Welcome to today’s meeting of the Health and Social Care Select Committee, the first session in our inquiry into community mental health services. Throughout this inquiry, we will examine how we can improve access to and the quality of support provided by community mental health services, as well as how services work with organisations outside the NHS to address the wider health and social needs of people with severe and enduring mental health needs. We have received over 240 pieces of evidence so far, which is a lot in the context of a Select Committee inquiry, and we expect to receive many more. Throughout this inquiry, and indeed in all our work as a Committee, we are committed to putting people who access these services, their families and their communities at the heart of everything we do to understand what high-quality care and support looks like from their point of view. It is therefore with delight that I welcome our very first panel of our very first session of this inquiry. We will hear directly from three experts by experience. May I start by asking you to very briefly introduce yourselves?

Thanks very much, Layla. My name is Ian Callaghan. I have experience of severe mental illness, as you will hear. Thank you very much for the opportunity to be here.

Hi. My name is Francesca. I also have experience of mental health services, as you will hear from me as well.

Good morning. I am Chris Frederick. I am a suicide attempt survivor, global citizen and mad “Star Wars” fan.

You and I have that in common. May I start with Ian? Could you briefly—I appreciate that this is a lifetime of experience you are bringing, but as briefly as you can—tell us your experience of accessing mental health services?

It is a long story, but I will try to keep it brief. My story is about 40 years old. In my early 20s I had my first episode of severe mental ill health. A bit like Chris has just mentioned, I am a suicide attempt survivor. I have experienced community services for most of my life since then, intermittently. I have had episodes of good mental health, as it is at the moment, but also episodes of very poor mental health. I have received many forms of treatment from many different care teams. If I fast-forward to the present day, I do not have a community mental health team at the moment because I am deemed to be too well. That is one of the things that we will probably come on to a little bit later. There can be what sometimes people call a bit of a cliff edge. When you are deemed not to need a so-called secondary mental health service, often you are discharged. Discharge can be very anxiety-provoking. You feel that you are left without the support that has helped get you well and keep you well for many years. Fortunately, I have an excellent GP, which is something that I benefit from. I know that I have that port of call if I start becoming unwell again. Unfortunately, at the moment, as I say, I have been discharged for just over a year, about 18 months. My experiences are very varied. I have had community mental health services provided by secondary care teams. That has ranged from just occasional visits to a psychiatrist to, when I last came out of hospital, having a full care team, which was a psychiatrist, CPN—community psychiatric nurse—social worker and psychologist, which I will come on to later, to tell you a little bit more detail. I have had a very varied range of experiences, some excellent and some very poor, and, as I say, at times none at all. I have experienced long waits to be seen. Before my last admission to hospital, which was a long admission, I was very ill. I was in crisis and went to the GP. Unfortunately, the GP did not really know what to do and tried to contact the secondary team. It was a six-week wait to be able to see a psychiatrist, and that was when I was in quite considerable crisis. Another problem is that crisis teams often do not accept people who are not known to a secondary service, so I was not eligible to be seen by a crisis team, even though I was very clearly in crisis at the time. That led up to a very long admission. I spiralled downwards very quickly and very severely—it was one of my worst episodes—and needed admission to hospital. We will probably come on a little bit later to the strengths and weaknesses of services. There could have been a much better service that could potentially have prevented a long admission to hospital.

Thank you so much, Ian, for setting the scene there. Yes, we will have plenty of time for follow-up.

I have a lot that I want to say, so I will try to get through it pretty swiftly. My experience accessing community mental health services has been highly fragmented and frustrating. One of the most exhausting aspects is the constant need to explain personal circumstances repeatedly to different professionals. Each time support is sought, you have to recount a full history, what has been tried, what has worked, what has not worked and what is still needed, because there is still no effective continuity between services. It often feels like starting from scratch with every new professional, which is not only emotionally draining but also a significant barrier to effective, rapid and informed care. Another major issue that I have noticed is the often complete lack of follow-up. When SMI symptoms have been identified and services have been accessed, there is often no ongoing support to check for improvements, assess changing needs and determine whether additional help is required until a crisis point is reached. Additionally, for those struggling with mental health, maintaining physical health can become an insurmountable challenge. I have found that there is no additional mechanism to ensure attendance at medical appointments, such as blood tests or scans. This leads to worsening health conditions that then exacerbate poor mental health and build an overall health anxiety, which could have been prevented with proper support. The absence of this kind of co-ordinated approach that I have noticed means that the burden falls entirely on the service user to navigate these multiple disconnected systems at a time when it is least manageable for them. One of the most concerning aspects that I have noticed is being dropped or delayed from accessing services due to a lack of response. SMIs make it difficult to respond to calls and emails. Yet, instead of recognising this as a symptom that requires greater outreach, individuals that struggle the most are most often ignored and excluded. There is little to no effort to ask service users, “What is your preferred communication method?” That results in worse mental states being left without support, so you end up being the most underrepresented and the most underserved when you are in the most vulnerable situation. I have also noticed, as everybody has noticed, that waiting times to access the support are really unreasonably long. When services are actually received, they do not fully address individual needs, so they still feel very generalised rather than personalised. They do not take into account wider social conditions, physical health conditions, the cumulative toll that it takes on a person to repeatedly try and fail to get adequate help, and that exhaustion. The long gaps between appointments also contribute to this lack of continuity, which makes it difficult to build trust with a single provider. Without trust, engagement with treatment becomes even harder, and concerns may go unrecognised and misunderstood as the person becomes more jaded with the system of trying to access help. Financial barriers are another thing I wanted to mention that further complicate access to necessary care. When you are struggling with your mental health conditions, you face challenges securing stable employment, but you are expected still to cover costs of multiple medications and transport, without assistance in navigating financial aid and coverage options. Access to essential treatment becomes unsustainable. This creates the cycle in which individuals are unable to afford their medication and experience worse mental health. It further limits their ability to work and then to support themselves. There are also significant weaknesses that I have noticed in how wider needs are considered in mental health care overall. Social determinants such as housing instability, employment struggles and financial insecurity are rarely addressed within the treatment framework, but they impact so much on someone’s ability to manage their mental health conditions. There is minimal recognition of how these external pressures exacerbate the conditions and it leaves service users without holistic support. Programmes to address both physical and mental health are becoming more common but are still rare, despite being the most effective in providing this comprehensive care. These are all the things that I have noticed in my experience.

Thank you so much. We are really keen to hear more specifics about that as the session goes on.

Ian and Francesca have said everything I was going to say, which actually is a good thing, because it means that we are all experiencing similar things. Following on from Francesca, I have always felt like a case number and not a real person throughout this entire process, which is perhaps not as long as my two colleagues here. Whether I am visiting my GP or being visited by crisis teams or therapists, each time I have to relive my trauma of attempting suicide, because they are asking the same questions over and over again and I have to repeat that. It is very traumatic. Again to Francesca’s point, there does not seem to be much continuity of care or communication between all the different services. They seem to be operating largely in silos and not integrated, which causes folks like us a lot of undue stress. When I returned from Asia in 2018, I found the system completely fragmented. I had lived all over the world—I was in Asia for 20 years—and I experienced what I consider impeccable support and care in very small locations like Singapore. I expected when I got back to London that I would largely receive something similar, but it was completely the opposite and very disappointing, to be quite honest. I think about an analogy of walking through a maze, and we are not talking about a Hampton Court-sized maze here; we are talking about a “Harry Potter and the Goblet of Fire” sort of maze, which is very scary and daunting. You are trying to figure out where you turn left or right. Do you go straight? Despite some of the referrals, recommendations and lots of content on social media—“You should try these different techniques”—you really are on your own. There is nobody there to support you. What you are actually going to receive is a lottery. I have asked countless times when going through CBT, “Can I please speak to a black therapist?” The answer has always been, “We do not have one available, but if you are insistent you will probably have to wait a year, so either accept what we give you or wait.” I have got so used to hearing the word “no” that I just accepted it. It was not until early last year by pure chance that I happened to be glancing through my feed on LinkedIn. I saw a post from Black Minds Matter, which is a great charity. It was offering 10 free sessions for black clients to have a black therapist. I thought I had won the lottery. It was just so exciting, and for the first time in a long time I felt real hope. I immediately jumped on and referred myself. The whole process, from the initial email response to the final 10th session, was life‑changing. That is somebody who is technically very adept on social media. The question I ask myself is “I could have missed that post on LinkedIn, so what about everybody else out there? How are they going to know that that opportunity is available to them?” The other thing is that I am somebody who likes to take control of my destiny, despite what has happened. In between all the different months I have had to wait for therapy, I have had to go out and research the industry. I managed to find what I call buffer services. I do not know how many people in my position actually know of these services, but I have mentioned organisations that were just superb, such as The Listening Place and James’ Place. They were there for me to buffer the six-month gaps while I waited for CBT. I felt that that self-recovery journey was very much down to me. If I could teach that to all the black men in London, I tell you, they would be chewing my arm off, because they would not necessarily know all the different services that are available. There are some outstanding services out there, but we are not communicating that and bringing that together in one central resource, repository, hub or whatever you want to call it. Systems are primarily reactive. Care came only when I reached breaking point and not before. This is life‑threatening stuff we are talking about here.

