Welcome to the fourth session of our inquiry into community mental health services. In this session, we are going to be looking at examples of good and innovative practice within community mental health services. We will have four relatively short panels looking at different themes. We are trying to learn what changes need to be made to the current system to enable innovative practice and for it to be spread more widely. With that, Jake, can I ask you to introduce yourself?

I am Jake Mills. I am the founder and chief executive of a national mental health charity called Chasing the Stigma and an initiative called Hub of Hope, which is now the UK’s biggest and most comprehensive directory of mental health services. It is a charity that I set up as a result of my own lived experience of living with depression, anxiety and a suicide attempt 12 years ago this year.

Good morning. The Hub of Hope has been described by NHS England as the main signposting tool for mental health services. You have already talked about its scale and size. Could you talk us through how you came to develop a tool that has been successful in that way and particularly reflect upon the factors that have enabled it to be successful?

It is worth mentioning that I knew nothing about the world of mental health or the help and support that was available when I was struggling with my mental health. It was only through speaking publicly following a suicide attempt that I suddenly became thrust into that world, if you will. That was because my story got picked up in the press locally and then nationally; it went viral. As a result of me speaking publicly about my own mental health, people started coming to me and asking me for help. I believe there is a power in lived experience. I was talking about myself, not anybody else, but people felt like I was talking about them. Finding help and support was so incredibly hard. When people came to me and asked me what they should do, I said, “Have you ever spoken to anyone about this before?” They were saying no. I did not know about the help and support. It simply started as a bit of a fact-finding mission for me. I was trying to find any support that was available. From my bedroom in my mum’s house, I put together a list. I started to realise very quickly just how many community assets, voluntary sector organisations and peer support groups existed. That was not even mentioning statutory services. I started to put it together as a list, which was just on a spreadsheet on my computer. I thought, “We need to make this publicly available”. Why should you have to come through to somebody else to find this information? The truth of the matter is that we can be born, raised and live our entire life in a city or town but not know about the mental health provision that is on our doorstep. After a lot of coffees, meetings and conversations, we eventually built it into a website and then into an app. It is now a directory of services that consists of just over 14,500 services of all types. We want to create consistency around signposting. Whether you are looking for support for young people, older people or everything in between, we want you to be able to go on there and type in a city, a town or a postcode, or just say “find nearby,” and find the nearest local support to you, in the same way that you would if you are looking for a takeaway.

In your written evidence, you highlight the financial pressures caused by the growing demand for your service. You recommend long-term funding models to drive collaboration and integration. What could those funding models look like?

First of all, it is worth mentioning that in the last year Hub of Hope has had over 300,000 users and over 1 million searches. One third of those users have come directly from NHS sources. We know that at least 75 NHS trusts and 50 Government Departments are signposting to Hub of Hope every single day. We are not funded—we do not receive any statutory funding at all. Right now, we are running a service that we are not being procured to do but is really important to the mental health system. I am also very conscious that there is a lot of pushing downhill. Signposting to community mental health assets and community support is important, but we need to fund them to do the work that they do. There are many other charities that are propping up the work of the NHS, particularly given the Government’s recent ambition for the route from hospital to community. We are often thrown a bone. “There is a little bit of an underspend here” or, “If we can get you some money here, we will do that”. What we cannot do with that is to demonstrate impact, demonstrate evidence or plan. We need statutory services to look at the voluntary sector as an asset, as something that they can embrace and not compete against. We need longer-term contracts so we can work together. It is not about the voluntary sector taking something for nothing. It is about having strategic partnerships and longer term contracts that can allow us to plan and demonstrate evidence. We are not going to demonstrate evidence in under a year. If we have a pot of money, we cannot really do anything else with it at the end of that. We need longer strategic partnership and proper integrated care when it comes to the community. The NHS needs to do what it does well and the voluntary sector needs to do what it does well, but we need real wraparound support, particularly with the funding to do it.

Before you go on, could we welcome our second panellist? I am sorry to stop you, Joe, but our second panellist has now arrived. Could I ask you to introduce yourself?

My name is Darlington Zvionere, and I am the head of clinical governance for Black Minds Matter UK. We are a charity that provides 10 weeks of free therapy sessions to the black community.

I will continue with Jake Mills, if that is okay. The Hope in the Community initiative used insights from the Hub of Hope to develop a new model of support. How do you use data to inform service design, and what are the broader lessons for good use of data?

Again, by creating a national directory, we have generated the biggest asset-mapping exercise that has happened in the country. We can see where mental health provision is and, importantly, where it is not across the country. We can see that nationally and locally. The tool is completely anonymised, but through data analytics we are able to see insights of how and where people are looking for help and support. That can be based on gender or age; it can be nationally or hyper-locally; it can be based on time of day or day of the week. Just for example, we could see that men between the ages of 34 and 50 in Croydon were looking for self-harm support at 7 o’clock on a Sunday evening. Is that support there? If it is not, how can we then influence commissioning and policy to allow that support to be there to meet that demand? Hope in the Community is an initiative that we have been running in partnership with Central and North West London NHS Foundation Trust. We have Hope in the Community Westminster, which is an initiative we launched in February of last year. We were able to see that people in the area were looking for voluntary sector support. That support was not necessarily available in the area. These are communities who would not usually engage with statutory services. We took over an area in the Gordon Hospital in the heart of Westminster, just a walk down from here. We transformed the former section 136 suite. The NHS trust subsidised that space to make it free. We looked at the data from Hub of Hope. We looked at what people were looking for and the needs of people. We went out to an application process and allowed voluntary sector organisations to run their services from this space for free. That means we have been able to develop a monthly calendar of events, delivered by the voluntary sector, that better meet the needs of their community and integrate people. It is in an NHS building, but it looks like a Chasing the Stigma initiative. Hope in the Community is not a clinical space. It does not look like a clinical space. We can then integrate the two. It is just one example how we can use that data to drive change and make something for the community.

That sounds very good. If I could turn to our second panellist, how is Black Minds Matter addressing the barriers that black people experience in accessing support for their mental health? Could you just introduce us to that?

As a charity, we have tried to understand the needs within the black community. We have different pillars, one of which is awareness and advocacy. Through our workshops and social media, we try to educate people regarding what mental health is all about and what they need to do to access mental health services. We predominantly offer one-to-one free therapy sessions to our community, but on top of that we also run workshops for other organisations and our community in general to introduce them to some of those things, and to discuss and most probably enlighten some of those stigmas. Where do they come from? How do you overcome them? What does it mean to go into therapy? We try to destigmatise things such as, “You only go to therapy when there is something significantly wrong”. We try to be responsive rather than reactive to our community. We try to usher them, to get them to understand their rights, and to ensure that when they go to their GP they are able to explain what they are going through with their mental health. Looking at the issues that they will have experienced, very often they will have tried to receive therapy on the NHS. We are working in a very culturally competent and sensitive way. We believe that understanding the individual first of all, before we start treatment, will cut down the timeframe. In the feedback from some of our clients, they talk about how it was so easy to go through our therapy sessions because the therapist understood them before getting to know their problem. They did not have to explain who they were as a person before they started working on the problems they were having.

Do you have any case studies of proactive support that you can talk us through as an example of the support you provide?

As I was saying about therapy, a range of people come to us presenting with different needs. As a good case study to understand the importance of cultural sensitivity and competency in these areas, we had a client who came through who was considered to be autistic. They had been to different services. However, the problem was finding the right person who could understand them. Fortunately, on our list of therapists we have a therapist who is also autistic. They work together. It was a match made in heaven. When they came back to us, they were like, “They speak the way that I speak. They understood me. I did not have to go through all these other things that I went through with other services”. That is one of the key things that keep us going and show us that what we are doing is right. When we put our clients together, we do not just ask them to choose their therapist. They go through an assessment process with a qualified assessor, who sits with them to understand what their presenting needs are. Then we match them with the right therapist, so that we avoid people dropping out unnecessarily. Some of them have never had therapy before. How can we expect them to understand modalities, specialisms and all the jargon that is associated with therapy?

We understand that you are looking to expand the work you do. What are the greatest barriers to expansion for you? How would you navigate those barriers?

