Transcript of roundtable with practitioners for the Health and Social Care Committee Mental Health Expert Panel on Tuesday 12th October 2021.

Group 4: Adult Severe Mental Illness

Stephen Aldhouse: Hi everyone. Thank you all for coming today. As Jane Dacre introduced, this is part of the panel’s evaluation process of the Government’s mental health commitments. Just to give you a little introduction, the panel approached the Department for Health and Social Care and asked them to send the list of commitments that they had made in the last five years which still relate to policy making in the area of mental health. They sent back a list which was divided into a certain number of groups, but when you broke them down I think there were around 120 individual, commitments. So, when Jane was talking about the process that the panel went through to narrow down those commitments, that was difficult in itself, and we narrowed it down to 4 commitments in the area of adult severe mental illness, to evaluate on the basis that they might be quite generalisable and they could therefore speak to Government progress across the board on this area. Over the course of this session I will let you know what the specific commitments we’re looking at are, but I don’t want that to particularly structure the session. We have some broad questions to work through and I hope everyone will have an opportunity to express their general views on Government progress in this area, or otherwise. Before we kick off with the first question, it might be useful if we go around the room and have everyone introduce themselves.

Participant A: Thank you very much for including me. I’m a frontline clinician (psychiatrist) and the Chair of the Faculty of Eating Disorders at the Royal College of Psychiatrists. In my roles, I have a view across the different levels of eating disorder services across the UK.

Participant B: Hi everyone. I’m a consultant clinical psychologist working in the South West. I’m also a trustee for a charity that delivers counselling to people with cancer.

Participant C: Hello. I am a Social Services Manager in the North West. I manage the Deprivation of Liberty Safeguards Team. I’m also involved with the British Association of Social Workers.

Participant D: Good afternoon everyone. I work as an Interim Nurse Consultant for mental health in London.

Participant E: I am currently a second-year trainee clinical psychologist on the Trent programme.

Participant F: Good afternoon everybody. I’m speaking to you from the North East, where I have spent my career in mental health nursing. I am currently a nurse consultant, working part time in a secure mental health services community team. Over the years, I have worked in inpatient and community teams as a clinician, but I’ve also had different commissioning and voluntary sector experiences.

Participant G: I’m a consultant clinical psychologist working in the South West. I clinically put my time into the early intervention psychosis service, but I’m also the psychosis lead.

Stephen Aldhouse: Brilliant. Thank you all very much. I should say that although I’m a general policy advisor for the Committee, and my job title is Committee Specialist, I am in no way as much as a specialist as any of you, so I will certainly be doing more listening and learning than speaking. So the first question that we thought we should consider is do you think progress against the Government’s commitments has been sufficient to meet the mental health needs of adults with serious mental illness. So, we’re really asking where you think we are at the moment, and what does the Government’s progress look like. If needs be, I can flag some of the specific commitments that we’re evaluating, but does anyone have any general views that they would like to share?

Participant A: I specialise in eating disorders, and whilst there has been significant progress in CAMHS eating disorders it seems there is a huge disconnect between the child and adolescent programme and the adult programme. That is quite unique, I think, in the history of the NHS. Because, for example in early intervention you have the investment, you have services linked and the CAMHS access and waiting time directive was very ambitious and it has been put in place with ringfenced funding, so people are supposed to be seen in one week or a month which is fantastic, but the minute that you hit your 18th birthday you are facing a void with two or three years waiting time for treatment. So progress has been made in the sense that we have Adult Eating Disorders commissioning guidance, but we haven’t got ringfenced money so we can’t actually implement the commissioning guidance that has been published by NHS England because of the lack of targeted funding. There has been progress with the provider collaboratives, but it doesn’t take into account the increasing prevalence of eating disorders. The number of patients requiring hospital admissions in 2007 was about 4000, in 2021 that was 21,000 so you’re talking about a really major increase of people being so unwell that they need hospitalisation and that is not reflected in the national policy. We had a meeting this morning with NHS England and they’re saying that the money will arrive by 2024 as part of the Long Term Plan, and we have three years until then so what are we going to do with the patients who are high risk. So there has been some progress, but the risk is enormous on the front line and that has an impact on recruitment, retention and I’m pretty sure that it’s similar in other areas not just for eating disorders.

