and sustainable.
Firstly, this type of partnership working between services is essential to delivering support to service users that is holistic, efficient and sustainable. Without partnership, the joined up, consistent and efficient support that helps people with SMI stay well in the community is impossible. Without integration, services are ineffective in meeting the needs of service users and as well as failing residents, siloed services waste public resources.
CMHS can work with social care, local government and the third sector to ensure that care and support is delivered according to an agreed and shared service user care plan, created by mental health, social care and VCSE professionals, in co-production with service users. Up-to date and innovative technology should be used to ensure plans are safely shared and updated live on a platform that is accessed by all teams involved in the service users’ care.
A shared care and treatment plan will ensure accountability from all services and their teams to deliver effective support for service users to manage their mental health in the community. Duplication can also be avoided by partnership working between organisations.
Local authority housing departments must be involved the multi-agency partnership working described here because housing is a vital element of independent community living. Appropriate housing, whether social or private, can and ought to be accommodated by housing departments for residents with SMI. Support to sustain tenancy can be the difference between someone staying well in the community or falling into crisis and losing their home.
Accessibility along the community mental health pathway is poor, accountability structures for staff need investment and data collation will be required to assess performance. Monitoring programmes can be supported by technology and digital platforms can enable a more interactive service for those with SMI in the community, to initiate contact and follow up support and treatment.
Investment into data storing, sharing and accessibility systems is essential as it can address many challenges currently impacting patient and service users. The Darzi report highlights deficits in investment into technology which contradict aims for joined up care in the community. To enable CMHS to function efficiently, information storage, sharing and updating must be optimised by supportive and safe technology.
It is time to stop frontloading funding into hospitals where people in crisis end up and balance investment into the mental health pathway in the community, where crises begin. Preventing people from reaching crisis will enable a reduction in emergency support, which is traumatic for service users and very expensive for services.
Investment reform must ensure funding into community hubs so that early prevention initiative are holistic and accessible, with joined up services and classes available that deliver stable support to those with SMI to integrate into their communities and develop skills and gain support that enables them to partake fully as equal citizens in our society.
Blockers:
1) Barriers to access; non responsive teams and professionals, stigmatisation and marginalisation of those with protected characteristics, and dual diagnosis policy which causes substance use to prevent mental health treatment.
2) Funding barriers; whether short term cycles, unevenly allocated to statutory partners and crisis-centric rather than preventative.
3) Technology and data; data collation, measurement and sharing are inefficient and put vulnerable people at risk.
Enablers:
1) Capacity building and upskilling of CMHS staff to deliver person-centred support to people, to take a ‘no wrong door’ approach and treat service users with dignity and respect.
2) The just culture model chosen by the NHS to address neglect and abuse of patients needs to be put into practice. A human rights based approach to delivery of care, treatment and services must be embedded within CMHS. This will only be achieved if person centred principles are part of training for all staff bands in the NHS, not just frontline, to counter the current stigmatisation of those with SMI.
3) Talking therapies and therapeutic interventions which are evidenced to be effective in supporting those with SMI to manage wellbeing in the community, must become standardised, and prescribed alongside medications. Accessibility, regularity and security must be markers of psychological support for those with SMI.
4) Community care hubs must be restored to all localities and expanded to deliver one stop support for those living with SMI so that they can receive holistic support; social, physical, financial and employment.
Good and innovative practice in CMHS can be defined by integration and person-centric approaches; multi-disciplinary partnership working between agencies and organisations to provide holistic support and practical solutions to meet the needs of service users.
An example is South London and Maudsley NHS Trust’s community rehabilitation partnership with SIG as a VCSE specialist provider of SMI mental health support services. We provide holistic support for people to recover, integrate into community and develop skills to maintain their wellbeing.
Clinical in-reach is provided by the Trust including psychiatry, psychology and occupational therapy. CMHS Care Coordinators ensure integration and support from all partners for the benefit of service users.
Once residents are ready to move into independent living in the community, our floating support services Penrose Community Care and Support, STEPS (mental health hospital discharge service) and Support Time and Recovery Services, enable us to continue delivering regular support to them to ensure they maintain recovery and independence.
Our home visit and outreach services allow us to be adaptive to the changing needs of service users and to support them through partnership working and referrals to community partners such as GPs, CMHS, community centres, social groups, and information and advice services.
SIG offer a range of services that are structured around service user needs and aspirations in niche communities. Responsive services for those with SMI such as day centres for socialising, skills and activities, housing support services, and street outreach for homeless people, are delivered according to place and neighbourhood needs, in partnership with NHS and local authority partners. This model is effective and cost efficient and we continue to expand nationally.
1) Firstly, the government needs to follow through on their plans to allow data sharing between NHS Trusts and to facilitate ‘digital passports’ for service users to be in possession of their medical notes and treatment plans.
2) Investment is needed to expediate data sharing systems between NHS, Ministry of Justice, local authority and VCSE so that our services can integrate in working toward person-centred outcomes for service users with SMI. A live care and support plan must standard for each person and monitoring facilitated and mandated by policy.
3) Standards of access, treatment and ongoing support must be raised so that the level of need is met in a timely and consistent way, by CMHS that are person centred, compassionate and skilled. Local and national standards must be mandated and upheld with accountability from NHS leaders and frontline staff. The impetus to perform well needs to be introduced to statutory services.
4) Wider community services must be revived, accessible in all localities, with a holistic range of services available according to neighborhood need. In this way health inequalities and social challenges can be addressed and service users can develop citizenship and stability in their local communities. Evidence of the positive impact of social prescribing on those living with mental health in the community supports investment into community services.
February 2025