It is similar to what my colleague was just saying. Funding is the main barrier. Limited resources can make it difficult to retain some of our therapists because we operate a cohort system and a waiting list. If we do not have enough funds, we are forced to pause the waiting list because we cannot proceed. We are asking for ring-fenced funding that lasts more than a year. Similar to what my colleague was saying, we cannot show the right evidence or prove what we are being asked to prove in some tenders if the funding is for only a year. If it for more than a year, we can definitely show the progress that is happening with these people. We can put in place feedback. We can go back and ask people, “How is life after therapy? Where are you?” We can provide the aftercare that is required after therapy, signpost people back into work and different things.

My next question is to both of you. When thinking about people with severe mental illness in particular, which interventions will have the greatest impact particularly in terms of driving up access to services and/or reducing stigma?

It is important to differentiate between those with severe mental illness, because that is something that will require different treatment and different interventions. I am very glad that you have asked that question. When we are talking about the conversation around mental health, we need to make sure that we are not putting everybody into the same bracket. Stigma comes from not having those really clear conversations about the difference between severe mental illness and the other end of the scale. The intervention is going to be different. It is going to be things that will require hospital treatment, more hands-on treatment and longer term support for those people. Again, we can look at the models that have been released in terms of the 24/7 pilots that NHS England announced last year. Those people can still be in the community. Those people can still belong in the community. It is about finding a way to integrate the support that they will need with the support for people on the other end of the scale with less severe mental illness. There can still absolutely be a conversation about that, which can reduce the stigma that is associated with that. When we talk about this, we need to make sure we are quite explicit.

I am really very interested in the work around reducing stigma. Someone came to give evidence in a previous Committee meeting who receives therapy through Black Minds Matter. He was extraordinarily complimentary about the work that you do, but he was very clear that there is an enhanced stigma for black communities in particular. How do you allow people to step away from that to access the services that they need?

The main thing that we have been trying to do is to educate people and make them fully aware. People are coming from very different experiences. In the black community, there are so many different cultures and different religions, if you want to put it across that way. We are actively educating people that we all have mental health. The key thing is that people often do not want to talk about mental health because they only associate it with a negative. When somebody is well, mental health is involved. When they are not well, it is also mental health. It is about educating them on those differences and getting them to understand that it is okay not to be okay. That is one of the key things, especially in cultures and communities that focus on power and perseverance. When someone is feeling vulnerable, it is okay. They are crying out for help. We are educating them through workshops, social media, one-to-one therapy and even the assessments themselves. When people come for an assessment, they might not necessarily know what they need. They know that they need help, but by educating them in those assessments we are finding that people are now going out to the community. We believe in the ripple effect. It starts with one person and then it goes further to everybody else who is around them, their families and their friends. Most of the recommendations or referrals that we get come through family and friends. We are finding that that is working.

It seems like both of you are saying you are reaching people through non-traditional methods of access. That is an interesting way to break down the stigma. Jake, could you say something about some of the data that you see coming back? I have had a look at your app, by the way. It is fab. Are some of the people who are accessing that app those who perhaps would not interact with mental health services in another way?

Yes, absolutely. Over the last couple of months, 72% of people who have been looking for help and support on Hub of Hope were looking for voluntary sector support. To answer your question a bit more directly, on the back of what Darlington said, I believe fundamentally in the power of community. People trust their own community; they have knowledge and understanding of their own community. Why are people more likely to go to voluntary sector organisations as opposed to statutory services? More often than not, it is due to their lived experience. More often than not—this is exactly what Darlington said—it is because people see, know and recognise, “This is okay. I have been here”. Once they see their own community engaging with that, they are much more likely to look at it. If you look back at how this started, I was only talking about myself and people were coming to me saying, “I want to talk to you now”. They had never spoken to anyone about it before. Our data shows quite dramatically that people are more likely to look for support from community sector organisations because they see their own people.

How do you two find the interaction with community mental health teams, if there is any at all? How does that work out? I am thinking specifically for people who have severe mental illness. The scope of our inquiry is looking at people who fall into that category and how community mental health teams can be transformed to suit their needs.

There are two answers to that. First, we find it incredibly difficult every single day. I mentioned the number of NHS organisations that use us but do not talk to us. Every day we will hear people say how good what we do is, but the reality is that we have seven months left to exist as a charity. That is all the money that we have in our bank account. We are having to find that money ourselves. Every time we have a conversation with public health, whether it is an NHS trust, an ICB or whoever it might be, they will say all the niceties, but they do not want to fund us and work with us because they want to use our service for free. On the severe mental illness side of things, we need to be talking about how people can stay well in their communities and how we can keep people well within their communities. Once you come out of statutory care, how do you stay well? We need to be working on this integrated model. We have a lot of niceties. I am sure so many of the other voluntary sector organisations have a lot of niceties too. There is not an integrated or joined-up way of working, from my experience.

It is the same for us. Given that we are not funded by any statutory bodies, we solely depend on donors and well-wishers. We often find referrals coming in from GPs and health and social care professionals. It gets a little frustrating. We understand that they have a pot of money for that, but they are referring people to us, which takes things away from what we need to do. However, we understand that sometimes it is about our clients having issues with cultural competence and wanting to be understood on that level. The interaction is more or less just referrals coming through with no explanations or follow-ups. It is most probably just, “Can you see our client? Can you see our client?” We have a waiting list.

Do you ever have any interaction where a local community mental health trust or similar would come to you and say, “This is what we need” and you can say, “This is what we need”? Is it much more piecemeal—“We have identified that you do a thing and we are sending someone to you for this”—rather than what I would almost call co-production or co-design?

There has not been any co-production or co-design. It is exactly what you are saying: “We have a client who requires your services or we think would benefit from your services. Can you please see them?” We then have all the follow-up emails. These third-party referrals increase our workload and take the focus away from what we are trying to do. If there were pathways that were designed to streamline that process and we knew that this was how we were working together formally, that would help in the long run, rather than just having referrals coming in that way.

It is the same with us. It starts with how we are described by NHS England. We are written into policy. We are written into the Government’s suicide prevention strategy. We are described as the first place to go to find all this help and support. We know that there has to be some signposting through NHS 111, option 2. They just use us. We do not even have conversations. We have to fight tooth and nail to get any conversation that we possibly can. There is no model to follow. They use us for free because we are a free product. There is so much more that we can do when we talk about data and all the things that we can offer, but it is down to us. It often comes down to a relationship with an individual, who might just get it and might do it. As soon as that person leaves, there is no guarantee. That is nationally and locally.

One of the purposes of today’s session is to look at models that work successfully and how they might be scaled up. Jake, your Hope in the Community project is great, but I get the impression that you have lots of ideas about how that could go further with good working with your local healthcare providers. What have been the key ingredients of your success that could be replicated nationally? You have said a lot about how healthcare providers could go further at the moment. Feel free to feed that in as well.

We have a huge potential to scale up. We would be able to achieve so much more with the correct funding model and with the strategic partnerships that we aim to have. We can share so much in terms of data insights to understand need and whether there is the support to meet that need. Help in the Community is a very simple model. It is really cost-effective. When we talk about the perfect model around community mental health, it does not necessarily have to mean spending more money. It is always good to spend more money, but it is about spending money better and looking at who can help you do it. Not one person, organisation or system has all the answers. We have to be seen as equals in this. We need to have longer-term funding and wraparound support that involves all the parties. We need to be able to learn from the data, the insights and the people who are using it. There is so much more that we could do, but we need that support and guidance. We need it from national level right down to local and regional level. That will allow us to achieve the potential that we know we can achieve.

That was really helpful.

We have the same ideology regarding support nationally, getting people to understand and setting up areas. We have predominantly been online. We are now working towards going on the ground. We have been trying to work at the grassroots level, where we identify even people in the older generations who want to access therapy but do not know how. Some of these things are not spoken about. Those stigmas are still very much rooted in there. We are having to reach out and speak on the level where people can understand, on a one-to-one basis or on a group basis. Building up communities that are able to sustain and support each other in the long run might help to tackle the issues with mental health that we are finding within the black community. It is really down to scaling up, being supported and being seen as equals rather than, “They are just a charity. They are doing things for free”. Rather, we need to have those conversations where we can say, “What we are doing is working”, then evidence that and replicate it. This is about our communities and making them well enough and resilient enough to deal with mental health issues that come along.