Participant B: I work more in core mental health services like CHMTs and sometimes inpatient units, and we’ve been very involved in the Community Mental Health Framework that is often called the Community Service Framework, which is a really largescale project driven by NHS England and Government policy to address some of the huge needs within our core services. I’m often noticing, not just within my trust but neighbouring sites as well, and even in the pilot site in my particular region, that progress can often be made in areas that we’re already reasonably good at, however things that we are less good at- for example the delivery of psychological therapies- progress has been very, very slow and sometimes a little bit tokenistic. To give you a sense of the disconnect there, one of the ambitions of the Community Mental Health Framework is to deliver NICE compliant evidence based psychological therapies to everyone with severe mental health problems within secondary care. The gap between that and what my Trust, and my neighbouring trusts, currently do is absolutely staggering. It’s almost a case of if a particular area is well understood and well established, staff are very confident in drawing up new plans and moving things around, but if you’re looking at real fundamental change in what we do as a service then people tend to put their heads in the sand and very little progress is made. I think this movement from community mental health teams that contain people, and assess them and manage their risks, towards community mental health teams that are geared towards actively treating underlying mental health problems is something that people are finding very difficult to process. Progress is glacial at best.

Participant G: Just leading on from that, I think I would echo those sentiments in terms of provision of psychological therapies. Obviously, I’m here with a psychosis hat on, in that psychosis and bipolar is the pathway that I’m lead of across the trust, but I work quite closely with my colleagues in what’s called the emotional regulation pathway as well, and we’ve been a pilot site from the transformation, so that’s moving from a secondary care model to essentially amalgamating primary and secondary care and people being able to move very fluently throughout services. And I think there is something around the ethos behind that which I applaud, and my colleagues applaud, about people being able to move in and out of services more easily, have their needs acknowledged and then responded to and that there is some attempt at funding which I think is appreciated in terms of training and skilling clinicians up. I think, again, there is a real disconnect between what is theoretically possible and what is practically possible on the ground. I think a lot of progress has been difficult because of real basics that clinicians on the ground need in order to put a lot of these commitments into place. So things like recruitment and retention of staff, places to see people, people having capacity and resources within teams to be able to go off on quite onerous training programmes. I can understand the commitments to providing highly evidence based, good quality interventions, however I think some of them are unrealistic in the way that they’re hoping to be implemented. There is something around that connection between what actually happens day to day in the clinical world, compared to particular standards from national directives. And having some way of bridging that gap would actually allow people to access psychological interventions, and other interventions, more easily. I think my fear is that, in trying to improve access to psychological therapies it’s almost taking a step backwards, because it’s so difficult to get people trained up on it to a level that is required that nobody does it. So even the low-key psychological interventions that were maybe happening are now being deemed as not effective or not good enough, so it’s become very specialist or very manualised around what the psychological interventions are for particular groups of people. And then it’s becoming more specialist, so within EI I would echo what I think Participant A said earlier about EI being incredibly well resourced, and I would say that is a particular area of progress and it’s done really well. Although locally it’s very different and varies between trusts how EI services work, and whether they’re given access to the funding that they need, I can only speak for our trust that that has been something that we’ve been able to look at and increase workforce numbers, and capacity and we do feel that clients are able to get a good service. But that is very much ringfenced around EI, and then trying to incorporate that and broaden it out more widely to core community services is very, very difficult.