How did you access that care at that point? What did you do? Was it a GP? Was it a friend or family member who intervened on your behalf?

I will be honest with you: I took an overdose. I was admitted into Ealing hospital and saw the clinical psychologist, and then the crisis team came to visit me. It was only then that they started to share and recommend different opportunities and places I could go. I did not know anything before that. Even my mum would say that maybe this was a call for help. It was. I do not mind saying that it was a call for help. It was not until that moment that I realised that there were people out there who could serve my needs, but I had to go to that length.

Thank you for sharing that. That is difficult to share. Ian, I notice you are nodding your head at that. Is that similar to your experience?

Absolutely, yes. You fall to such depths sometimes without the right support and, as Chris said, without knowing where to go. There are places to go, but if you do not know where they are, nobody is telling you, nobody is supporting you and sometimes you get into such awful depths of despair. I have also self-harmed in that way when particularly unwell. It is only at that point that you sometimes get held and helped. It is a medical emergency and people do not realise that we are talking life and death. We are talking similar degrees of crisis to physical health crises that get managed, hopefully in some cases in a timely way. There just is not the timely support for people. Having said that, I was under a good care team. I mentioned that I have had some very good care. I was under a secondary care team that had a crisis team attached to it. Because I was known to the team, they could make the referral that then would be guaranteed to be accepted by the crisis team. It was one Christmas, which I used to find a particularly difficult time of year, and the crisis team were excellent. They visited every day—not for very long, for 15 minutes sometimes, but that was enough and that got me over. I know that at other times, when I have not been attached to a community team, I have not had any crisis support whatsoever, because they will not see you. That is when things spiral out of control sometimes.

Francesca, you spoke about social determinants and wider support for the whole person. You mentioned physical health, but also housing and financial help and support. Did you find that there was anything out there for you in those cases? Were you asking for this but it just was not there, or are you saying, “In hindsight, that would have helped”? I wanted you to dive into that a bit more. Also, Chris and Ian, if you have experiences of the wider social determinants that might have helped you recover more quickly, we are very keen to hear about that.

It is definitely something that I have asked for and did not get.

Who did you ask when you asked?

I asked my GP. The most help that I have ever got that has been useful has been from these small charity groups that the other two on this panel have mentioned. Being able to access those little services has been the thing that keeps you going, because the actual system itself, with GP and mental health services, is not providing that sustained safety net for you to be able to grow and improve what is going on with your situation. It has only been the references that I have got from other smaller charities that have been able to help me, not from the GP and not directly from other mental health services.

What kind of help did they provide that was useful?

They provided actual sessions and in-patient treatment. They provided recommendations to other charities that would help.

What was that about, so in housing for example? You mentioned housing specifically. What did you need and what were they able to offer?

What I mean by that is overall having a sense of financial independence and feeling like your creativity and talents are not being looked over. For me specifically, the encouragement that I have been able to get about applying for different roles and things like that has been from charities rather than from any referral that I have got through the actual mental health care system. That kind of support has not been there to push all the other elements of life forward that would benefit mental health.

Chris and Ian, very briefly, did you have anything to add?

I have come into this space having spent nearly 30 years in the private sector. As a lived experience adviser, I often have quite a different perspective on the rudimentary ways in which I believe the sector and those within it should operate. I keep coming back to this one word, which is “communication”. It is the failing that all these different experiences and resources that are out there are often hidden and masked behind complex websites and all this sort of stuff. I live in north-west London, in Kensal Green. If I walk around my neighbourhood, go to my local jobcentre, and sit there and look at the notice board, it is empty. That is where foot traffic goes. I go to the library and the community centre. I occasionally would visit the church. None of these places has any posters talking about, “If you are experiencing mental health issues” and signposting you to here. Churches are sitting empty and I sit there and think, “What a beautiful place this would be for something like a healing circle, where you could invite a dozen people to come along on a Wednesday afternoon and just sit and talk.” At the heart of all this is something that very few people talk about in this industry, which is chronic loneliness and social isolation. At the most unhealthy level, that will be life-threatening. That is something that I also suffer from. I sit as an adviser to the national Campaign to End Loneliness as the only lived experience person, but also the only person of colour in a group of experts. I am constantly saying to all these individuals and many others, “We need more people who look like this and who are brave and vulnerable enough to tell us exactly what is on their mind and really advocate for change.” That is what I do every day, and it is not easy. I do it on my own in my room, so sitting here next to these two today is a blessing. It really is.

Thank you. We are so grateful to all of you.

You have very eloquently described the things that have gone wrong. What does good-quality care, specifically community‑based care and support, look like to you? Do you have any specific examples where you have received good-quality community‑based care and support?

As I mentioned, I had a long period in hospital. Partly as a result of that and just happenstance of where I lived, where I was discharged to had a very good, well-developed community team. This was in the days when we had things called CPA—care programme approach—meetings, which you probably have heard of. I had regular meetings with my psychiatrist, CPN and social worker every three months. As I say, I had a fantastic GP as well. They liaised with each other and kept tabs on how I was. The last thing they wanted was for me to be readmitted. I was on a waiting list for psychology. I was discharged and they said, “There are no psychological services available,” but after 18 months on a waiting list I got some therapy on the NHS. I managed to pay for some privately in the meantime. There was access to an occupational therapist for things like finding out things to do in the community. A bit like Chris says, often the information is not out there, so I had somebody who had a connection with the community. That was really very helpful. I was discharged into supported accommodation, which had pros and cons, but supported me in many ways until I was fully back on my feet. I was very fortunate in that I had somewhere I could volunteer. I was not ready to go back into employment at that stage. There was a local recovery college that I attended, which was very helpful. There was a local peer support group that, again, was very helpful. It was a Rethink Mental Illness peer support group. We have a national network of groups, but we do not have one everywhere and there is not one everywhere. I found that very helpful. That is not everything, but those are some of the things that I found particularly helpful. Unfortunately, as I say, the more well you are for longer, the less support you get. You can understand why that is, but then you get left to your own devices. We are talking about people living with severe mental illness. These are not things that are passing. These things are enduring, unfortunately, for many of us.

I also experienced recovery college, which was very helpful. There was a programme that Mind charity ran, which was philosophy for mental health. That was really great. It was a fantastic experience, because it is not just taking different philosophical approaches, which really suits some people, but also the sense of bringing people together consistently who knew each other, had similar struggles and had similar experiences. There is an issue with those things. They are brilliant. There are lots of different kinds of little experiences like that that I have had, which have been really great. Once you get into a programme like that, it lasts for so long and then it just dissipates. As much as you try to continue it—people form WhatsApp groups and try to continue—without that structure and support around it you then lose it. There is no follow‑up from that. You never hear about the programme again, so you do not know whether it is just a one-off or whether it is going to be repeated. You would hope that it is going to be part of a wider pathway to working on your mental health and challenging severe mental illness. To me, what great care and support looks like to me is having that comprehensive system where you are on a pathway and it is not just a very short, “You are going to get X number of sessions and that’s it,” but it has a longevity and structure to it, but is really personalised to the individual. Some people might not find any value in doing philosophy for mental health courses, but for me in particular, that is the way that I like to approach things. It is about that personalisation that needs to be integrated into the support that each individual needs.