Before we go on to the next panel, I have a rapid-fire question. I am going to do it with every panel today. If there were two things, out of everything that you have said this morning, that you want Government to hear, whether that is about scaling up, financing or whatever, what would those things be? I will start with you, Darlington.

The two things would be support with funding and being given the voice to represent our community and make changes to policy.

First, do not look at the voluntary sector as the enemy or the outsider. What the voluntary sector does and delivers is so powerful. It can absolutely complement what you want to do. It is the key to doing that. Secondly, do not just use us. Do not look at charities as if they are not businesses. If you want a good service, you have to fund it because you need the best people, so look at long-term sustainable funding.

On that point, thank you both for coming this morning. That was absolutely brilliant. Witnesses: Abdirahim Hassan and Karyn Kirkpatrick.

I am sorry to have to rush, but could I ask the second panel to introduce themselves? Then we will start asking questions.

My name is Karyn. I am chief executive at KeyRing. We are a national voluntary organisation supporting people in the preventive side of support.

My name is Abdirahim Hassan. I am the founder of Coffee Afrik. We run seven buildings across north-east London. We run 29 projects, two women’s hubs, a problematic drug use space, a research lab, a systemic litigation space and about 10 mental health projects in the community.

This is addressed to Abdirahim, first of all. Could you take us through some of the culturally sensitive interventions that Coffee Afrik carries out? I am particularly interested—I think the Committee is as well—in how you are addressing some of the stigmas and how you are reaching out to a community that does not traditionally engage with mental health services.

We run seven buildings, which are co-designed and co-produced by community. Everyone in the organisation—there are 29 of us—has lived experience of mental health and other services. We run two women’s hubs, which are designed by black women who have lived experience of surviving genocide, domestic violence and other challenges. It is a space that is culturally sensitive and faith-based. It is designed with indigenous practice. It is not new because we have had systems such as this for over 400 years around our culture. The other space is our youth hub, which is now one of the busiest in Tower Hamlets. It was designed by young people who live in the borough, who are predominantly working-class, who have experience of serious violence and systemic harm. Similarly, the mental health work that we do is designed by people who are neurodiverse and who have serious mental illness, who just do not access services at the moment. One of our longest-standing contracts is with East London NHS Foundation Trust. We have been working with ELFT for five years now. We are co-located with the mental health trust, which is quite rare in some respects. It is an award-winning service. It is the most engaged-with service on the Isle of Dogs, which is quite a complex part of Tower Hamlets. On one side there is Canary Wharf and on the other side you have severe deprivation. It works because the team are blended. There are psychologists, occupational therapists and social workers in that team. The team at Coffee Afrik also provides a service that is by and for people predominantly with SMI and physical health issues. We design services that are language-sensitive, aware of people’s different needs and support people from a whole human perspective, so with housing issues, welfare and so on. I struggle with the term “stigma” because it often blames the groups that are not engaging. The challenge is the system itself, whether it is the NHS, public health systems or local systems. In my view, they have been designed to create further sickness. They are not there to heal people, certainly. That is what our experience is. We are a group within a large institution, the NHS, that is providing a different way of working.

I am very interested in the fact that you co-design and co-locate. You co-produce, would you say, as well? What have been the barriers to being able to do this? Have the local mental health services been helpful and supportive? Have you had a difficult relationship at times? How did you overcome those?

We are very stubborn as an organisation. That has helped. We have kept pushing through our ways of working. We believe people know what they need. We believe in self-determination. We believe in anti-racism and equity as an organisation. We believe that services should be designed with communities, not at communities. Predominantly, it works very well because the people who approach our services also live within the communities in which we reside. We predominantly live in Tower Hamlets. It works because it is a tried and tested method. As I said, for five years hundreds of patients have been supported. One of the key things is that we have a mental health trust that genuinely understands communities in ELFT. We have had many challenges, like many organisations. Sometimes those challenges have been political. If you know about Tower Hamlets, it has a very complex political situation. It has an independent mayor. Equally, it has teams of people who, from a public health perspective, will not always understand the communities they serve. We have always spoken about anti-racism in mental health services. That does sometimes challenge some people. Those are the challenges. From a funding perspective, we have worked very hard to sustain our organisation. We have just received £1 million to carry on this work from an amazing foundation called the Tudor Trust, which truly understands health justice and health models. From an NHS perspective, our drugs work and mental health work comes from NHS England and the current and future models. Otherwise, we have experienced challenges. Sometimes other community leaders have not fully understood what health liberation, in my view, or health justice should look like for communities, particularly working-class communities.

It sounds almost like the thing that drives you is your very strong philosophical drive, but you also have a mental health trust that is genuinely supportive. I am quite interested in that. You also pointed out that there are some teams who find your anti-racist work almost a challenge. As I said to the previous panel, in today’s session we are looking at those pockets of very good work and stuff that is working, and how that can be scaled up. What advice would you give to either other NHS trusts or other groups that are looking to do similar work to you in other areas?

That is our biggest systemic issue. We have multiple impact reports—some incredible impact reports—that provide recommendations that can be implemented nationally. We have presented that evidence to Parliament and at a local level. We have presented that evidence to most of the London trusts that we are familiar with. We are speaking at a CNWL—central and north‑west London—conference soon to create what we think is health justice, which is policymaking that is rooted in love. When we speak about love in healthcare, people look at us like we are dysregulated. That is why so many of the systems that are designed do not work. They are often designed with minimal empathy or understanding of community. For me, I would say this is not just about NHS systems, but the police, the Government and the welfare cuts that are coming. These challenges are creating significant impact at a community level. I studied economics. What I know about economics is that, if you cut a budget in one area, it will certainly impact another. That is what we are witnessing from a welfare perspective too. At a systemic level, our patients are already in crisis because of those cuts. It is really important for people to listen and to have that humility, especially because we really understand our communities.

You said something there about seeing people as individuals. In a lot of the lived experience sessions we have had, which I have found particularly interesting, people living with serious mental illnesses have talked about how being seen as an individual contributes to their good mental health. They are not just being treated for their condition; there is an understanding of the things that contribute to their good mental health. You mentioned social justice work. Someone said they always have to have that side of what they are doing. Other people need a creative outlet; other people need physical health to be really high on the agenda. Is that a focus of the work that you do? Is that reflected by ELFT? Does it see people in that regard? You said you have a good relationship. Is there further work to be done?

There is significant work that needs to happen. Often when patients arrive at mental health services, they are treated in a moment of crisis. They are seen as someone who needs something or who is broken in some ways. When you then diagnose the person as emotionally unstable or as having borderline personality disorder, you are telling the person that they have a disorder and their traumas are not necessarily the reason why they are sick. I am autistic. I have lots of lived experience, with rough sleeping and many other aspects of my life. I survived all that. As I said earlier, as the founder of Coffee Afrik, I am fairly stubborn. Philosophically, when I look at the Black Panther party, for example, I believe we know what we need in our communities. We just completed a research paper funded by London’s VRU. In that research paper, 98% of the 110 young people we surveyed said they experienced violence on a daily basis in Tower Hamlets emotionally, physically and mentally. That is a significant proportion of young people. The other challenge with systems at a local level and a national level is that often we are not looking at communities and understanding that the built environment is traumatised. We have landscapes that are traumatised. Our estates are traumatised. Air pollution is creating trauma. Schools are creating trauma. When we are diagnosing one condition, we are not looking at the person, where they live and what is contributing to their long-term sickness. In my view, many parts of London are traumatised landscapes. That is a challenge that we often experience with clinicians, political leaders and others. There is a misunderstanding about what living in a poor area, where the system deliberately discounts your opportunities, does to you physically, mentally and emotionally. I am not speaking about something that is exclusive. The Centre for Mental Health speaks about this from a co-morbidity perspective and a life expectancy perspective. Those are the challenges that we witness.