Participant F: I suppose, and some of this goes back further than five years, but it’s still pertinent. The huge thrust towards physical wellbeing, or addressing the physical health, of people with severe mental illness has been a worthwhile and understandable endeavour, and it absolutely is of importance. However, from the perspective of a field worker, being at the care face, I think the emphasis of that has come at an expense in that the thrust of resource and demand to be able to achieve something that is quite physically difficult to do, comes at the expense of time to do other things. Participant G’s point about being able to do EIs, is a really good one. A huge effort to make services for people with an emerging mental illness to get the right psycho-social interventions, and advanced psychological interventions, those efforts going forward to the whole of the adult population become very depleted when the emphasis is on physical healthcare. And also, I think in terms of levelling-up, it’s really difficult that all of the emphasis seems to be on mental health providers to improve the wellbeing of their patients, whereas I don’t see those efforts from colleagues in the acute sector. The other thing is that the emphasis on recovery has been taken up by this Government, and other Governments beforehand, and I think that gets bastardised. The pressure on services to manage caseloads means that people with long-term disabilities are cared for on an intermittent basis, so we lose huge amounts in continuity of care, and the idea of people being treated in primary healthcare for major mental illness just does not make sense whatsoever. I’m going to try and ease of the accelerator a little, because I’m getting a few nods, so I think colleagues know the drift I’m at, but we’re expected to do a huge amount at a time when the physical resources of where you see people, and colleagues working in a hospital sector which is a hugely pressurised business. Recruitment is a major problem nationally.

Stephen Aldhouse: Thank you. We are going come onto workforce problems in a moment.

Participant D: I agree with what Participant F was saying there. I think even if you look back over the last 18 months about how patients with SMI have been disproportionally affected through COVID in terms of missing out on services. We weren’t able to provide them with a robust alternative to hospital care, things disappeared so there was an issue with the system there. As people said there is lots of variations across the patch, and I think services have become quite skilled at screening people out, probably due to capacity, and people fall through the gaps. I still think the model of offering services hasn’t shifted since I was a student nurse and that just leads services at weekends and evenings under immense pressure and it’s not working as it could do. The concept of integrated care and PCNs sounds positive, but as people have said I wonder if the workforce is there to make it reality.

Participant A: I just wanted to add about the physical health monitoring, because to my amazement eating disorders are constantly forgotten when we’re talking about physical monitoring of the “severely mentally ill, and this is the highest mortality rate for physical reasons. From my position, I’m seriously thinking we would be better off if under-resourced specialist services didn’t exist and we somehow merged with AMHTs, but then there is a massive issue around training and capacity of workforce. So I kind of feel that eating disorders have an internal stigma within mental healthcare. We are at a potential risk of where addiction psychiatry ended up where already, more than half of inpatient services are provided by independent providers and there is then an impact on training and research, as private units don’t offer training the next generation of psychiatrists and don’t have research indemnity. 

So I’m thinking that when we’re talking about mental health, eating disorders should be in the core of skills and knowledge for the workforce. It’s like depression. So, you have people with mild depression, and you have people with life threatening depression. 16% of adults screen positive for eating disorders. In secondary care they see life-threatening eating disorders and we can’t wait three years as there will be hundreds of people dying.

Stephen Aldhouse: Thank you very much. What I’m going to do now is I’ll put into a chat the four specific areas in the area of SMI that the panel are actually evaluating, that we’ve received submissions and data on which might help shape some views. Some of you mentioned the aspect of physical health and that’s the first commitment that we’re evaluating. I don’t know if anybody has any initial thoughts on those four commitments, and any specific reflections on progress against those.

Participant A: So number one, eating disorders are not included so we need to include them.

Stephen Aldhouse: Ok.

Participant B: I would also wonder where evidence-based intervention comes into it. I see interventions being mentioned in the inpatient environment, but I think people with severe mental health problems should have access to that in all parts of their treatment pathway. Unlike Participant G, my specialism isn’t psychosis, mine is more in the within the field of personality disorders and complex trauma, and one of the difficulties we have is that the treatment that is the usual approach for our client group doesn’t tend to fulfil NICE guidelines. There isn’t an equivalent of early intervention services for my sort of clients.