That is a great question. What does good look like? I experienced good once I was discharged from Ealing hospital, but it lasted six weeks and after that essentially the baton had to be passed on. I love recovery colleges as well. The Brent recovery college that I attended for about 18 months was superb. It ran courses. I am a big techie. I love artificial intelligence. I close my eyes sometimes and I could imagine I had an AI assistant that was here that had my entire case history in its file. Any time I had a question, I felt a little bit low, or I needed to find a frisbee football peer support group for men on a Saturday at Hyde Park, my AI assistant would say, “Right now, from where you are, Chris, that would be a really great opportunity for you to hang out with some guys and talk about what is going on in your lives.” Unfortunately, we do not have that. I have to try to find all those different opportunities to share, care and basically talk. It is not easy, particularly when you are suffering from that social isolation and that loneliness piece. It can be quite scary to go out and meet strangers and have those sorts of conversations. AI or something like that is what we need.

Can I ask a question about medication management? You guys spoke about talking therapies, CBT, psychiatrists and psychologists, but we know that it is quite specialist prescribing and your GP is the one who is the ongoing gatekeeper. I am seeing both Ian and Chris furiously nodding.

It is such a good point. I actually completely forgot about that until you mentioned it earlier. I have been on anti-anxiety and depression meds for about four and a half years. It is funny because I do not think about it, but I take them every morning. Nobody has reviewed them in four and a half years. Nobody has had the conversation with me. To Ian’s point, if I am feeling better and I start weaning myself off those meds, what is the impact going to be on me physically and mentally?

Has anyone ever talked to you about the dangers of doing that?

No, not at all, and nobody ever mentioned to me the side effects of these medications.

Wow.

I know I do not look it, but I just turned 55 a couple of weeks ago. I have put on a lot of weight in the last couple of years and the blood pressure is getting dangerously high, but I do not know whether these meds are contributing to that, or whether it is diet and the meds. I am not doing a lot of exercise, but I do not know enough about this stuff to even question it. Every morning at 9 am, I pop my meds and just carry on. There you go.

That is something that worries me as well. When I was moved from the very good care team that I described earlier to the one that was okay but subsequently discharged me because I am too well, the last time I saw the psychiatrist they increased my medication because they thought I was not doing quite so well and would do better—and, indeed, I did do better—with a slightly higher one, particularly the antipsychotic medication, but I have not seen the psychiatrist since then. My GP does not want to do it, which I think is often the case because GPs are not so specialist and defer to the specialist. They do not want to change it. I have done reading about reducing the dose, de-prescribing, but do not want to, just in case. I am left a bit high and dry. I do not have the connection with the psychiatrist any more. If I were to have one, I would have to be re-referred, go to the bottom of the waiting list and start again. There is another thing as well. I am even older than Chris and starting to develop other physical conditions. The GP is kind of saying, “I am not sure if that will interact with this medication; I am not sure if that will interact with that. I cannot give you this even though I would like to because of that, and I do not want to touch that because it is not my remit.” I am fortunate in that I have annual physical health checks, which not everybody gets. About 60% of us do, which is great, but it should be 100% of us getting them. It keeps an eye on certain things, but it still is not the same as having direct support for those things.

Was that psychiatrist who prescribed it initially known to you?

No.

You saw them once. They prescribed antipsychotics and then that is it.

They increased the dose and that was it, yes. That was when I had a monthly visit from a care co-ordinator. She was very honest and said that it was her manager who was going through her caseload and said, “I think that you do not need to see Ian any more,” and so six weeks later that was it. That, unfortunately, has happened.

Do you want to add something, Francesca?

It is a similar story. I have been on certain medications for ages with no review, like for years—one of them in particular for six or seven years, with no reviews at all to see whether this is the right level or not. Every time I just push the button to request it from the GP—“Here it comes again”—without any kind of review system in place. When I have been to talk about other potential medications, recently I was prescribed one and it was not until I got home that looked it up and was like, “Wait, I tried this medication. That is in my history that I have tried it before and had horrible reactions to the side effects.”

Was it a GP who prescribed that?

No, that was a specialist, who had to go into the system and look through the system to figure out, “You have actually been to this location before.” I had to recount everything and he tried to understand as quickly as possible what I had already tried. In all of that, it was missed that I had actually been on that combination of medications he wanted me to try and had really bad side effects from it. That whole appointment was wasted, because I cannot go forward with this prescription that I have got: I am not confident about it any more because of my knowledge of the history, which I only figured out after the appointment. The other thing that I have noticed is that lack of knowing what you have already tried. There are a lot of medications that they have suggested to me as well, but, like Ian has mentioned, there is always that, “This is going to cause a lot of rapid, huge weight gain.” That is already something that I am struggling with that is having an impact on other medical conditions. Why would I then want to exacerbate that? All of the choices become very limited and are not thoroughly reviewed with all of the rest of your medical situation of what you have already tried and what other medical conditions you are trying to balance.

Thank you very much. This is a question to each of you. Thinking of the experiences you have had, what one or two things would have made the biggest difference to the care and support you received?

For me, I go back to that crisis before my long stay in hospital, and it would be not having to wait so long for a referral from a GP to a psychiatrist or some specialist support, knowing where else to go. As Francesca mentioned, it would be having somewhere else to go to get support and not feeling completely bereft, disconnected and on your own. My partner at the time was calling. He got the number for the crisis team, but they did not want to know. The GP was saying to me, “What would you like me to do?” I was saying, “Do something, at least,” and they did, but it was six weeks later. By then I was the most unwell that I have ever been. To be honest, I did not think to go to A&E. Nobody said, “How about going to A&E?” I just did not. I thought, “I do not have a physical health problem; therefore I will not bother them.” Systems need to be more responsive, talk to each other and have the same IT system. Surely there must have been a better way that could have potentially—it might not have, but I think it could have—pre-empted a very long admission to hospital.

Francesca, what would have made the biggest difference to you?

It would be having one point of contact that I would be able to go to, where what I have tried and what I am working on and working towards is all managed through that person in a personalised way. I am a very creative and ambitious person, and I am not doing work consistently right now that fulfils that creativity and ambition, so that is having a real negative impact on my mental health conditions. It would be being able to sit down with that person and say, “Here is the list of the different areas where, if I had improvement on them, I could get to a really good mental health state and would not be feeling the impact so much of the SMI that I am struggling with.” It is all those things, so being able to have that consistent communication with one person and co-create my plan for, “This is what I need to have that improvement in all these other areas,” which will have a massive positive impact on my overall physical and mental health, which then will give me a much better prospect for being able to seek out any kind of additional help that I need in the future.

That is very useful. Thank you.

The friendship bench: have you heard of it?

No, but I hope I am about to.

It is from Zimbabwe. It was started in 2006 by Dr Dixon Chibanda. Right now, I am supporting the project to bring the friendship bench to London for the black community. It is a community-led, peer-supported mental health initiative. This model removes clinical barriers and provides accessible, human-centred care in local spaces. In Zimbabwe, they have trained over 3,000 grandmas. The eldest was 95, who died last year. When Dixon started this in 2006, he had a budget to train 16 grandmas, because they have the most beautiful EQ. Individuals would book six sessions to sit on a friendship bench and go through basic-level problem solving and trying to understand what the real issues are. Then the grandma would signpost that individual to clinical care. As a buffer service, this is one of the most beautiful community-led initiatives I have ever come across, recognised globally by the World Health Organisation and the Clinton Global Initiative. It is opening all over the world, slowly but surely. Working with the London School of Hygiene and Tropical Medicine right now, we are hoping that by the end of this year we will be able to bring the friendship bench to London for the black community. That could be a very real game changer.

Thank you very much, all. That is the end of our time with you this morning.   Witnesses: Kadra Abdinasir, Dr Courtney Buckler, Harry Dyson and Lucy Schonegevel.

Welcome to our second panel of today’s session. We are delighted now to have even more experts in front of us. I would like to start by asking you all to introduce yourselves very briefly, for those watching.

Hello. I am Lucy Schonegevel. I am the director of policy and practice at Rethink Mental Illness, a national charity supporting people severely affected by mental illness.

Hello. I am Courtney Buckler. I am senior policy and campaigns manager for NSUN.

I am Harry Dyson. I am a peer researcher and public involvement officer for the McPin Foundation.

Hi, everyone. I am Kadra Abdinasir, associate director for policy at Centre for Mental Health. We are an independent charity with a mission to tackle mental health inequalities through bridging the gap between policy, research and practice.

Thank you all. You heard our very erudite and moving panel up front. I wonder whether I could ask for your very brief reflections on what you heard.