Thank you. I am so sorry that we do not have more time. I could talk about this all day.

Karyn, going from the geographically very specific and very much advocacy-based—I was very impressed by that—KeyRing is more nationally based. You were started in 1990. Tell us more about how you work.

We started in 1990. We operate in 23 local authorities across England and just into Wales. We have a very localised community offer. Listening to my colleague here, so much of that resonated for me. It is really interesting. We have a way of working. We are not specifically a mental health support organisation. We do not offer therapy. We support people who are eligible through local authority funding to get support. We do that in a way that brings people together in a neighbourhood. We do not follow the model of local authority-funded support, where somebody has a need, a worker is sent to address that need, and then they go away and the person gets on with their life. We try to work with people in a neighbourhood, bring people together, extend their connections and the resources in that neighbourhood in order to improve their overall wellbeing, as well as responding to their eligible support needs or the support needs that they have. That sounds very complicated. In real life, we find that, when somebody gets to the point where a local authority will offer them support, they will very often be quite socially isolated. They might not be connected to other people. They might not have family or friends who are helping them. That really affects their well-being. They can be referred for all sorts of reasons, but a fundamental part of our approach is about working with people to look at what they need and want in their lives, what they can do for themselves and what other resources are available to them—not just as an organisation, but the community, their neighbours, the people around them, the things that they are interested in—and connecting people to those activities and that work.

On a practical basis, as I understand it, you also arrange or provide accommodation. Three projects in the UK have been given plaudits by the WHO, no less. You say you are not really a mental health organisation, yet the WHO describes you as such.

Yes, because we are addressing people’s mental health needs in a certain way. As an example, we work in Warwickshire, and we are part of the Wellbeing for Warwickshire collaboration. That is a really interesting, funded piece of work. It was a tendered opportunity; it went out for competitive tender, but the council was really clear that it wanted a collaboration to think about what citizens in Warwickshire need and what would help them the most. Rather than commissioning lots of different bits of mental health support, they wanted to know what overall picture could come out of this. In that process, they took away some of the blocks. They said, “We will contract with each individual organisation”. That solves a lot of the tendering and contractual legal issues. It clears that place. It leaves a lot more time and space for the different parties in the collaboration to think about and talk to the people they support about what they really need and what would work across this area. In Warwickshire, they have ended up working with a number of providers. They all offer something different, but somebody who wants that support has one phone number and one front door, and gets passed to the right group of people. It involves a number of organisations, such as Mind Coventry, Warwickshire and Worcestershire, Qwell, Recovery and Wellbeing Academy, as well as KeyRing. We are all part of a mix. Our bit is about helping people connect with their community and get back on their feet.

There were lots of process references there. I want to get down to the nuts and bolts and the bricks and mortar, as it were. How much professional assistance is provided, whether that be administrative and about co-ordinating things? How much volunteer effort is going in? Accommodation seems to be a key element of what you are doing. Are you a landlord? Do you provide services? Do you act as a go-between? In what way do you provide that stability in people’s lives?

We are not landlords. We work very closely with housing departments and private landlords to help people find their own homes. We work with people living in their own homes, their own accommodation. That is partly because we started by helping people with learning disabilities who were leaving long-stay hospitals. We now do a lot of support work to get people engaging with mental health teams. We have some really good examples around the country of NHS provision that works really well. Where NHS trusts and local voluntary and community sector organisations have really pulled together, and that approach works extremely well. There is a great example at South London and Maudsley hospital, for example. We are very connected there. For us, there will be a support element. Our staff will be helping people access the mental health services that they need. A lot of our work is about helping people maintain that access. People will often find it difficult to present at a GP surgery or to follow up on appointments. They find it difficult to maintain their connection with the therapeutic or other interventions that they need. This can be quite significant. My staff spend a lot of time with psychologists and psychotherapists making sure people are getting the right support, but that only takes you so far. This is what you were talking about earlier. It is that bit about love in the community. What is it that people say makes the biggest difference? It is very rarely “my psychologist”, although they may be getting really good support there. What they say makes a difference is, “I have some friends now. I have some things to do. I know other people. I am not alone in this space”.

Can I just interrupt you there? You are saying that a lot of the benefit of the service that you provide is through peer support and volunteers.

That is the impact-driven side.

I just wanted you to say that. I want to be clear that we are not talking about professionals hand-holding people as professionals to book appointments and make arrangements for them.

No.

You are building up a community of mutual support.

Yes, absolutely.

When you are commissioned by your 23 local authorities, do you have a template offer to them or do you tailor it to the needs of that particular local authority or ICB that is commissioning? Are you commissioning with the ICBs or the local authorities? You said, “local authorities”, so I am not clear.

We have a preferred model, which we know works best. However, if you are doing any sort of work with a local authority, it will have a very clear idea of what it wants and so you need to adapt and fit with that. We retain the core elements that we know work really well. We will not take a commission that does not allow us to do the stuff that we know makes the biggest impact. We work with two ICBs at the moment. That has been a bit of a slow burn. Again, it is a really interesting thing. With one of the ICBs, we have a network up in Gateshead. They particularly want us to do a lot of health prevention work. That is absolutely fine. We can do that. In order to make people engage and keep interested and focused, we do a lot of social activities and present that health promotion work in a positive light because we are looking to help people change their behaviours, change their treatment programmes and really get engaged with it. It is a bit of a sleight of hand. There is what we do in the formal sense and then what we do through peer support and community support, which helps people engage, keeps them on track and means they do not just lose out.

Can I ask you both—I will bring in Abdirahim as well—about the process of commissioning from ICBs or local authorities? First of all—this one may be primarily aimed at Karyn—what is the national picture? Let me just be devil’s advocate. If we are depending on the voluntary and community sector to provide services, we could end up with a patchwork of famine and feast around the country. There could be places where you have fantastic services—I am very impressed with what is going on in Tower Hamlets—but then nothing at all in a neighbouring authority. Can you just address that? To what extent do you have a wider geographic view of what is happening across the sector? Are you part of a peer support and benchmarking group of voluntary and community sector organisations that talk to each other?

Yes, I can respond to that. We certainly are part of a group who talk to each other. The Association of Mental Health Providers gathers together all the community and voluntary sector organisations. It has a huge membership and does an enormous amount of work representing all the organisations, from very small organisations to really large charities. It is sterling in its work. Around the country, it is very variable. It is getting more difficult. One thing that I have noticed is that the work we do on the prevention side, helping people reduce or delay the support that they access, is being less addressed because the impact that we make often is on the funding of other services. We might work with an A&E department to help someone who re-presents every single day and try to change that pattern. We might work with the ambulance service to help somebody who calls it 10 or 12 times a day. When we make that behaviour change and we work with the person to redirect that need and find other things to do in their lives, the beneficiary is A&E and the ambulance service. The local authority, which is funding this, is no longer seeing that as a priority any more. If we intervene with somebody who is struggling with their behaviour, we may be in meetings with the police, the town centre managers and the mental health team looking at how, through our support work, we can help them adjust that behaviour. From the local authority point of view, they are increasingly narrowing their interpretation of Care Act eligibilities and what is reasonable for them to be funding. We understand why, but the ongoing impact of this is quite significant. You talked about traumatic neighbourhoods. We have a significant problem around housing. If you are in receipt of benefits, you have a restricted amount of money to spend on your rent. The pool of places that you can rent is getting smaller. We are finding people with complicated needs being squashed into smaller and smaller neighbourhoods. It is very difficult for communities to offer good support to those people. That is a problem.

Because of the time limitation, I just want to bring in Abdirahim as well. You are focused on your own area, although I am not saying that you do not look at how you compare with others. One assumes that you are benchmarking against things that are happening in a wider sphere. Where do you sit? How is the commissioning process for you?