Participant G: I just wanted to comment on a couple of them. So the physical health checks within specialist teams like the EI are really hot in auditing on that. The second point on the transformation agenda with the integrated community models, I think from my understanding that is varied across the different pilot sites. I know locally that has been almost entirely taken as being within the personality disorder pathway, called the emotional regulation pathway, that’s where a lot of the transformation bid has focused it’s attention looking at a specialist service. So the complex emotional needs service that we have locally for kind of the top tier of people meeting that diagnostic criteria and they are then looking at the pathways within the core teams about the NICE evidence interventions around that. So there has been some progress in that area. I think for the psychosis side of things, it’s been a little bit more located within the specialist teams only. Thinking about EIs we’re lucky to have an AOT, so that is amazing, and they do a really good job, but again it’s kind of seen as another specialist team even though it’s within our community SDU. It’s kind of seen that people with psychosis have their needs met there and nothing is needed to be provided within the neighbourhood teams across primary and secondary care, so that is something that we’re currently looking at in the psychosis pathway. But I think it can be quite hit and miss where that emphasis is placed across the different transformation sites. The inpatient issue was something that I wanted to raise, and I know that my colleagues within the acute sector have been wanting to ask about that because I don’t think that any progress has been seen in any way within the inpatient therapeutic offer for people on wards. This is especially true of some of the trauma informed ideas or trauma informed environments. Locally, we’ve got a little steering group around it but more nationally I don’t think we’ve seen any particular money or funding or anything like that. And ditto with the crisis team, they’re very much operating as usual I don’t think there has been any particular progress around that. But equally we do have a crisis and home treatment team, so I guess that that’s met to some extent.

Stephen Aldhouse: Thank you, that’s really helpful.

Participant C: Various colleagues have mentioned issues around delivering psychological therapy and from my own experience I’d like to flag that as well, particularly in the context of older people. The issue that I’m particularly thinking of is people placed in care homes who have a diagnosis of dementia, whose behaviour is causing a problem and staff are looking at support from mental health services. Often that support can be very difficult to obtain, but I’ve seen it work really well when the connection is made. It’s not just about mental health services being unable to do it, there are issues around can the providers actually meet the persons needs in the way that they say they can, what services are being commissioned but it certainly causes a problem as people have to move from placement to placement when often that might not be necessary if better support can be provided at the beginning. We know that the proportion of older people in the population is going to grow, so the proportion of older people with mental health issues is going to grow, so this is something that my colleagues are already struggling with and I can see that it is going to be a bigger issue in the future.

Participant F: I just wanted to put something in about inpatient services. I still think that the burden on beds is huge, and the burden on acute inpatient psychiatry is just incredible due to the diversity of patients, the demands on the staff and I think there is a bit of poverty of attention on that. I think if some of the violence, to put in bluntly, faced by staff in acute inpatient settings had an equivalent in the acute sector there would be a public outcry, so I think there is a lot of work to be done in that area. It just comes back to that problem about how you attract staff. The big focus on the therapeutic offer is about activities, and that is literally can we provide an activity in the whole of the morning that we might get one or two people coming to. You know, can we have a coffee morning or something like that. It’s very, very low level, and sometimes that’s necessary, but it’s a far cry from offering evidence-based interventions across the piste.

Participant A: One of the things that I’ve been thinking about, is that obviously we have the various NICE guidelines, and we all refer to the NICE guidelines. I don’t think the Government has ever done a cost analysis of the funding that is needed for the implementation of the NICE guidelines for psychological treatment, and I think that is something that we’re all struggling with. You are talking about various types of services where psychological intervention is key and to be fair psychological treatment has been progressed in the last 10 years, medication hasn’t really progressed in the last 30 years, so that’s a major gap because there is almost a chasm between what is the guidelines and what is happening on the front line. Without actually having that economic analysis it just feels like we are working in unknown parameters with massive demand. We know what good practise should look like but there isn’t a national commitment or strategy to implement those guidelines.

Stephen Aldhouse: Before I bring other participants in, I just wanted to say that one of the questions that we are meant to consider is: do you think that the funding is sufficient to meet these commitments that the panel are evaluating, as well as comments on funding more generally. So, when you’re considering your remarks on funding you may well want to consider remarks on resource in terms of workforce as well. I just wanted to flag that now.