I really commend the Committee for putting lived experience at the forefront of this inquiry. There are so many reflections that I think we will talk about a lot in this. My utmost reflection is that, if Chris, Ian and Francesca were at the centre and at the decision-making table on what care should look like in the community, I don’t think we would be here investigating this with the same experiences. I think that we would see a very different system, a really compassionate, caring system that supports people socially as well as mentally and clinically, and keeps people well and out of hospital.

I do not know whether I can keep it particularly brief. I will try to choose only one of the long list of things I have to say. A very common thread throughout what people were sharing and what we know from our membership is the extent to which the burden of achieving good care falls upon individuals themselves. That is especially difficult for anyone facing any kind of trouble with their health, but when the context of that is mental ill health, distress or trauma, that cognitive and emotional labour of advocating for yourself repeatedly takes a very different kind of toll. There is a dynamic that you will see happening. If people cannot keep up with their care—they might not be attending appointments or they might miss things—they will be penalised for that. Sometimes that will be called non‑engagement. Sometimes they will be discharged from services because they did not turn up. How are they supposed to keep up with X, Y and Z? On the flipside, with an NHS in crisis and more people also in crisis seeking support, there is this increased language around high‑intensity users and frequent flyers. There is this problematisation of people who are just being advocates for their own care. They are people who are saying, “I don’t think you should prescribe me that,” or “I’m not going to take that.” That then will be non‑engagement. People who have not had support will be pushed further into crisis, will be turning up at A&Es and will be seeking more support in increasingly distressed states. We find interventions and innovations, of which I can list many, that are being trialled in the NHS to essentially dissuade people from advocating for themselves and to punish people for the crisis that they are being pushed to on account of poor health services.

Can you give us a specific example?

I can, yes. There was a programme called Serenity Integrated Mentoring, which was a for-profit programme delivered by, or innovated by, an ex-police officer. That was being rolled out across NHS trusts. That was to do with people in mental health crisis turning up at A&Es. It was a new innovation that would put police officers into A&Es and basically punish people with fines in multiple instances: “If you turn up again in X amount of time, you will be fined.” There were collectives of activists who were actually fundraising to pay these fines for people. The successful halting of these programmes was not acknowledged or recognised internally. That was the unpaid labour of activists, supported by NSUN and many other people, in identifying this. It was in fact halted by NHS England through the quite frustrating process of people who are themselves in crisis identifying this and calling it out.

That is very helpful.

There were some really powerful testimonies from the first panel. As a peer researcher, I work from a lived experience perspective myself as well, so a lot of the things discussed on that panel resonate with me on a personal level, as well as on a professional level and in our research work. Building on what Courtney was saying about the responsibility being placed so often on people who are suffering and people in crisis, the thing Chris said about being told no so many times that you just accept it and get this defeated position is something that really resonated. There was lots of stuff about the thresholds to care, so people not being unwell enough to cross a threshold where they get care and waiting and waiting. It takes someone getting into crisis to then get care, and when you start getting well again you are back under that threshold. There is an aspiration, I know, in the 2019 community mental health framework of things being tailored and personalisable, but this rubs up against the bureaucracies where care is allocated based on these categories and diagnoses. Something that really came up in all three was about these thresholds.

Are the thresholds something you think the Committee should be looking at more specifically?

Yes. There was so much other stuff, but particularly the re‑explaining yourself to different teams and different professionals, not just as a tedious thing, but, as Chris really elucidated, actually reliving a lot of traumatic experience. That can actively harm people and be anti-therapeutic. There was the stuff around the social determinants as well. There is a lot in the research about that.

Building on what my colleagues shared, something that really struck me and that resonates with our research is the sheer fragmentation across all these systems. Each of them is overstretched and under-resourced. You would think that it would make sense to work quite closely to share resources and information and to improve outcomes. The other key thing for me is that person-centred approach, enabling people to have choice and flexibility in the type of care they have. I have been working quite closely with Chris on something called the Black Mental Health Manifesto to tackle mental health inequalities. The last thing for me is recognising the vital role that charities play. I think Chris referred to them as buffer services. They are picking up the slack where statutory services, unfortunately, are failing, but are also massively under‑resourced. Things like the upcoming national insurance hikes are going to have massive implications for this already overwhelmed part of the system. I would really urge the Committee to pay close attention to that part of the system and see it as crucial to the overall community mental health service.

That was very helpful. Thank you.

Yes, there is an absolute data issue when it comes to mental health services. It is part of the lack of parity across mental health services and physical health services. We do not have prevalence statistics, or we do but they are extremely out of date. They are from 2014. It is very difficult for ICBs—in other words commissioners—to be able to look at their population and plan for that population. The fluctuating nature of mental ill health also means that there are ever‑growing numbers of people who need that support from the system. We heard from Ian about how he went to services and was told he is too well now for certain services. We also hear people saying that they are being told that they are too unwell for other services such as talking therapies, which you cannot access if you are experiencing a severe mental illness. Community mental health is supposed to be there for everyone with moderate and severe mental health problems. It should not have thresholds. The idea behind the community mental health framework when it was published was that it should be about getting rid of thresholds of care, it should be accessible to all and there should be no wrong door to that support. If someone is experiencing any kind of symptoms, they should be able to go to a certain part of the system, whether that is a GP, a crisis service or secondary care, and get that support wrapped around them wherever it is in the community, both the clinical support and that social support. The NHS long-term plan set out that 370,000 more adults should have access to community mental health services, which was a bit of a finger-in-the-air figure. The good news is that that has been met. However, as you say, there are hundreds of thousands more on waiting lists. A more accurate statistic to look at, at the moment, is waiting times. We can see that those waiting the longest for community mental health care are waiting more than twice as long as the longest waits for elective care, yet the Government are saying to the system that it must prioritise elective waits at the moment. Mental health waiting standards are not included in that. Again, it is very concerning to see the issues with data and the very muddy waters. ICBs are not able to look at their populations and understand how to plan appropriately and provide the right services amid growing pressures and growing demand.

My answer does not address your specific question, but adds some other things around the edge. One problem when it comes to gathering data around community mental health services is that it is very unclear what they are, where the edges are or where the boundaries are, so designing some kind of research project with inclusion and exclusion criteria is going to be extremely difficult. That is not just a thing about data; that is also the experience of people who are trying to navigate this system. What is it? How does it vary in different areas? That is the first point. We need to understand and improve community mental health services. That is part of the reason I am excited to be here today. There is a lot of discussion and effort around reforming mental health services at the moment, a lot of which is in very good directions such as reducing detentions or police involvement, etc. In a lot of those initiatives, you see the assumption or hope that, if we do not have detention, people will be supported in safe and accessible community mental health services. Those are not there. It is exciting, the prospect of creating an alternative and reducing coercion in mental health services. Finally, on data specifically, there is also increased talk about co-production, designing research and reimagining services alongside people with lived experience. In fact, we have quite a lot of data, but is it considered data? Do we consider what was said by the people on the previous panel as data? Is that enough to decide that something drastic needs to be done to improve these services? That is also an essential and often missing part of the conversation around co-production and lived experience involvement. They will act as nice stories, or often sad stories, to contextualise this kind of work, but they are often not sufficient to motivate the action or investment that we need. Instead, it is about “the numbers” or “the real science”. That is something that we need to reconsider.

Building on what Lucy has said, the 343,000 are people who have been waiting for over a year. The testimony from the first panel really puts into stark context how long that is to be waiting. We do know what good community mental health looks like, on the level of what service users want—the people with lived experience and the clinical teams who work in this setting. The area where less is known and there is more uncertainty is the gap between these aspirations and principles about what good mental health care is and the actual delivery. A lot of the things we heard about in the first panel have been captured in the community mental health framework but, evidently from today, are not being delivered and have not been improved on. It has not worked through the system. What good community mental health care is will never be finalised in a static definition. It will need to be constantly refreshed as this transformation project takes place. It needs to be sense-checked by involving people with lived experience throughout the process. It would be really great to involve people with lived experience in the actual data collection. Local trusts could involve them in collecting and analysing this data and sense-checking it from the bottom up.

I just want to build on the points that Lucy made about access and waiting time standards. There was some consultation with the sector by NHS England about a year ago. We really think that just needs to be adopted. It draws on the learning from the waiting time standards that were introduced in eating disorder services and early intervention in psychosis. That is proven. One key element that is missing in the data picture is around outcomes. Again, we are looking at waits and access, but is the quality of care good? Is it helping people to recover and stay well? We just do not know that. Co-creating what those metrics would look like with people with lived experience is crucial. As a final point, we have recently been advocating for the establishment of an independent mental health commissioner. This would be an office at national level that can look at practice across the system and in all the relevant Departments to tell us what is going on with the nation’s mental health and whether people are getting good-quality care and provision. Hopefully, we will see some success on that through the Mental Health Bill.