We have worked in Barnet, Harrow, Tower Hamlets, Hackney, Newham and four other boroughs. From a London perspective, certainly, we are on eight different boards and various alliances. We can see that within the sector there is definitely a push to reimagine healthcare. Certainly, from a Coffee Afrik perspective, we welcome that NHS England is being restructured or changed, or has gone. We also welcome the 10-year plan and the other changes that are happening. From our side, just as Karyn was saying, there is definitely a real crisis within the sector. More and more local authorities are pulling on us for advice around strategic needs assessments. Commissioning structures are changing. Local authorities are too scared to work with local organisations in some boroughs. They are working with large national organisations, such as Save the Children. That is creating a complex crisis at local level. I will not mention one organisation, but a large national one recently had its contract terminated where we are based in Tower Hamlets because it really struggles to carry out outreach and understand services from a mental health perspective locally. That is what is happening at a local authority level. From our side, we are able to benchmark with some of the great organisations that we work with, such as Decolonising Economics and Land In Our Names.

I am just trying to bring this all together. You mentioned the 10-year plan. You see all the talent out there in the voluntary and community enterprise sector. How should the Government engage with you to ensure that all the talent that is there is harnessed and best utilised going forward? How can you be commissioned in such a manner that you are deployed to improve the reach, effectiveness and efficiency of mental health services and support services throughout our communities? As I say, there is a lot of talent, but it is disparate and piecemeal. It is famine and feast. How do we commission? We heard in the earlier session that Chasing the Stigma only has seven months’ funding left. There has to be some confidence in terms of its longer-term support. What advice can we offer the Government to harness your talents?

In the past 10 years we were not invited once to speak at a committee, although we submitted evidence. We were not invited to a roundtable. In the past six months alone, we have attended Parliament five or six times and spoken to the Secretary of State and the Minister for Public Health. When you do not create places that are equitable or accessible, it creates a dog-eat-dog sector. That is exactly what has happened. There is a big change happening at the moment. The systems have pitted us against each other. We are bidding for the same contracts. We are working late nights. We are using a corporate approach to community services. That is where a lot of damage has happened. On a very positive note, it is great to see this Government open up doors so that we can be heard and can influence policy.

I would agree with that. There is definitely a change in attitude politically at the moment. What I would really like to see is an effort to look at the biggest picture. What is going to make the biggest difference in this community? You need to look at everything. All the pieces fit together. You cannot just pick out and fund one tiny piece, and think that is going to solve the problem. You cannot put in a mental health support service and leave enormous housing issues, people not having enough money and poor-quality schooling. All the pieces need to be looked at and brought together. I am really interested in concepts such as community budgeting. That would make such a difference for organisations such as ours, because we could really start to talk about and think about how this local spend is actually spent. Does it meet what people who live here really need?

I am going to ask you guys the same question, as community and peer-led organisations or initiatives. Could I start with you, Mr Hassan? There has been lots of richness in your input, but if there were two key things you would like the Government to hear, which you do not want the Committee to leave out from what you have said today, what would they be?

The first thing is to significantly reduce the waste and duplication. There is too much of the same things happening up and down the country. It is really important to get value. The other key thing is to genuinely design further policies, where it is a 10-year plan or any other strategic framework, with us, not at us. It must be purposeful and intentional. That is a really important definition. It must be as inclusive as possible and reach a diverse group of people, across white working-class communities, Traveller communities, and black and brown communities too.

What would I recommend? We should be rethinking the whole of social care and our attitude, perhaps taking the view from Social Care Future that everybody wants to live in their own home, doing things they like with the people they love and just getting on with it. That is what support should be about. That is what it should be providing. I spend a lot of time in meetings, justifying, filling in forms and doing all sorts of things that do nothing to add any value to the offer that we have or other organisations have. I work with colleagues across many organisations and we are all in the same boat. It is a complete waste of money and time. I would love it to be different.

Thank you both for your brilliant responses and thank you for coming today. Witnesses: Michael Crilly and Janine Smith.

We are going to move swiftly on. Can you both introduce yourselves? Let us start with Michael.

Good morning. My name is Michael Crilly. I am director of social health and community inclusion at the Mersey Care NHS Foundation Trust and I am the service director for the Life Rooms social model of health, which is a non-clinical, socially focused service that is run by Mersey Care as an NHS mental health provider.

Good morning, everyone. I am Janine Smith. I am chief operating officer for NAViGO. We are a social enterprise delivering, among many other things, mental health services in north-east Lincolnshire.

The service originally launched in 2016 in response to the reality a lot of our service users tell us about, which is that the stuff that stops them recovering is the social stuff: “We want great clinical care when we need it, but how do we move on?” Effectively, we have managed to bring together a raft of non-clinically focused services, teams and interventions—six individual teams—that do one of two things. One will be an internal offer, in terms of activating people around managing their own health and wellbeing, behaviour change, ultimately helping them move beyond the dependency on services. The other is community access, where we network people to the voluntary sector. To that point in particular, we have wrapped around our secondary mental health clinical teams and services in a way that creates a pathway from the clinicians. The clinicians are often exercised by the fact that there are huge social issues presenting when they are trying to clinically work with someone, but they do not know what to do or do not necessarily have the resources. We have digital interoperability between our clinical information system and the digital social prescribing platform that the Life Rooms uses. Within four clicks, an individual clinician can make an express referral highlighting the social needs that the individual may have. Then that person is contacted by a Life Rooms pathways adviser, a social prescribing link worker, who will meet with the individual service user, listen to their narrative, understand the issues that they have and then, again, through our digital platform, network them to in excess of 200 voluntary and community sector organisations, depending on what the needs may be. We find that each individual will probably require multiple social prescriptions. It may involve referral to several voluntary and community sector organisations, and usually we will get better results if the individual also accesses the internal offer around health self-management and behaviour activation.

The recovery college model has been around mental health services for a long time.

Yes, absolutely. The recovery college model would take the lived experience of a mental health condition and marry it up with some form of professional expertise, giving parity to that relationship in co-designing a learning programme that someone may access. That could be around understanding anxiety or depression. It could be around building confidence or esteem. There is a range of clinical support management programmes, if you like, but it can also be broader than that. There can be a creative offering. There are huge numbers of programmes and activities that we have developed with creative and cultural partners, or around food and nutrition. It runs the whole gamut of how people might learn to skill themselves up, build confidence, take that into skills and then, ultimately, activate themselves around their own health, so that they are less dependent on resource structures that may be made formally through the organisation.

There is a broad network. We are still lucky. We have a very strong and vibrant voluntary and community sector. Sometimes that is a bigger struggle in more recent times, as we have heard from earlier panel sessions, in terms of the flow of funding. What we have been able to do, which maybe is a little bit different, is to create an infrastructure or a platform through which the organisation can more meaningfully, as a statutory body, engage with those voluntary sector community organisations. It is often quite difficult for the statutory and voluntary sector to work together. They are quite different beasts with different cultural understanding of how money should work and flow, and what success looks like. We have been able to create, if you like, a Spotify for the NHS. We do not own the wellbeing and mental health community artists that people want and need to access, but we create that platform through which they can download them at a given point in time, without having to worry about the complexity or the politics of how you bring those relationships and interventions into play for their journey.

We still, as I say, have a strong and vibrant offer. In terms of consistency, sometimes we do have duplication. We may have lots and lots of organisations, but perhaps they are doing similar things. In certain areas, you have pockets where there is not someone doing it or there is someone doing something twice, rather than them targeting the resources in a different way. That is what some of this platform enables us to do. We can be more targeted, particularly around health inequalities, in how we channel particular community partners into particular areas.

It is really difficult. That is a fantastic question. When we started out more than nine years ago, we had a board that was willing to listen to the lived experience of its people, a creative appetite for risk—knowing that the conventional models are straining to keep up with demand—and a solid financial base upon which to plan. That is a much more challenging situation now.

Primarily, the initial intervention was probably, in part, some subsidisation from within our own resources, but also creative redesign of things that we were already doing. Since Liverpool had been capital of culture, we had a range of cultural and creative programmes. We had launched peer support models. We had launched a recovery college model. We were able to creatively redesign them. This is where the possibility still exists, because Mersey Care, since I joined, has grown to three times the size. Each time, there has been another organisation come into the fold. We have been able to look at small teams and pots of funding that are socially focused. Within every NHS organisation, there are more of those teams than people realise. We have been able to provide an infrastructure that makes them more effective, instead of them languishing, perhaps in a clinical team, where the main focus will always be CQC registration and activity.

