The opportunity of a generation

blog | Words Nick Webb | 18 May 2020

The most vulnerable and disadvantaged are likely to struggle the most with the social and economic effects of the Covid-19 crisis. This includes people with pre-existing mental health conditions (who are likely to have physical health problems too), people living on inadequate welfare benefits, victims of domestic violence, overcrowded families, and people who are already beset by loneliness. Evidence from around the world shows that crisis brings more misery to more people in these situations.

The question for mental health policy makers is: what kind of system has the best chance of supporting people to live the best lives they possibly can, at a time when the state’s finances and ability to help are at their lowest for a generation? Exhausted by the war effort, where are the seeds of renewal and hope?

Seismic shifts already underway

In the NHS, radical changes have already been pushed through in a matter of weeks. Anxiety about public health and the impact on the NHS has elbowed out long-held policy and practice:

• Diverting access to mental health support away from hospitals
• Restricting access – tightening still further the number of people eligible for secondary care, including stopping informal or voluntary admissions
• Creating single points of access via phone lines – with a direct route into support from the voluntary and community sector
• Closing mental health wards
• Creating physically separate mental health A&E departments
• Merging CMHTs
• Delivering specialist clinical care and support virtually or in people’s homes

These and other changes could last a generation. Some NHS leaders and managers will not want to reopen closed wards, disconnect Single Point of Access phone lines, or cancel virtual appointments.

The NHS Framework – right time, right place

Some commentators, including campaigning mental health charities, may resist some of these changes, including the closure of hospital wards, and the resulting loss of beds.

But the NHS response to the crisis opens up a set of radical possibilities for improving patient outcomes, as well as making space to ask hard questions about the efficacy of traditional models.

We have an unforeseen but enticing opportunity to take insights, learning and new practices from the current crisis, and weave them into the development of new community models described by the Community Mental Health Framework.

The Framework outlines how the Long Term Plan’s vision for a place-based community mental health model can be realised, and how community services should modernise to offer accessible, whole-person, whole-population health approaches, aligned with the new Primary Care Networks. Published before the crisis (in September 2019), it aims to break down boundaries between mental and physical health, between primary and secondary health care, between health and social care, and between the statutory sector and voluntary and community sector.

The Framework guides the creation of new ‘front doors’ to local mental health systems – a single point of access for risk assessing, triaging and delivery of holistic, person-centred care that draws on the best clinical, social and community support.

People will be able to access person-centred help and support where and when it is needed, without relying on a system of tiers, waiting lists, referrals, hand offs, eligibility criteria, thresholds and repeated assessments.

Fundamentally, it puts the community back into community mental health. It recognises the contributory role that people’s strengths, social networks and wider community assets play in good mental health. People will be supported by multi-disciplinary teams and wider networks of voluntary organisations to co-produce their care plans and contribute to, and participate in, their own communities.

This kind of model is already being developed in Tameside & Glossop, Salford, Edinburgh and Luton – four places that are part of the Living Well UK programme funded by the National Lottery. You can learn more about their work here.

From disruption to redesign and renewal

For mental health practitioners, novel practice, experimentation and risk taking have become key features of life. They’ve had to – repeated cycles of social distancing is making it more difficult for community nurses, care coordinators, psychiatrists, psychotherapists and care workers to follow established protocols for care and risk management. For system leaders, crisis response is already giving way to recovery planning.

Disruptive moments like this can help shine a light on what is working and what is not, on what we want to stop, retain, change and grow.

New community models as described by the Framework are the strategically important place to focus local efforts on recovery and renewal, on radical system redesign for a post-Covid world. They are the perfect place to explore and design new ways to:

• Enhance the role of communities in supporting more people close to home, including those who might not actually require support from secondary care/hospital care
• Overcome fragmentation and redesign systems around the person
• Embed risk assessment, prioritisation and triage within community based multidisciplinary teams
• Respond more effectively to the intersectionality of social, economic and cultural determinants of health (including financial stress, poor housing and unemployment)
• Amplify and sustain the countless examples of care, compassion and kindness we’ve seen in the last two months and build humanity into new systems
• Invigorate a new public mental health narrative around the importance of mentally healthy communities of mutual concern and mutual aid – with local authorities playing a key role
• Expand and rethink the role of the voluntary and community sector, including in ‘holding’ higher risk patients, and enable it to build effective partnerships as community connectors, social network builders and market shapers
• Embrace technology as an integral part of service delivery (not just an ‘add on’), for example in finding creative ways of overcoming isolation and loneliness, or in enabling OTs, senior clinicians and peer workers to deliver virtual support fantastically well?
• Help to rebuild the social fabric and community resilience that has been undermined first by austerity and now by Covid 19.

Innovation Unit is supporting more places in England to learn from the Living Well UK programme as they plan to deliver the new Framework.

We are researching the big shifts taking place in mental health and will soon publish our findings. If you are interested in learning from our work, please get in touch via nick.webb@innovationunit.org.