In particular, I would like to talk about Somerset.

We are going to talk about Somerset later. That is to be noted for now; we will come back to that.

The theme of that is a “no wrong door” approach and real integration between primary and secondary care, not seeing these as two separate agencies with two separate client lists.

I have two points on the severity gap, or void, as it is often called. It is sad that there is even a term for it. First, I would emphasise the cruelty of the existence of that void. The national discourse around mental health is that we should tackle stigma and people should be talking about their mental health and so on. People often fall into this gap because they are being brave enough or wild enough to disclose the extent of their suffering. In their bravery, people are taking themselves over a threshold and finding themselves with no care at all. It also happens the other way: “I am doing a bit better”; “Okay, you are too well.” You can be in the middle. It feels somewhat incongruent with this emphasis on people being really honest. That makes it especially sad. In terms of best practice, we should be retaining care co-ordination and care co-ordinators. We had that. Where did it go? The experience of our members is that the community mental health framework has put that into some confusion. Do care co-ordinators still exist? Is everyone still entitled to one? Does it have a different name? Is it a connector or something else? There is variation across localities. The kind of care you will get depends on where you live. That is essential for understanding what those thresholds are and what other support is available, and making sure you do not miss deadlines or end up with benefits overpayments and so on. It is not an innovation; it is just keeping a thing that we had, which was doing quite a good job.

I agree on care co-ordinators. Francesca mentioned that one of the things she would want was one point of contact who has a holistic understanding. That is what care co-ordinators can provide, where they are available. Early intervention teams are a model to take an example from. These services are leading the way in joining up psychiatric, psychological, physical and social care, linking with other charity organisations for employment, housing and benefits, and promoting peer support and lived experience work as well. They have this holistic or whole-person approach. That is where to look for best practice. As Courtney has said, some of this stuff is being eroded. There are funding shortages and ambiguity around care co-ordination. There is a risk of this gap when people go through an early intervention service, typically for three years, and then are discharged. There still exists a risk there. There is an off-ramping process. You get sent away with a plan and a sort of reference: “If anything goes wrong, remember that we filled this out together—these are your trusted contacts” and stuff like that. There is still an area of risk when people leave early intervention services.

Kadra, it is lovely to see you again. I had better start by saying that I have had a long history in mental health. I do the associate manager role, so I do section in mental health. I just wanted to declare that before I open my mouth. I know Kadra from before, so I also need to declare that. My first question is about inequalities and access. From the work you have done over many years, Kadra, you know that in particular black men, as was highlighted on the first panel, access mental health services late. Nine times out of 10, there is denial within our communities. They feel some shame about what they are going through. For many reasons, services are accessed late. Families also sometimes block off access because it is not until it becomes quite acute that they get into the mental health service. It also is not diagnosed early enough when people from different groups have issues. Once it is diagnosed, community intervention, as was highlighted in the first panel, is very hit and miss. It is very much a postcode lottery. Even the talk therapy is six sessions and then it is finished. Sometimes it is just not enough and it is not continued enough. Thirdly, it is not only black men. We must also remember that people with disabilities, transsexuals and LGBTQ communities also struggle in this area. Kadra, this is my question to you. How do we address the factors driving inequality?

Thank you for that, Paulette. Tackling inequalities, as I said earlier, is our bread and butter as an organisation. As you pointed out, there are several groups that face increased risk of mental health problems. Sometimes this is driven by discrimination itself causing mental health problems. There are other groups that may have co-occurring issues including disabilities and so on. There is a real lack of understanding around this. These are whole individuals who also have lots of other characteristics and identities that need responding and catering to. I wanted to touch on a couple of advancements that have been happening that we can draw from. The mental health sector is really privileged to have the first anti-racist framework in mental health services, called the patient and carer race equality framework. By April, each mental health trust is required to publish a co-created action plan on how it will meet a set of competencies to address this. We can build on that. For us, this is about having a community mental health system that is designed from the margins for the groups that face the harshest inequalities, and then thinking about ways of improving access and support from there. Another key thing is working with community-led organisations. Chris mentioned a few settings such as parks and churches. The people who face the harshest forms of marginalisation are based in some of these settings. We need to be going to where they are and not expecting them to come to clinical services. Rethinking how care is provided and what partnership looks like in this space is critical.

Thank you for that. I am not going to ask anybody else because you are the specialist. I am going to move swiftly on to transitions. This has been a bugbear of mine—I will just declare that—for many years. I could never understand why it just drops off a cliff when a young person gets to the age of 18. The problem with transition is that you go from children to adults, and we lose them until they are 25. They have promised us a comprehensive offer, but that offer has not appeared to date. What progress is being made in this area? What actions do we need to prioritise to improve performance?

This is a personal bugbear of mine too. Next month will be 10 years since the Government published a document called “Future in Mind”, which looked to overhaul services, including addressing that cliff edge. We are here 10 years later. That nought-to-25 vision is a bit of a postcode lottery, sadly. It depends on where you live. The idea was to have a period of extended transition. If young people felt comfortable transitioning to adult services at 18 they could, but they could also stay on until 25 or even up to 30 in some areas. There are some interesting shifts happening that I would like to point to. For example, we have been campaigning on open access mental health hubs for young people in the community. That does go up to 25. The Government have committed to that as part of the Young Futures programme. There is a core focus on 10 to 19 within that. It is quite key that we see that bridge up to 25 as part of the services. The other thing that I would point to is the student population. Our colleagues at Student Minds have been doing really phenomenal work around the university mental health charter to address, for students who might be out of their home setting, how we can continue care and support for them in those settings. There are some promising shifts in the space, but we really need to get a hold of the battle that you tend to see between child and adult services and who is responsible for commissioning for this cohort of young people. As you said, this is a time where we see a marked deterioration in mental health needs. We really need to get it right for that cohort to ensure that their life chances are protected in the long term.

It is worth the Committee looking at early intervention in psychosis services. That is a really fantastic example of a service that is for all. It is based on presentation rather than diagnosis. Because it is for the first episodes of psychosis, it does tend to see a majority of younger people. It has a waiting period of two weeks, has really clear standards and has very holistic support when people do get access to that support. Again, though, the transition from having that support to going back into the community is very much a cliff edge, but a lot of people see community mental health as being a much greater, larger and multi-layered version of this. If we can get EIP right, we can get other services right as well.

Can I add one more thing that I forgot to mention? It goes back to Harry’s point earlier about thresholds. One thing we hear a lot from young people is that adult services have much higher thresholds than children’s services. That also needs to be considered.

One of the things that came across today was patchy access in the experience of mental health provision. CQC figures show that less than half of those who managed to access mental health provision said they got what they needed. I think it was 39%. Why is that, Lucy?

There will be various reasons. There has been increased demand over the last five or six years, and the workforce is not keeping up with that demand. There are significant workforce shortages. There has been a lot of investment and focus on the mental health workforce and we have seen improvements, but nowhere near enough compared with the demand that we are seeing.

Just for the report, is that because we are not training enough people, because not enough people are going into training or because we are not employing enough people?

Because of the long time it can take to train psychiatrists, mental health nurses and so on, there is a lag. There has been investment since the long-term plan and the workforce plan, but there is a lag before we can see that workforce coming in and providing support. In the meantime, we have seen a lot of retirements and a lot of people moving out of the workforce. There is a vicious cycle problem with mental health as well. People go into working in mental health to do good and to care for people. More and more, we hear about how that is not happening in mental health. In a lot of cases when we talk to professionals they say, “I am basically here just as a gatekeeper, not to care for people.” There is a real problem with culture and people wanting to do a good job and not just be a gatekeeper. There are so many solutions to the workforce problems. Those are not just focused on the clinical workforce; it is really about looking at the voluntary sector and other forms of workforce, such as the peer workforce, to be there to support people. As we heard earlier, what some people have found the most beneficial to their recovery has been peer support, navigation and the voluntary sector stepping in and providing that real local community with creative forms of therapy and so on.

This may be more for Courtney and Harry: are we a little bit too focused on expecting people to be the perfect patients, with no co-occurring conditions and things like that? What kind of models can help us move beyond that?