Absolutely, yes, and this is where there will be challenges. There are challenges around funding. There are mixtures of how organisations are going to work and what commissioning will look like. However, a number of the interventions that we are supporting are ones that are growing at the moment and in recent times. For example, individual placement supported employment for severe mental illness cohorts is expanding through community mental health transformation funding even now. Despite those challenges, there are opportunities as well if we are creative.

Through outcome measures that we have used, we have been able to demonstrate a statistically significant improvement in mental health and wellbeing. More recently, working across the Cheshire and Merseyside system, we have been engaged in a data analytics piece. Because we are an NHS service, rather than a voluntary and community sector organisation, we have been able to collect NHS numbers. Using that fact, we have been able to link data across a five-year time slice. We took a five-year time slice out of the social prescribing platform that we use. Over those five years, 16,000 people had accessed the Life Rooms service. We matched around about 7,500 NHS numbers and we did a sophisticated matched cohort study, in order to really understand the impact of Life Rooms interventions. We matched a cohort who had not used the Life Rooms with a cohort who had and, when we drilled deeply down into that, in terms of the demographics, we were able to see a reduction in clinical care contact in the use of CMHT—community mental health teams—GPs, liaisons, psychiatry and early interventions in psychosis. Those are quite small in the first instance. There is a need to do further data analysis around this, but we are beginning to see that impact. We see a greater still impact if the social prescription that we use is employed alongside some of that health activation and behaviour change work that we do.

In 2011, we were part of the NHS spin-out. We were under the right to request and became a social enterprise. In addition to that, we also have the section 75 arrangements in north-east Lincolnshire, so we provide both health and social care within an integrated model. The uniqueness of that social enterprise model enables us to improve access for people. It gives increased autonomy. We can never go into a deficit position. That gives our staff clear autonomy and ownership. They own the out-of-area budgets. They own the social care budget. They own the health budget. They have to drive that money to be well invested for the people they are there to serve. That autonomy drives a lot of our outcome and performance. It also allows us to address the wider social determinants. While we deliver and our core budgets come in from the Department of Health and Social Care, we are able to deliver a much more rounded model. It has been described by people who have been to visit us as entwined services with people’s lives, their families, their hopes and their future. We have courage, we have will and we have inspiration in how we adopt our services. We use our own data, and we use what our service users and carers tell us, to see the gaps and, with them, design the solutions to those gaps. That is why you will see that, for example, we own a garden centre. It does great social value in the local community. Local people spend there and that money gets reinvested into improving mental health for people in the area. None of our auxiliary services are delivered by anyone other than people who have used our services. People who have experienced our services then use that value to work and have meaningful roles and occupations. We have been able to set up supported living home care charities to bridge gaps and find housing solutions for people. It is about seeing those wider determinants and being able to provide solutions. By pooling the budgets and having access to money in a different way, we are able to be much more innovative and creative in how we deliver services.

This resonates with what people on the other panels have said today. We work very much on the ethos of people having somewhere to live, somewhere to work and someone to love. If you just see the health element of a severe and enduring mental illness, you can give an evidence-based treatment, but, if you do not address the determinants that are surrounding that, you are never going to succeed and you are never going to encourage recovery for those individuals. The model very much works because we see people as people. We value people as people. We are an employee-owned mutual. We work on that relationship of everyone having an equal voice and say. If you empower people and give people the power, they design their own solution, rather than us designing it for them.

Yes, that is an absolutely fair reflection. This is where addressing stigma, building compassion, understanding and empathy in local communities and neighbourhoods, gaining their understanding of what a severe mental illness looks like and what it is like to live with that, is important. What can they do, as local communities, to help support that? It is around environments, employment and working with local housing providers to take some of the risk away. A lot of people will be banned from lots of providers, which will not provide them with solutions, so they get stuck in a system. If we work in equal partnership, with you providing the housing and us providing the in‑reach and support around that, it is win-win for everybody.

You have both been involved in trialling innovative models for delivering mental health services. Can you give me an idea of how challenging it has been to get the funding and support to be able to do that? What are the enablers to scaling up the models, once they have been piloted?

It has been challenging. You will probably hear lots around social entrepreneurship in this context but, for my journey, it has been social “intrepreneurship”. How do you begin to change hearts and minds within a conventional psychiatric model? That can be challenging. To be honest, the biggest opportunity is probably some of the challenge that we now have. As an organisation, we recognised that we could not indefinitely keep doing what we had always been doing. That gives you opportunity to think differently, to be creative, to shift left into models that can be more effective, while also being less costly. The opportunity is perhaps that some of this stuff is not only the right thing to do, but is also a more affordable thing to do.

To echo that, the pooling of budgets and resources allows you to be really creative with your skillsets. What is the need for the local population? Then you can work with the local population to design the solution. That freedom of not having to put things into boxes and say, “This is health money. This is social care money. This is voluntary sector money”, enables you to deliver what is needed. It is led by the people and it goes back to the fundamental ethos. We always say to our staff, “Is it good enough for your family?” If the answer to that is no, we need to do the challenge, we need to change and we need to bridge that gap in a different way.

You have both been very positive. I would not want you to go away from here without having the opportunity to describe what might be improved in that situation. In terms of the funding and support model, is there more that could be done?

There is definitely more that can be done. There is a real risk, in the current climate, that we retreat back into what we know, rather than thinking more creatively around the whole-system approach, taking seriously that shift left philosophy. That is going to be a challenge, because people are making tough decisions right now and some of this is not mainstream commissioning. That means it could be at risk.

I would like to add to that. My organisation would never forgive me if I did not mention it. We need to be on a level playing field. As a social enterprise, we have had restrictions put on us in terms of access to digital, to capital, to moneys and so on, which then creates a postcode lottery. Rather than being prescriptive around models, if you have designed a solution that delivers the outcomes, do not allow that to become a barrier in the future. That local population should not suffer detriment because of the model that has been delivered in that area.

Reflecting upon the wider social needs for people with SMI in particular, what action would you like to see from Government—and, indeed, NHS England, while it still exists—to enable services to better meet the needs of those people?

For me, it would be around long-term sustainability and funding, with a recognition of the increased demand from a mental health perspective, irrespective of the model that is being provided. We cannot be prescriptive around the model and instead should be focused on outcomes, so that local places can design their own local solutions.

Who is currently restricting you and being prescriptive about that?

The way guidance comes out is often prescriptive: “Community mental health has to deliver the following things; NHS talking therapies have to deliver the following things, with fidelity to this model”. Sometimes, you have to consider people’s hopes, wishes and visions, and the best way to deliver it. It should be a place-based approach. The neighbourhood should be designing what that looks like for their own neighbourhood. There is a “big is not always beautiful” element. Seeing health and social care in isolation needs to stop. Integrating all of that would drive much better outcomes for people. If we do not address the wider social determinants, people are not going to recover well and retain their recovery.

I would echo many of those comments, particularly around sustainability and a system-wide approach. I would add to that the need to take a whole-person health approach here. It is not just about physical health, about mental health or about social health. It is about the whole wraparound, which will deliver the outcomes for individuals and communities.

I do not want to put you on the spot, but are there things that NHS England could be doing differently to achieve what you are trying to do?

I will reserve judgment until I see what is in the 10-year plan. Will the funding follow the rhetoric about those shifts to prevention and community and, indeed, to digital?

Can I thank you both? Before you go, I am going to do the same thing as I have done with the other two panels. Quite quickly, if there were two things that you want us to get from what you have just told us in the last half hour, things that you want us to ensure that we capture in our report, what would those two points be? Can I start with you, Janine?

We work on the mantra of “culture kills strategy”. If you get the culture right and we start working in a much wider way, addressing the wider social health determinants, that will drive positive mental health outcomes for people. Long-term sustainability would be my other point.

The first one is definitely that flow of the funding and the shift left. The second one would be to give real attention to how the voluntary sector and the NHS can relate. They often speak very different languages. You have to get that right if both sectors are to work in harmony and deliver the outcomes.

On that note, can I say thank you both so much for joining us today? It has been absolutely brilliant. Witnesses: Professor Belinda Lennox and Professor Steve Pilling.