Participant B: Thank you. And I think my point probably speaks to all of that. Firstly, what Participant A said about the cost of implementing NICE guidelines and the economic modelling that would go behind that I would fully agree with. Because I suspect that there is an opportunity cost around not having not introduced NICE guidelines across the board, because of course those clients that aren’t being treated or perhaps better managed within their care are then within services longer, or if have the difficulties that mean they’re going to be long-term clients anyway, then the level of care they require is going to be greater and it’s going to be more costly. So I think implementing evidence-based treatment usually saves money in the long term. One of the bits that we’ve been looking into within the Association of Clinical Psychologists has been around the importance of having board level representation for psychological therapies. We noticed the huge revolution that the NHS went through when a nursing director became legally mandated, and the profound impact that had on acute care, and we think that introducing something similar within mental health NHS providers, where each board is required to have a Director of Psychological Therapies would have a similar impact and may well help people refocus their attention to some of the points that have been mentioned in the chat. For example, the fourth commitment around intensive services, as Participant D has written in the chat, the reality is that patients received medication rather than therapy. That’s absolutely true. I’ve noticed that in every single NHS trust that I’ve worked in. We’re very good in these crisis teams of getting medication to people when they’re in crisis, but we’re less good at getting evidence-based therapies that would have a similar effect. I guess my big recommendation that would touch on the points of resourcing, money, meeting the Government’s commitments, staff would be to really look at this relatively small change of mandating this director of psychological therapies on the boards of mental health trusts.

Participant G: Yes, couldn’t agree more with that point. My other point also speaks to some of the things that might come along with that as well about recommendations. There are pledges and commitments and I think it’s often with the how of implementing these commitments that things start to fall down. As psychologists we talk about Maslow’s hierarchy of needs, and there is something around having the basics in place to be able to do any of this other stuff. We have all the NICE guidelines that tell us what would be helpful, if you had enough so and so to do it. So the question on do you think that the funding has been specific, I think there has been some effort to put funding into that, and there has been in a lot in the NICE guidelines and a lot of the implementation guidance around psychological therapies in particular and actually highlighting that a little bit. And that’s great, but there’s nothing around them pledging to have rooms where you can see people, or a chair where you can have therapy, or enough staff to meet demand and those are some real basics around provision of a service. Expecting more and more things with not enough people, not enough places, not enough car parking spaces. It’s this daily stuff, that then when you’re reporting back on your audits or the therapies that have been implemented, I think there is all the will in the world in the clinical staff to be providing this, but there are just not enough bums on seats. We can’t retain staff because people are getting sick of not having enough space or resources to be able to do things. And COVID hasn’t helped. One thing that I did want to say about the NHS having these very high stipulations around COVID precautions, compared to the rest of society, is making things very, very difficult. We’ve seen more and more losses in staffing, essentially because they’re finding it hard to maintain social distancing, not being able to do as much face to face working, all of those things that I think people thought were going to be quite temporary not being temporary. It’s incredibly hard already with recruitment or retention, and this has made it a little bit more difficult. You spend a year or two training someone up on an HEE funded course to become able to provide therapy, and you’re lucky if they get through it or if you keep them at the end of it. The commitments are very honourable, and we agree with them, but the implementation and the funding around implementation- beyond funding training courses- is something that really needs to be looked at, because there needs to be governance and resources to sustain any of those interventions after the training has been done.

Stephen Aldhouse: Thank you, and it’s helpful that you referenced COVID there. I think one of the thing that the panel will have to do with their evaluation, is look at the commitments and consider which you can reasonably critique in the COVID context. Are there any that you would say have gone out of the window because of COVID and are there other comments that despite COVID we could still potentially be quite critical. The other thing I wanted to add, is that at the beginning Jane might have had a little slip of the tongue because she said CQC style recommendations. The panel is tasked by the Health Committee of making CQC style ratings of Government progress against it’s commitments. So at the end of this process the panel will have to say whether it thinks overall in the area of adult SMI the Government’s progress is Outstanding, Good, Requires Improvement or Inadequate. You may have your own opinions on whether those kind of ratings can be applied in this way, but the panel has established this methodology. So they can apply them to each individual commitment and overall as well. So I just wanted to flag this in case anyone wanted to express a view on what they would give the Government as it stands. Does anyone want to add anything further on workforce and funding?