I do not know what I have to say about the expectation that people are perfect patients. Nothing springs to mind on that particularly. I would emphasise the point that, in dealing with increased demand in mental health services, we are seeing trends—it takes some thinking to join them up—towards approaches that turn people away from mental health services. There is a nudge in that direction. If you look at the changes in welfare reform or the innovations that are happening in mental health services to deal with high-intensity users or frequent flyers, the suspicion becomes somewhat that the perfect patient is not a patient, that they are just “the demand”, which is of course horrible. To build on a point that we heard from the previous panel, we often hear about the excellence of the third sector, particularly this peer workforce that you are talking about. That work is essential. I am biased perhaps in that regard. To emphasise, that sector is also in financial crisis. It is also chronically underfunded. I have some numbers here. There was a brilliant piece of research that came out very recently from Disability Rights UK, which was looking at the work of disabled people’s organisations. Those are organisations where the majority of people who are staff on the board are people with lived experience. Over 90% of DPOs are experiencing increased demand, but over 40% do not think that they are going to financially survive. For the most part, we see large-scale charities getting huge amounts of funding and money, while these smaller organisations, the praises of which have been sung today, face huge barriers when it comes to accessing funding and being sustainable themselves. We are asking that peer workforce to pick up the slack of a mental health crisis in failure. They are doing the emotional labour that that system is not doing. That workforce also requires support and care, but it is having additional burdens put upon it.

I am thinking about your question from two angles. The first is the service user perspective on these things. Even if you get through to services and they are adequate, if you have waited for over a year, you probably do not feel like you have got what you required. There are also a lot of other issues, which were discussed with the first panel, on the more institutional or systemic side of things. There are the things we know about, such as workforce shortages, funding pressures and disruption from team restructuring. All of those were compounded by the covid-19 pandemic as well. It is challenging. It is really difficult to implement transformations when systems are strained, exhausted and being pulled in all these other directions. Staff get burned out as well, especially by moral defeat. You have gone into these professions wanting to help people and it is just not happening. All of those are factors. There is a real fear that we feel from some of our colleagues about transformation. If there is constant transformation, things are not given a chance to mature and put down roots.

Thank you. I really appreciate you all taking the time to answer my questions.

I have two areas of questioning. The first was in relation to what you thought good community health services look like, but, following the excellent first panel and what you have said already, we can see the component parts and we can probably collate that ourselves, if you do not mind. We are also running slightly behind time and I will otherwise be under pressure, quite rightly, from the Chair on this. The second area of questioning was co-production. I remember when I was indirectly involved in a charity that was co-ordinating mental health user groups more than three decades ago. The whole concept of co-production or user involvement in the design of services has always been there. There is this sense of, “We are going around it still further, so why has it failed?” I will use the word “failed”. We are still there and we still feel like co-production does not appear to be happening. Because of time, I will pick randomly at Courtney and Kadra to answer this question. In terms of co-production, is the reason why we are not making progress that the service providers smile benignly at you but go away and disagree? Is it a more mundane lack-of-resource reason? If it is the latter, does co-production provide a method by which the service can become more resource-efficient? Is that too many questions in one? I do not know. I will start with you, Courtney.

I will try my best with all of those. The main point that I would like to make around co-production, despite being a person from an organisation that advocates for it, is that it is a really complicated and hard thing to achieve. If you have a situation in which someone is experiencing so-called severe mental illness and then you have the monolith of a mental health trust, there is a power dynamic going on there that we need to be honest about. Dealing with and attending to that is going to take quite a lot of work. Service users are developing a real lack of faith. We will have an instance in which someone with lived experience gets to speak or join, and then all of a sudden we have an output that says it was co-produced. Is that necessarily the case? I am not sure. Genuine co-production requires some very mundane things, as you say. You need to level the playing field, so to speak. People need to be paid for their time and supported for their time. In terms of the dynamics, there needs to be an equal willingness to do things differently. We have co-production initiatives in which people with lived experience come in and get to choose: “Would you like us to do option A or option B?” They are not asked what the options should be, how they want it to run, how they wish to work together and so on. I would argue that doing bad co-production and still claiming it is probably worse than saying, “This is really complicated. I am not sure we have achieved it, but we have done X, Y and Z. These are the things that we were able to do.” There is some truth telling that needs to be done there, because it is an extremely difficult thing to achieve. It is worth doing, but it is not easy.

Is it all lip service?

I will defer to Harry, because he is going to have some really brilliant points on this.

Thank you, Kadra. I will build on what Courtney was saying. We definitely see an inflation of terms. The way that I generally think about this is with Arnstein’s ladder, which is a framework where you have non-participation at the bottom and equal partnership co-production at the top. The inflation of terms happens when things like consultation or involvement, which are great things to do but are somewhere on the middle of the ladder, get done and it is called co-design and co-production. That is an inflation of terms. The real challenge that comes with doing meaningful co-production is that it is ultimately about sharing power, and it does cost money. To do substantive involvement and have people meaningfully involved in projects, reimbursed for their time and paid for the work they do costs a lot of money. It involves devolving power to people with lived experience. Within NHS structures, you might have leaders who do not feel particularly empowered or particularly flush with cash, but they are being asked to share power and spend money. There is a real friction there. Yes, there are lots of initiatives around lived experience involvement and pathways. Personally, through my recovery I started doing lived experience work and got involved in a research co-design project, which led on to what I do.

If we as a Committee wanted to go and look at a location where co-production has been handled well, sincerely and with meaning, and has resulted in satisfactory outcome, where would we go? Can you point us to anywhere?

McPin has definitely been involved in projects that we would confidently proclaim to be co-production. From my anecdotal experience, I definitely got to a ceiling with AWP, but they definitely have elements of co-design and a robust lived experience pathway.

It would be really useful if any of you could point us to any locations.

You can write to us afterwards.

Yes, you do not need to do it now, but certainly point us in the direction of any location where we could identify a place where co-production has really worked and has resulted in outcomes that we can be proud of.

We will definitely write to you.

It is worrying that no one is jumping at the opportunity to tell us, “Yes, there is this example.” That is worrying.

We can definitely share some afterwards. I am conscious of time, but, for example, there is Coventry and Warwickshire. It works with the Cultural Inclusion Network, which is co-produced in and of itself. They worked in partnership to design what the transformation should look like in Coventry and Warwickshire, then developed this REACH service, which is all about peer support in terms of delivering mental health support in the community. That is in our submission, and we can share more on that.

I imagine that there is a concern among providers that it will result in raised and unfulfilled expectations and more resource. Surely there must be examples that one can identify where involving users has resulted in more resource efficiency.

Yes, absolutely. There are some really amazing clinical leaders out there who have really driven co-production in their places. There are a number of examples in our submission, such as Norfolk and Waveney, Sheffield and Somerset. Resources are now so tight, and those clinical leaders do not have ownership over their budgets any more. Budgets are being signed off by financial directors and CFOs. They are not prioritising co-production.

Thanks so much for coming along. It is really interesting to hear from you; the same goes for the previous panel. I wanted to ask you about the integration of services in a broader sense: integrating mental health services with physical health services. Are there examples of good practice in this area? What more could be done? For example, we heard from the NHS Health Check team a couple of weeks ago. Darzi did highlight that there was some good work being done in that area, but I would be really interested to hear your thoughts on how those two services, which have been pulled apart in a slightly bizarre way, could be better integrated. I do not know whether Lucy would like to start with that.

One of the great initiatives, which again we heard about earlier, is the physical health check, which everyone with severe mental illness is entitled to annually. There is, or there was, a target. That is now no longer in the planning guidance for the NHS. It is no longer a target for the system to increase the number of physical health checks. Talking first about what the physical health check does and the benefits of it, it is an access point to primary care, so that people with SMI can get a holistic view of their health, including how medication is impacting them and other lifestyle factors. They should then be signposted and transferred to other support, whether that is smoking cessation services, weight management, diabetic health checks and so on. There tends to be another drop-off point there, where there is no follow-up support. The first issue really is that people are not accessing their physical health checks, understandably. The numbers of people who have been accessing them over the years has really fluctuated. At one point it was, and at the moment it is, 60%. In previous years it had gone down to only 20% of people with severe mental illness accessing physical health checks. Without that really focused and sustained drive from systems to prioritise physical health checks and support people to access them, we are undoubtedly going to see that drop-off again over the next few years.

Thanks so much. I wonder whether anyone else on the panel has any thoughts about how physical health is integrated into mental health services. Looking at how the services are, they do look quite separate. I just wonder whether you have any thoughts about bringing physical health into the mental health space, or vice versa—bringing mental health into the physical health space.