Can I welcome you both to the Committee today? Ladies first, can we start with Professor Lennox? Can you just introduce yourself, your title and why you are here today?

Hi, good morning, everybody. My name is Belinda Lennox. I am a professor of psychiatry in Oxford. I am head of department for psychiatry and I undertake clinical work in severe mental illness, particularly psychosis. I work clinically in early intervention in psychosis services.

I am Stephen Pilling. I am a professor of clinical psychology and also a head of department at University College London. By background, I am a health service researcher and I also do some clinical work in one of the local trusts in North London.

Thank you both. I am asking the first question. Can you briefly talk through the aims and the remit of the ODDESSI trial and, within that, can you share any preliminary results with us, please?

That is very good question. I am very happy to do that, but I have to issue a bit of a health warning, unfortunately. We do have the preliminary results, but we do not have them fully for the health economics and we have not had them signed off, either by NIHR, the funders, or by the programme steering committee. I am going to have to be a little bit cautious, I am afraid.

We appreciate that.

Within about three months, we should have the results. If it would be okay and if you would find it helpful, I will forward them to the Committee at that point. That rather damp introduction to it over, I will just say a little bit about the trial. The trial is a large, multi-centre, cluster randomised trial, where we are comparing open dialogued. This is an intervention, in fact, developed in west Lapland some 30 or more years ago. The essential ingredients are that it is a team-based model, which provides immediate help at point of crisis and continues to provide care throughout the episode, with a single practitioner often having not just responsibility for case co-ordination, but also a central role in delivering care. There are a couple of other things that mark out the open dialogue approach. One is an emphasis on network meetings. There is an intention to try to involve the family and, beyond that, carers and friends in initial meetings. The central focus of the programme, independent, if you like, of the diagnosis—and I will say a little bit about that in a minute—is an attempt to develop a shared understanding of the problem and a wish to have the individuals themselves as the central decision makers in the nature of the care that they receive. As a consequence, a degree of uncertainty is tolerated, at the beginning, about how the programme may develop. It is also right to say, though, that it is very much about promoting the use of effective pharmacological and psychological interventions, of which we know there are many. It is not saying it has an answer to everything. There are clearly effective treatments, but it is often about helping people to better engage with them. The hope is that, as a consequence of that, not only does the individual’s mental health begin to improve, but they also develop a better sense of agency and autonomy, and are able to take more of a role in managing their own care. That is the intervention. I could, if you want, say a little bit about the training and development, or we could move on to Professor Lennox at this point.

Even though you cannot give a lot of information about the preliminary results, can you share a little more about what your views were? Just a sentence is okay.

I can say a bit more than that. To the question of why we did it, I should have said in the introduction that I have had a couple of spells as adviser to the Department of Health and Social Care. One was some years ago, developing what was called the functional team model, where we had a crisis team, an assertive outreach team and a community team. We had first episode services, which we will hear more about. We got to a situation where, as I put it in the development of a further programme, the community mental health framework, we had a team for everything, but a place for no one. There was a state at one point where there were more referrals between services than there were in and out of mental health services. That was one of the incentives behind a wish to explore the possibilities of what open dialogue could bring. What were we interested in measuring? This comes to the outcomes. I will try to get through that fairly quickly. We were interested, first of all, in whether people got better and recovered, but also, crucially, whether they stayed better. We had a measure called time to relapse after initial recovery. It was developed by colleagues in south London. We felt that that was an appropriate, robust measure. We also measured a range of other things. The primary outcome I cannot say much about, but we collected quite a lot of data on hospital and general service usage. I can say that, in the open dialogue programme, there was better long-term engagement with the programme and that had impacts, which you will learn about shortly, on the use of hospital beds. We also looked at people’s self-defined recovery and people’s overall experience of care. Shortly, we will be able to give you the answer to all of that.

Professor Pilling, you have talked about better long-term engagement. You have talked about how people got better and stayed better. Do you feel that the ODDESSI trial was proven?

What I can say is that, having seen the preliminary results, I am in a fairly positive mood, but there are some caveats to that, which I cannot go into. One thing I can say that impressed me is that, in the open dialogue programme, we had much better staff retention. It is multidisciplinary training. I have spent a lot of time working in psychosis, as Professor Lennox has, and having people around, being able to talk to people, being able to work out your plan and having that validated by the team is quite a powerful intervention. We saw that in staff retention and in the general satisfaction with care.

That is awesome. We will move straight on to Belinda Lennox. The establishment and expansion of early intervention in psychosis services have been identified as examples of good practice. Why do you believe this should be seen as such a successful intervention?

It is quite interesting that we are sat here together, because EIP has been something we can be really proud of in NHS mental health services for the last 25 years. We have a really robust evidence base, but the introduction was in the absence of very good evidence. It just sort of made sense to everybody. It was a bringing together of patients, charities, clinicians and scientists all saying the same thing: that intervening early and giving holistic, wraparound care to people just made sense and was better than the alternative. They had been around since 2000 and we should be really proud. They are accessible to everybody across England. We have a national clinical audit that measures the quality standards of the delivery of that care. Over 70% of people access EIP services within two weeks of referral, and referral can come from anyone, whether that is a self-referral, through a GP or whatever. We can demonstrate that they are cost‑effective. They save the NHS money. We calculated that £4,000 per person, per year is saved, mostly because of preventing admission to hospital. We can show that people are more likely to be employed. You are 116% more likely to be employed if you are under an EIP service and 52% more likely to be housed in mainstream housing. These have real-world, tangible benefits to people taking part. The other key aspect is the involvement of families and carers. The involvement of families in the treatment of the individual is, again, one of the key predictors of satisfaction with the service.

Do you believe there should be any other specialist referral pathways established for the work that you are doing?

We have to follow the evidence base. My key message is that research is vitally important. We have effective treatments that we need to make sure are implemented everywhere, but we also need innovation. We need new developments and new ideas, and we need to robustly evaluate them. Then, if they are effective, we need to be able to spread them out very widely, very rapidly. Of course, there is desperate need for new treatments and new pathways. I am thinking particularly of people who do not respond to the treatment, who have enduring psychosis, schizophrenia and complex needs, who are not well served at the moment. Having that ongoing recovery-focused treatment is absolutely essential. It is the assertive outreach approach, if you like, which has been somewhat lost since it was originally introduced.

Moving on, why do you personally feel it has been such a success?

There are several factors. When it was established, it was a different time. It was in the NHS plan. It was very prescriptive as to what you had to do. Trusts then interpreted the rules slightly differently, but the introduction of the access and waiting times standard in 2016 was transformative. It was clinically meaningful. It was not just time to access care; it actually said it was access to evidence-based treatments. The outcome measures that were recorded were meaningful and evidence-based. It was evidence-based psychological treatments, social treatments and physical healthcare as part of the provision. It made sense to everybody.

I have a final question to you around this area. We had someone from the Royal College of Psychiatrists come to see us, a Dr Lade Smith, and she said that she felt there was an erosion in early intervention psychosis. Do you have any concerns that it could be eroded? Even with all the fantastic work that you have done, could those services be eroded in the future, if we do not guard them, since the sustainability will not be there?

Of course, I am concerned about that. The main issue is the lack of ring-fenced funding that has to go to EIP services. That is not in place. It is human behaviour that people perform against the measures that are recorded, but what is not recorded, and should be, is, for instance, the team make-up. The key predictor of a good experience with an EIP service is having a care co-ordinator and a low ratio of patients to care co-ordinators. The range provided in EIP services at the moment is 1:7 to 1:35. Being more definitive about what a good service looks like would be very helpful.

Going back to both of you, starting with Professor Pilling, I know you cannot tell us as much as I would like you to tell us.

I would, too.

Do you think there are any policy areas that could help support what you are doing, or that need to be looked at or added—with what you cannot tell us, I am feeling very confused here—that we can move forward with?

