Organisation objective

• NHS Long Term Plan

Working with people and communities

What approaches have been used to ensure people and communities have informed this programme of work?

• recruited patient and public voice (PPV) partners
• consultation/engagement
• qualitative data and insight, for example, national surveys; complaints
• quantitative data and insight, for example national surveys
• partnership working with voluntary, community and social enterprise organisation

The actions detailed throughout this paper have been informed by clinical and lived experience advisory groups. Quantitative surveys have been used to understand the scale and progress made on many of the mental health conditions, patient and public safety incidents, demand, and supply of services.

Action required

The Board is asked to note the information provided in the report and provide any recommendations on next steps.

Background and context

1. Adult community mental health (CMH) teams support people with serious mental illnesses (SMI) such as psychosis, bipolar, personality disorders, and eating disorders. Access to Adult CMH teams has increased by 29% since March 2020, following c.£1billion of investment in the NHS Long Term Plan (LTP) to support more personalised care in the community. Other key areas of progress in CMH services since the start of the LTP include:

• 87% of Primary Care Networks (PCNs) are meeting all the key criteria* of a transformed community mental health service and providing access to 600,000 people.
• 71% of people experiencing their first episode of psychosis accessed care within two weeks of referral.
• Secured circa £200m in the Autumn Statement for Individual Placement Support (IPS) delivered through CMH services. On track to meet 2024/25 target of 37,000 people accessing employment advice and support.
• Over 361,000 people with a severe mental health problem have received a physical health check (68% of people on the SMI register).
• Increasing the quantity and diversity of the workforce through the development of new roles including Mental Health and Wellbeing Practitioners and primary care based Mental Health Practitioners (over 2,000 in place nationally).

2. Despite the increase in access and steps to transform services, a significant treatment gap remains. Referrals have increased faster than supply, impacting on waiting times – the 90^th percentile wait is currently 114 weeks.

3. In addition to rising waiting times, notable Serious Untoward Incidents have occurred recently involving Mental Health patients who have not received the care they should have. One of these is Valdo Calocane (VC) who was convicted of manslaughter in January 2024 on the grounds of diminished responsibility due to severe mental health illness. He is now detained in a high secure hospital. The Secretary of State subsequently commissioned the Care Quality Commission (CQC) as the regulator, to undertake a Section 48 review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust. The review did not identify one single point of failure, however the CQC identified multiple points where poor decision-making, omissions, and errors of judgement contributed to a patient with very serious mental health issues not receiving the support and follow up that he needed. Immediate actions were, and continue to be, taken in the wake of this incident at local, regional and national level. Many of them are described in this paper which sets out the ongoing work at a national level to improve patient and public safety in CMH services.

4. Although incidents of this nature are rare, they can occur, and it is important to acknowledge that any life lost in this tragic way is unacceptable. The most recent research from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), showed that between 2010 and 2019, across the UK, 11% of people convicted of homicide were patients under mental health care, an average of 61 per year. The number of convictions has fallen steadily over this period but remained constant between 2016 and 2019 at an average of 50 per year. Two key factors stand out in NCISH studies of patient homicide: (A) disengagement/not receiving treatment as planned and (B) alcohol/drug misuse. 94% of SMI patients convicted of homicide had one or both of these.

5. Between 2011 and 2021, there were 18,339 suicide deaths in the UK by mental health patients (i.e. people in contact with mental health services within 12 months of suicide). This equates to an average of 1,667 deaths per year and 26% of all suicide deaths in the general population. The patient suicide rate in England has fallen over the same period but with little change in recent years.

Inpatient services

6. The pressure and risk held by community services is heavily affected by patient flow in and out of inpatient services. The current mental health inpatient bed base commissioned by the NHS across England is around 24,000. This has reduced over time in line with clinical policy, for example to reduce the reliance on unnecessary use of inpatient care for people with learning disabilities and autism.

7. However, pressure remains on the inpatient estate, with bed occupancy at 95%. 334 inappropriate adult acute Out of Area Placements (OAPs) were active at the end of June 2024, and length of stay was at approximately 50 days compared to lower than 40 days before the pandemic. Challenges with discharge and flow are preventing the mental health sector from using inpatient resource to its best effect.

8. Staff shortages also remain a key risk. As of June 2024, the vacancy rate for nurses working in the mental health sector is 14.3% compared to an NHS average of 7.8%, while for medics working in the mental health sector it is 15.1% compared to an NHS average of 6.9%.

Wider service dependencies

9. Due to the complex and co-occurring needs of people with SMI, active input as part of their care is also required from other agencies, including social care, housing, public health, criminal justice system, and the Voluntary, Care and Social Enterprise sector. Over the last decade funding for these vital services has decreased, deteriorating the vital wider support for patients. This has contributed to pressure on mental health services, for example by increasing the number of people who are clinically ready for discharge but waiting for suitable housing.

Actions to improve quality and safety in community mental health

10. Several key actions have been put in place since the start of the year to improve patient and public safety.

11. Review into assertive outreach approaches: The 2024/25 NHS Planning Guidance asked all integrated care boards (ICBs) to review the services and approaches they have in place for Assertive Outreach and Intensive Case management by the end of September 2024. We have subsequently asked for these reviews to be discussed and presented at ICB public board meetings. These reviews will identify, at a trust level, existing practice and any potential gap in what is required to support this at-risk group, including whether dedicated teams are in place. We expect this to identify no cost / low-cost actions, and actions that require additional resources. Reviews of ICB actions will be followed up at six and twelve months to understand the progress made against their local action plans.