I will pick up on one area where these issues are particularly pronounced, which is around people with co-occurring substance use. Unfortunately, due to the cuts in public health, that has been really undermined. There are some examples that we can share with the Committee where that provision has been integrated and the two are seen as issues that exist hand in hand. The previous panel talked a lot about social determinants. There are other services that need to be integrated within mental health and physical health services, such as housing support and welfare advice. There is a great example in Hampshire and Isle of Wight, which integrated a citizen’s advice service within a mental health in-patient setting to provide comprehensive ongoing support for people. We could look at some of those examples and see how we can build on that, too.

That is very helpful. Thank you very much. That takes me on to just a few more questions about social determinants. Harry, do you have any research on this? We spoke about how housing and welfare need integrating, but what about businesses and workplaces? Do you have anything to show the extent to which businesses understand severe mental ill health issues and the ongoing needs of people who have them every single day? Has business really wrapped its head around this? Is it stuck on “time to talk” and mental health first aid? Those things are not quite at the same level. Does anyone have any research or data that points to this as an issue? I will start with Harry, but if others want to come in, that would be helpful.

I do not have anything prepared today. Do you mean in terms of employers?

Yes, to keep people thriving at work. As we saw from our first panel, it may be that you have a severe mental illness, but you are an incredible person. As Francesca very beautifully said, they want to be creative at work and live their best selves. To what extent do businesses in this country genuinely understand that?

I am happy to comment on this. I just wanted to point the Committee to the IPS—individual placement and support—model, an internationally recognised model with 20 years’ worth of evidence. It is a principles-led model that has been co-created with people with lived experience. As Francesca said, this is about providing in-reach employment support and advice. The principles include things like honouring people’s preferences for what types of work they want and how important that is for them to recover, sustain and get into work. They include integrating employment support within mental health services. This is quite key. The long-term plan looked to expand this provision. We hope that is taken forward as part of the forthcoming 10-year health plan as well.

That is very helpful. We know that there are disparities in performance between areas in terms of integration. I am turning now a bit more to disparities across the country. I do not know, Lucy, whether that is something you feel able to comment on. We would be really keen to know whether it is the same in urban environments and in rural environments. Is there a north-south divide? How does this look across the country?

When we talk to our colleagues in ICBs around the country, they very much say that there is a difference between the delivery of mental health support in urban areas and in rural areas. If you were to speak to commissioners in Somerset, they would have a lot to say about that, particularly around the fact that a lot of reporting is based on evidence from urban areas as opposed to rural areas. The point about integration is very interesting. What we see more of in areas with good rather than poor practice on integration is around the relationships between areas and the power imbalance, which usually stems from funding. How is the local authority doing in terms of its funding? What does the NHS look like? What is that power balance? It is also about how the voluntary sector is involved as part of that. Is it seen as a genuinely equal third partner or as lots of little charities and maybe one big provider that the local authority wants to give a bit of money to for a few bits and pieces, rather than genuinely including in the decision making? The introduction of alliances has been a bit of a step change in how we can integrate the third sector, alongside local authorities and the NHS, as a way of getting rid of the trust issue between charities and the competition for funding. Bringing the charity sector together with community groups and faith groups, and being able to flow money through, means that it is much more sustainable and the money goes to the right people who are the real experts, whether that is the big local charity or the really local community groups.

I am hearing you put a lot of stock in individuals demonstrating leadership within systems, but a barrier could also be financial flow. Is that a fair point?

Absolutely, yes. It is a big barrier.

Here is your chance to talk about Somerset. Crack on—tell us about Somerset briefly, please.

Really briefly, Somerset was one of the early implementers of the community mental health framework, alongside some other ICBs in the country. It has had another two years, compared with other ICBs. There is a particular example that we talk about a lot. Someone was in mental health crisis on a roadside bench and happened to speak to someone who took him to the local crisis centre. From there, he was able to get all the support wrapped around him. That was not just the immediate crisis support provided by the local charity, but he was able to immediately then get NHS support, which, in so many cases in Somerset, is co-located, along with other support around money advice and particularly housing support. The most amazing support is being provided by a co-located charity on an NHS site. It supports migrants, particularly people who have come from Ukraine and other parts of the world. It gets rid of the barriers, both the language barriers and these referral barriers. In so many cases, people have to meet a certain threshold, as we have talked about, to be able to get that support. The three key words at the centre of the roll-out in Somerset have been “no wrong door”. It really is true. There has been peer-reviewed research into this, which has found that that means individuals who are experiencing mental health problems can then get that wider support, whether it is from primary care, secondary care, the local authority or the voluntary sector.

What about the police?

That is a good question. There is a way to go. If you were to bring someone from Somerset to the inquiry, they would say this is not the perfect solution and they are not at the end of the journey yet. There is still so much more to do, and probably more integration to do as well. For example, it is a very rural area and there are issues with ambulances being available for people. They have been trialling a mental health ambulance. That has not necessarily been that successful, but I would definitely speak to them about that. The statistic that is so powerful, which really demonstrates the success of the area, is that over the last few years we have seen a 15% reduction in A&E presentations and a 16% reduction in in-patient admissions. That is the case for adult mental health because there has been this transformation in adult community. Unfortunately, we have not yet seen the same for community mental health in Somerset. There has not been the same transformation in children and young people’s mental health support.

It is an example of best practice. What is the mechanism by which this could get rolled out elsewhere? The Secretary of State often talks about taking the best to the rest, but how is that theoretically going to happen? Is it happening? Are people noticing?

Definitely, it is happening. It is delivering what the community mental health framework said. It definitely is happening around the country. There has been a real programme of NHS England promoting what has happened in Somerset and sharing that best practice. The mechanism now for rolling it out is the Secretary of State’s drive to roll out neighbourhood health. Our real plea is that he makes mental health a core part of that because it is already there. We already have the frameworks for it. We just need to say that it is a priority again when systems are really focused on elective waiting times now. Systems need to hear that community mental health is the priority and the roll-out of 24/7 mental health services is the mechanism for doing that. The Secretary of State will have that as a ready-made solution to roll out, aligned with his shift from hospital to community.

That is a very good question. We can go away and look at that and share further information on it. I absolutely agree. It is not rolled out across the country at all. Somerset had the same amount of money as everyone else, though. This is really about the relationships, what it did with the money and the real leadership to drive this forward. People with lived experience have been at the centre of designing and delivering it as well.

That is extremely helpful. Thank you.

I am going to ask a bit more about the community mental health framework. You have touched on this already. In the Somerset example, you started to discuss the aspects of success. Rethink has previously described the framework as a once-in-a-generation opportunity to change care and support for the better. To what extent has the roll-out achieved this ambition?

That is a really good question. Unfortunately, we do not have a clear answer to that, because there has not been a national evaluation on it. There have been pockets—there have been fantastic evaluations by McPin and the Centre for Mental Health on certain aspects of it—but we have not seen a national evaluation. With the Government wanting to roll out 24/7 mental health, we need the evaluation to be happening now in order to be able to make the case. This is always what holds mental health back. When there is no evaluation, commissioners cannot keep proving to their financial directors that this is what they should be investing in. Then everything falters and stutters, and attention goes elsewhere.

Your key ask is really an evaluation of the framework.

Yes, absolutely.

I do not know whether anyone else wants to comment on the framework specifically. If not, I will move on. While we do not have clear evaluation, we have certainly heard about the sense that there is a lot of variation. As we heard from the witnesses earlier, there is clearly massive variation in services. Building on Deirdre’s question about financing, are there other barriers that have meant that the adoption of the framework has not been as quick or as effective as it might have been?

The pandemic happened right at the start of the roll-out of the community mental health framework. Interestingly, if you speak to Somerset, it will say that it used that as a reason for getting rid of all red tape and bureaucracy, putting everything behind this and driving it forward. That was not the case in the majority of places. There was supposedly a three-year roll-out of the community mental health framework. One and a half of those years were during the pandemic. We had another year and a half during which demand soared. There have been so many setbacks and issues. As we have said before, this is a long-term piece of work. It is not just that there is a transformation over a few years and then something is done. This is a really complex, multi-layered, multi-agency transformation of a whole range of services for a whole range of people with many different conditions. It needs that really consistent support, investment and focus from all the commissioners and all the people involved. All these stops and starts, and all the other pressures on the system, are some of the biggest barriers to continuing to roll this out.