It would echo quite a bit of what Professor Lennox has just said. In the open dialogue model, we have a clear idea about the central co-ordination of care. Professor Lennox mentioned case management. That link with an individual practitioner who has the time to respond at points of crisis and at other times is essential. Keeping the case limits at a reasonable level is an essential part of that. The other element is effective and continuing training. We have probably trained about 1,500 people in support of the trial. It is a four-week training. It is multidisciplinary and it helps build the shape of the team. A focus on continuing training and professional development is essential. The other one that, again, just came up is about outcomes. We have very good evidence that the robust measurement of routine outcomes—and that means at each contact with an individual—drives change. You see that in the NHS talking therapies programme, where you contrast adult and child programmes. The adult programme had routine outcome measurement; the child programme did not. The improvement in outcomes in the adult programme is startlingly better than in the child programme. Getting that built in is an essential component of it. I work with the National Collaborating Centre for Mental Health. We recently produced a set of recommended outcome measures for secondary care mental health services. Unfortunately, they were not mandated. I would like to see them mandated, saying, “You have to be doing that. You have to report on them and”—crucially—“make those reports public”, so people can see what is happening in the services that you or your family members may be in receipt of. Driving good outcome measurement and good outcome reporting drives positive change. It should be part of what we do.

My first point is that the commitment to research funding as a core part of all NHS business and community mental health services should be established. The mental health investment standard is very welcome, but a mental health research investment standard would be equivalently required. We have the National Institute for Health and Care Research, but maybe a national institute for mental health research could ensure that dedicated funding for the evaluation of new service models and new treatments. My second point is around the mental health estate. I know that point has been made by the Royal College in its submission as well, but we really have a crumbling infrastructure and estate. That feeds into the discussion about stigma. If I am coming to the building where I work, which is the hospital that has been in the longest continuous use in the NHS, since 1816, I do not get the impression of a high-quality, modern mental health service. Our plan is to redevelop that, alongside a new neuroscience centre. Some commitment to modernising the estate would be important.

The early intervention pathway on psychosis is particularly interesting. I may have got this wrong, but you said that you did it without the evidence to say that it might work, because it seemed fairly obvious that it would. Could we do that in other areas? You did say there is a need to have the evidence base before you take this forward. I am thinking particularly of a bipolar pathway, where maybe just doing it and evidencing afterwards would be appropriate.

It is just very difficult to do health services research. As an example, I put forward a proposal and was funded by the NIHR to evaluate an extended time for early intervention services, because they are three years in length, which does not make a lot of sense. What about extending it to five years? The NIHR funded it, but the NHS said it could not provide the funding for that, for instance. There are lots of areas like this. There are risks as well. We have to be rounded in our evaluation. There is a risk of having silos and disorder‑specific pathways that then exclude other people. The big issue for me, as an early psychosis researcher, is people with co-morbidities. There is a large amount of drug misuse. There is a large number of people with autism who get very little service otherwise. Everything is provided by us. There is a lack of evidence as to what we should be doing.

It is just helpful, how it interplays with some of the community-based services that we have seen. It feels like there is not necessarily that ability to data-capture what they do and how that interacts with more NHS, state-provided services. If there was a way to do that, would that be transformative to how community healthcare is delivered?

It absolutely would be. To give you two bits of information, in the part of the world where I work, we have just had social work withdrawn from our community teams to meet section 75 responsibilities. It was absolutely integral, particularly in older people’s services, to the delivery of care and that is now gone. The other one—other people mentioned it earlier—is the impact of wider social factors on people’s health. Simon Wessely was doing a review of the Mental Health Act and we were asked to look at what changes in mental health law might have impacted on the increased use of section 135s or section 2s and 3s. We plotted along the bottom of the graph, on the X axis, things such as Bournewood, the introduction of DoLS and Cheshire West. We also put two other points in, along the X axis, and it was those two other points that led to the increase, the inflection in the curve, which was about a 10% to 15% shift in section 135s, 136s, 2s and 3s. It was nothing to do with mental health law changes. It was the global financial crisis and the beginning of austerity. You are right that the social determinants have a powerful impact. We need to be resourced to address the consequences of them.

Beyond what we have already discussed so far, are there any other areas of research that you believe could be most transformational for improving outcomes and experiences?

Yes, there are lots. We have not explored the use of digital technology. We have not discussed that yet, but the research that some of my colleagues have done is really exciting and shows a lot of potential. Particularly for people with severe mental illness, I want to mention the work of Daniel Freeman, a colleague of mine who has developed a virtual reality intervention for people called gameChange for people with severe anxiety and agoraphobia, who often cannot leave their house and are severely disabled because of that, or people with schizophrenia and psychosis. It has demonstrated a significant improvement with a virtual reality intervention. That is completely outside of the normal level of care provision, but it has exciting potential. We have done a lot of work on delivering psychological therapies using digital means. Again, you have to evaluate that carefully, because it is not for everybody and there are large risks of excluding people who cannot use those technologies. There have been really promising results for childhood anxiety, for instance, showing effective results and reduced clinician time. They are now NICE‑recommended. A very widely used treatment for insomnia, Sleepio, was developed by our academics and demonstrates reduced use of GP time, increased productivity at work and a 76% improvement for everybody who uses that app. These are really novel, different ways of delivering care.

I have been involved in two of those trials. They were excellent. To pick up on another point, this is a bit of a sorry tale but, if you look at the treatment of depression, we have not improved pharmacological and psychological outcomes since, respectively, the 1950s and 1960s. We do not have bigger effect sizes than in the early imipramine trial or the early Rush trial. That is a problem. It is not because we do not deliver effective treatments. We do, but we do not have the added benefit that you have seen, for example, in the treatment of anxiety disorders. The research issue is a challenge to track back down the developmental pathway. The median age of onset in depression is 24. It is a disorder that emerges in late adolescence and early adult life. As a priority, researching both preventive and early interventions, to try to reduce the long-term incidence and impact of depression, is another area where we ought to be putting our efforts. It is the biggest cause of suicide, for example. Early intervention and prevention in depression would be one I would put up there.

Can I mention, then, that the Office for Life Sciences and the NIHR have invested in the translational research collaboration for treatment-resistant depression, with an infrastructure across the UK? It is hosted in Oxford. There are clinics for people with treatment-resistant depression, where you have access to innovative treatments coming down the line. We have done trials of repurposed drugs used in other conditions that we can show are hugely effective. You are right. We really need advances. In terms of new therapeutics being developed by pharmaceutical companies, it has been a bit of a desert for many years, but it is an exciting time. There is renewed interest in neuroscience and in mental health, and conversations, new compounds and genuinely new approaches to treatment are coming down the line. We really need to be ready for that.

Yes, and we need them earlier along the line. That is the point. It is 50% relapse from one episode. You are in the 85% range if you have had three episodes. It is a lifelong disorder and new treatments will help, but it would be nice not to see so many coming through in the first place.

We need to understand the causes, to start with.

Can I just ask one last question? You talked about research and you highlighted the fact that there is not enough research. Can you give us a reason why? Why is that body of research not there? This is not something that is new.

Investment in mental health research is almost entirely funded by the Government. Other areas of medical research have a lot of public contribution. We always compare against cancer, because we are impressed at their amazing ability to raise money. We have about a fifth of the funding going into mental health research. If you take it with the numbers of people affected, 25 times more is spent per person with cancer than it is per person with mental illness. That is the number one point. The second point is the academics. Academic psychiatry is in crisis, and academic psychology similarly, in the UK. There are many medical schools around the country with no academic psychiatrists. The hope for training the next generation is really being lost. It is the numbers of people. The reason for that is that most individuals have traditionally been paid for by the NHS. We have been reliant on the NHS to pay for the research funding and that is a problem.

Can I just add one thing to that? I agree absolutely with what Belinda has said. UCL and Oxford are exceptions. We do rather well. A broader issue is what deters people—whether they are young doctors, clinical psychologists or others—coming in. The national critique about mental health services when things go wrong does not help us in attracting good, bright young researchers into the field. It is a responsibility for us. It is a responsibility for the Government to fund it, but there is a wider public debate about what we say about mental health and how we respond when things go wrong. It does not create the right environment and it would be nice to see it change.

Thank you for your fantastic responses, Professor Pilling, Professor Lennox. The meeting has now come to an end.