12. Resources: Assertive Outreach and Intensive Case management supports people where psychosis has become a long-term condition and where an individual has co-occuring needs (e.g. homelessness, substance use) and a history of violence or other offending behaviour. These teams have lower caseloads, which allows for a minimum of one or two contacts per person per week. The teams work extended hours and weekends to ensure they can provide support when individuals need it. They are resource intensive, creating an opportunity cost for what can be achieved elsewhere in mental health services that are under strain. This function was nationally commissioned in the 2000s however it was later decided that commissioning these teams should be a local choice. At present, around one-third of systems in England have a dedicated team providing this function, one-third provide a version of this approach, and we estimate around one-third do not have this function in place. We therefore anticipate the reviews into these approaches to identify that additional resources will be required to set up dedicated functions in many parts of the country, and in other parts resources will be needed to boost their scale and fidelity to recommended models.

13. Guidance and sharing best practice: 

• A longer-term review into the whole system approach to supporting people with SMI with a wide range of partners who support them, including but not to limited to: Primary Care, Urgent and Emergency Care, CMH Teams, Crisis, Acute and Secure Mental Health services, Community Rehab, Ambulance, and system partners like social care and the police. It will review what is in place, fidelity to models, how services are working together and integrating, what data, capital, and resources are required to meet demand, and what changes are required to ensure efficient flow and high patient quality care within and between services. The review will start at the beginning of 2025 and aim to report by the end of 2026.

• In the shorter term, the national team are already developing wider guidance on what good quality, safe care looks like for CMH Teams with our external partners including Royal College of Psychiatry (RCPsych) and CQC. This will include a review of patient safety and the basics of good quality care. It will also include the development of metrics and methods for identifying and overseeing live patient safety risks and align with CQC reviews for these services. The guidance will be published by the end of the financial year.
• The NHS England Mental Health team will also share best practice and increase training and education with our partners such as RCPsych. This will enable the skills and knowledge of good safe care identified around Care Treatment Orders, depot medication, continuity of care and family engagement to be improved and embedded across the country.

14. Continuous learning: The NHS England National Patient Safety team are reviewing and improving the approach to learn from Mental Health Homicide (MHH) incidents. This includes ensuring the process for identifying insight from MHH Independent Patient Safety Investigations is in line with the National Patient Safety Investigation Framework approach and translating this insight into national action in partnership with policy teams.

15. The Mental Health Act: The new Mental Health Act, which was included in the King’s Speech, will improve how patients remain engaged in services by developing the key characteristics of mental health services such as increased patient choice, requiring culturally appropriate care, and increasing requirements of patient engagement in care plans. The Department of Health and Social Care and NHS England are ensuring the learnings from the recent CQC report are reflected in the development of the Bill. We are clear that the safest services are those that engage with patients and a key problem in the VC case was the disengagement from services. We are exploring opportunities within the code of practice to ensure patients have maximum choice, as well as ensuring services apply the law correctly and proportionately to maximise safety.

Long term transformation of mental health care services

16. In addition to improving the safety and quality of services now, the NHS England Board has discussed previously the need to change the model of care within mental health. In February 2024, the Board heard of our work to improve the culture of care within our inpatient services and our ask of systems to localise the hospital care they commission. Both of these align with the learning from the care and treatment provided to VC, whose inpatient care was dislocated through the use of OAPs.

17. We also announced to the Board our intention to learn from international models which bring together community care, crisis care, and inpatient care into one team, located in local neighbourhoods. This model centres the role of continuity in care to people with mental health needs, as we know the vital role continuity plays in providing safe care.

18. We are working with six health systems across the country to implement 24/7, open access Mental Health Centres. The centres will be a place people can go to receive mental health care without booking an appointment and will bring together community teams, crisis services, and crisis beds. Drawing on international examples, the six centres are a stepping stone in helping us to create a new model of care, building on existing work in the community.

19. This integrated ‘one team’ approach builds on the evidence we have about effective engagement with people with SMI. The ‘one stop shop’ approach should mean that people can get the care they need closer to home and at an earlier stage with treatment in a comfortable environment – which will hopefully in turn reduce the need for a trip to Emergency Departments or admission to hospital.

20. This will be a cross-sector approach – people will also be offered advice on employment, volunteering, and other social skills and where people can be supported to stay well in their own communities.

21. The pilot sites are taking a phased approach to implementation with evaluation of the sites due to take place over the next two years.

Summary

22. Community Mental Health services have grown and transformed since the launch of the LTP however it is still under incredible strain due to the significant treatment gap. Every Serious Untoward Incident that takes place is a tragedy and lessons from these continue to inform the changes required to improve these services. Actions being taken are designed to improve patient safety oversight at a local, regional, and national level including through full scale reviews, sharing data and best practice, enhancing training, and evolving legislation. Alongside these actions we are also trialling new ways of working to fundamentally improve continuity of care which will enhance quality, safety, and productivity.

* The five key criteria ‘transformed’ services need to meet are; on access level, governance, workforce, holistic provision of care and outcome measures.

Publication reference: public board paper (BM/24/37(Pu)