That is helpful, thank you. Knowledge exchanges, evaluation and the evidence that we have seen all suggest that there is little robust evidence and no clear blueprint for commissioners and services to follow. You have pointed to a good example in Somerset. Do you feel that that is the case? Do you share the evaluation that there is no clear blueprint for commissioners or service providers to follow that is evidence-based?

I probably would not agree with that. I am not a commissioner, so I cannot speak for commissioners. There is a framework. The whole point of the framework is that it is supposed to be really high-level and national but also really place-based and locally delivered. That means commissioners working with their populations at a real place-based, local level to look at what that population looks like, what it needs and how they can tweak and change what is happening and what the local assets are to deliver it. You just cannot have a national prescription. You can have guidelines and frameworks. I know there are going to be more principles.

Is that one of the reasons that adoption has been slow? Is it that busy commissioners commissioning a range of services do not know where to look for what good looks like? As we have heard before, there is such variation in what is provided. In some places—you have pointed to Somerset—there are services that are working. There is always localisation; there is always a need to have culturally sensitive services that are aligned with users. Rather than starting from scratch with a headline framework, would it be helpful to have more of a sense of what interventions generally have evidence and seem to work?

Again, a lot of that is out there. The Centre for Mental Health has done a lot of research into this. Rethink has published a number of guides to the system, which share best practice. We have done webinars with thousands of attendees from ICBs, and so has NHS England. There is a lot of information out there. It needs attention and prioritisation, and commissioners need to have the headspace to focus on it again. What is the route to doing that? If the Secretary of State wants to set up neighbourhood health as the priority for shifting hospital to community, he needs to put mental health at the centre of that and say, “There is some progress. Let’s really bolster this now. Let’s really go for it. Let’s give it another three years of real focus and really roll it out again.” We cannot get away from the fact that funding is absolutely needed. There was ringfenced funding for three years. From last year, there was no ringfenced funding. It just went into the general pot. With all the pressures, that will end up going to different things.

The sense you have is that the framework is still the right model. It is still what should be pursued with those barriers.

Yes. The framework should evolve and has evolved somewhat to include crisis as well. The pilots of 24/7 community in crisis are the real gold standard. They are so local and place-based. That is what we should be aiming for everywhere. Anyone who is experiencing mental health need or crisis at any point in a 24-hour period should be able to access some form of support.

For our transcript, it is probably worth saying that the panel in general are nodding their heads as we are saying this.

That is great. Thank you. That is the end of my questions.

You will be pleased to know that I am the last person.

But not the least.

Thank you, Josh. I will try to be brief. I listened with great interest, particularly to the first panel today, about what does not work. As a Committee, we are very interested in what does work, and we are looking at what the Government should perhaps be doing. The 10-year plan is being consulted on. The consultation finishes tomorrow or on Friday, I believe. What would you want to see the Government committing to deliver in that 10-year plan? I would like to be quite specific about SMI mental health, rather than mental health in general.

A couple of years ago, there was a big national consultation on a 10-year strategy for mental health, in which nearly 30,000 people shared their views. There is a good grasp of the need from people with lived experience. I really think the 10-year plan should honour those perspectives and recommendations first and foremost. For me, it is about integration and strengthening accountability. While we do not want to be too prescriptive nationally, we need to get a sense of where funding is going, what impact that is having and how we can have more transparency of that information on outcomes and experience.

I have an example of something that is good and relates to a lot of what we have discussed. I hope I will not be too long. It is around a peer walking group intervention, which was trialled and evaluated. I was involved in it as a peer support worker. I would characterise it as a very low-cost and low-risk intervention. Fostering and incubating a culture where people feel able to promote these low-cost, low-risk interventions is really important. It was effectively group walks for people in early intervention services, providing gentle exercise—this comes back to physical health—and gentle social contact. It had that more holistic element and all those things that people have been missing, as we have discussed. We did our evaluation and presented this at the Royal College of Psychiatrists. After the presentation, so many people from other EI teams came up to us and said, “How did you get permission to do this? Oh, my God—you got permission to do a walking group.” I am really not exaggerating. People came up to us and asked, “How did you even get this off the ground?” That is a real indictment of the risk-averse culture and how brittle people feel in these systems. We need something to liberate people from that risk aversion and to foster peer groups and these grassroots low-cost, low-risk interventions. That can grow out of places. It can be place-based; it can be led by the people from those areas.

It is going to be hard to be succinct. I will try my best. A catch-all approach would be to take a care-first rather than a cost-first approach. We see increasing emphasis on the cost of those living with severe mental illness to the economy. That is the discourse around welfare and benefits reform at the moment. The costliness of the unwell is what is driving the creeping privatisation within mental health services. I mentioned the SIM programme; Oxevision is another one that you might want to look into. We have written about it at great length in our evidence submission, so you can see it there. We need to emphasise that mental health services are worth investing in. They might be worth spending a bit more on, not because that will drive productivity or boost the economy, but because that is the right thing to do. People matter. We care about having a world that people wish to be in. That is a better world to be living in, rather than saying, “We need to reform mental health services because it is too expensive to have people living in long-term distress.”

Is the mental health investment standard the best mechanism to ensure that funding? Should it be increased or extended? Should it be something completely different?

Kadra is a better person to answer that specific question than I am.

It has been an important mechanism for driving increases in spending, but that alone is not the solution. We need wider reform. Crucially, we need to think about the under-investment of councils and their role in it. By not addressing the social determinants, we are amping up demand for mental health services. If those things were addressed, people could be supported much more upstream in the system.

Lucy, you have the last word.

The mental health investment standard is a safeguard. It is not really anything more than a safeguard, but it is a really important one. Just before Christmas, when we were concerned about the mental health investment standard not being in the planning guidance, we heard from commissioners that they were basically facing an existential threat to their funding pots because, yes, it would no longer have been protected and the money would all have gone over to physical health. We have seen that happen historically, as was in Darzi. There are two things that I would really like to see in the 10-year health plan. I have already spoken about both of them already, to be honest. The first is making mental health a central part of the neighbourhood health offer and rolling out mental health as part of that, rather than separating it out as something else. If you are rolling out neighbourhood health, put mental health into that as a central offer with associated funding. The second is putting mental health waiting times on a constitutional footing alongside elective waiting times, always driving towards parity in everything and not telling systems that they can prioritise physical health over mental health. Both those things will enable systems to prioritise community mental health and really give it that bolstering and focus again.

I have one final question, which is probably a little bit out of left field. To what extent does successful localised mental health care, particularly for SMI, comes from commissioners getting the SMI landscape? Courtney has spoken very well on seeing investment in mental health care as a good in and of itself because of the people it benefits. Is there a feeling that if it works, it works because people understand that people with an SMI mental health condition are generally not going to get over it and you are not treating to cure? Is this something more fundamental about how they can follow target-driven things, but you need someone who gets it? How do you make that happen across the country?

It has been driven forward where there is really interested and passionate leadership at a commissioner level, whether that is clinical leadership or otherwise. A lot of the examples that we have provided are places where there are people who really understand that, who are so passionate about it and who have just driven it forward, even when other people in the ICB have not necessarily been. That is a concern. It should not be like that.

Is it fair across the country?

We cannot make a sweeping statement about people getting it or not. Commissioners are unbelievably stretched. They are having to make really difficult decisions. The Secretary of State said the other day that the reason why he has thinner planning guidance is that ICBs need to commission less. That is really concerning, because mental health is always something that drops off and is not prioritised, especially if there are no national targets. I am sure there are many cases of people not necessarily getting it, because it is really complicated, but there is a lot more going on. Commissioners are having to make trade-offs daily. I hope that that is really understood among politicians. When we are talking to commissioners day to day, they are going, “I’m sorry, I can’t. It is not because I don’t want to; I just can’t at the moment.”

I would just add that it is important to acknowledge the stigmatising narrative around mental health at the moment. That is fuelling a lack of understanding and compassion from decision makers nationally and locally. We run several networks where we support mental health champions at a local level to provide educational support by bringing in research and people with lived experience. It takes time, but it is a safe space for them to ask us any silly questions and to hear about how other areas are addressing severe mental illness. I am happy to share those examples too.

That would be great. Thank you.

Thank you so much, all of you, for being part of our panel today. Thank you again to our first panel, who have stayed in the room. We are delighted that you stayed with us. We have now come to the end of our session.