Participant A: I think if you include the point about having a proper cost estimate of implementation of the NICE guidelines that would be a key thing for me. What I’m hearing on the ground from our managers who are trying to use the investment is that it’s too expensive, we can’t implement it and we have to be creative.This basically means doing anything that looks like an intervention with unqualified staff. And it’s really scary and in the long run it’s harmful for our patients. The other point that I wanted to make is around the physical environment. It’s really important and the Royal College of Psychiatrists have flagged this up. We have the announcement around 40 new hospitals, but to my knowledge that doesn’t include any mental health trusts. That causes major problems around effective face to face appointments for sufficient amounts of people and just having clinical rooms for checking people’s physical health. On retention, something that we have found and I’m sure others have as well, but ever since the mental health nursing student bursary has been removed it has been extremely difficult to recruit any nurses, because of the discrepancy between the cost of living and the salary. And to some extent that is also happening with junior doctors as well now due to large student loans. So something on cost of living and pay has to be looked at in order to increase retention.

Stephen Aldhouse: Thank you. And we can come back to funding and resourcing at the end if people wish to. So the next question we’re look at is quite specific, but we can open it out, is: has the Government approach to meeting commitments had unintended consequences in other area. For example, diverting resources in ways that are unhelpful or negatively affecting or removing focus from some aspects of care. I think we have already touched on that, but any other views will be really helpful.

Participant B: I often think that this is a really difficult balance for any government to strike. On the one hand, you want to give provider trusts the opportunity to tailor their services to meet the demands of their local community, so you need to give them the freedom to do things their own ways. But on the other hand if you’ve made a national commitment about how you want things done better then it’s really helpful if that is closely defined, and by defining it closely you start to prescribe it in a particular way. And I think at times, some of the delay to implementation occurs when things aren’t neatly enough defined by what people mean. I think we’ve seen it here already with commitment three around increased investment in interventions and activities, and as Participant F was saying, that could cover a whole multitudes of things, everything from evidence-based care right the way down to having a cup of tea and a biscuit with someone. And I think when it’s that vague, provider trusts start to pull in resources from within itself in order to do things like form committees and working groups, include service user representation, include operational manager representation and clinical representation. All of that takes time and it takes resources away from the front line. And then when you’re asked to provide updates and reports about how well you are hitting targets, you need to pull a lot of data and that starts to take away resources from the front line as well. I guess I don’t have a neat solution to this one because I’m aware that it’s very difficult either way you go, whether you’re prescriptive or very loose about your recommendations or commitments.

Participant G: Again, I can only represent locally what we’ve noticed in terms of gaps, or areas where things have had to take a back seat. It depends a little bit of how trusts prioritise. I think older adults, as previously mentioned, have fallen through the gaps and I also think adults with learning disabilities, and that crossover that we find between adults with autism-spectrum conditions and mental health has taken a backseat. A major area of difficulty we’ve had is in terms of having expert by experience, or service user involvement. I noticed that that hasn’t come up in the commitments here, but it has elsewhere, but I don’t know it it’s been followed up everywhere. Payment for Expert by Experience time has been taken away from our trust, so it’s been really difficult to recruit for those posts that were really important in terms of co-production and different bits of involvement that Expert by Experience had with us. Those are some of the areas that we’ve noticed have been missing, but as you said the more you give to one bit the less you can give to another bit, so it’s really hard to prioritise.

Participant F: I was just thinking about what Participant B was saying there. It is a difficult task, but if we go back to the 90s and the beginning of crisis teams, EIP and Assertive Outreach that had an impact, but it came with resource that was ringfenced. And it did have an impact and continued to have an impact and could have an impact now. The opportunity to have eating disorder services that go from childhood into adulthood makes absolute sense to me. But there are also things that don’t cost money. People value relationships and we have systems that drive tractors through relationships. We don’t value continuity of care, we don’t value therapeutic relationships- we hardly talk about therapeutic relationships. I agree with Participant B that it is difficult to get that right from a policy perspective, but the message you give about what you expect is really important. Provider trusts will do exactly what Participant B was saying there, and the emphasis will always be on performance. I come from a highly regarded, highly performing trust and that thrust on saying what it is you’re doing, and how you’re doing it can actually be crushing and can actually affect the morale of staff trying to provide care on the front line.

Participant A: I don’t want to repeat myself, but again without actually knowing how much it would cost to implement NICE guidelines and then giving piecemeal funding to different services causes unintended consequences. So investment into CAMHS eating disorder services has been good, but that means that adult eating disorder services have lost a lot of experienced staff because people are going to a better resourced service and remaining in their specialism. Similarly, I heard from my colleagues that when the perinatal services were set up- obviously that was an important development- but that took away staff from AMHTs. So we need to have a national strategy to look at the proper data and look at how much it would cost to implement NICE guidelines. I’m sort of thinking if we would be in the same situation as diabetes or cancer, where we would say that we fund this bit, but we don’t fund this bit or that we don’t know how much it would cost to implement other new treatments to the NHS.

Participant B: Yes, and I would extend your cancer metaphor. I think the experience of many people coming into mental health services if of assessment after assessment of their needs. And then after, at times, two years plus waiting they eventually get a form of treatment that is not quite delivered right and is done by someone that doesn’t quite have the right training. If you imagine that happening within an oncology unit, within a cancer care department it would be an absolute national scandal that you were assessed six times over, and had to wait more than two years, to be given treatment that wasn’t even recommended by NICE. It would be just absurd, but because it’s mental health somehow, we get away with it.

Participant A: It causes stress, not only for patients and families but also for staff and that is why were struggling with retention.

Participant G: I think it comes back to about the how, and the actual implementation of things. Because I think with the transformation agenda that is exactly the things that it speaks to: not having to go through lots of assessments, getting NICE recommended interventions rather than anything that people fancy, and they have the time before. But in reality, there needs to be enough money and funding to put that into place. You can’t expect core community teams to suddenly get trained up in every single NICE evidence intervention, without there being more staff to do that. You can’t expect them to trained up in DBT, and CBTP and BFT and every other acronym. These are all the interventions that we’re meant to be doing, but how can you expect that same group of people, who are already up to their limits in terms of caseloads, to be providing this just because it’s been recognised that this is what we should be doing. There is a massive gap between recognising what we need to be doing and the on the ground implementation of how we do that and whether we have enough funding to do it.

Participant B: I agree, and I think that one of the challenges of the community mental health framework, is when it’s being rolled out it’s seems to duplicate some of the same problems that we’ve had before, because it is of course just doing more of what we’re used to doing. So in our area, and I think most areas nationally, we’re looking at Rs who are specialist practitioners that will be put into primary care networks who will be very good at doing more assessments. So we’re putting another level of assessment within there. But when it comes to delivering evidence-based care, we’re relying on much more on core staff maybe doing it as a side-line, a adjunct, to their current roles. And, my God, the core staff at the moment certainly don’t have any spare capacity to be doing things on the side. Again, to go back to my earlier point, that it’s perhaps because the people leading the change locally aren’t represented by the psychological profession, so there are no directors of psychological therapies that are mandated be on NHS provider trust boards, and that creates that gap at the top level which should be driving this change. And that’s not to say that there isn’t very good practise, my psychiatry and nursing colleagues often have specialist training and interest in psychological therapies, but that’s not their core role on the board and that’s not the focus of their attention.

Participant G: I think there is also something around front loading the assessments. A lot of the models that are set up are around having the least experienced people doing the assessments and just going through those and sending them to where they need to go. That’s a really complicated job, and I think the psychological professions should have more of a role at that front end because you’re talking about really complex formulations. If we can get away from this really diagnostic driven set up of services, and move towards more formulation driven one, then it would actually make things easier, because you’re just identifying what people need and then working out how the system can meet those needs rather than having to be going into a particular service or going into a particular diagnostic group. I know that’s a bigger conversation, and is beyond the scope of this meeting, but I think that would be helped by having some kind of psychological representation at a much higher level because then you’re starting to think about formulation and diagnosis all the time. And actually getting in there earlier might save so much money and time later on, and going through three or four assessments, jumping through hurdles and diagnostic criteria to try and identify what this person is actually presenting difficulty with, how can we understand that and what can we do to help with that, and this is the menu of stuff that we have that as a service that can offer. That feels like the idea behind it when they were coming up with it, but again the implementation is not being born through.

Stephen Aldhouse: Thank you. That pretty neatly takes us to our time. It’s been extremely helpful, and the transcript will be used to inform the panels report and eventual ratings. This is our opportunity to hear from people working on the ground so thank you for giving your time today.