Mental health 360

Mental health 360 aims to provide a ‘360-degree’ review of mental health care in England. It focuses on nine core areas, bringing together data available at the time of publication with expert insights to help you understand what is happening in relation to mental health and the wider context.

The nine core areas covered are:

Key messages

• Since 1999, prevalence of mental illness among children and young people has increased. The availability of timely data on prevalence is inadequate to support appropriate planning and delivery of services.

• National policy on mental health has prioritised access, resulting in more services and more people receiving support. However, measures of access across services are limited and there are variations in levels of access depending on the type of service, use of national targets, and local commissioning decisions.

• There has been an increase in the number of children and young people accessing mental health support. However, the NHS is unlikely to meet its current commitments to expand access for children and young people, leaving many unable to access timely support.

• NHS staff satisfaction and patient experience have declined in recent years. Systemic factors, including lack of workforce capacity and poor physical environment, impact negatively on quality of care. However, efforts to improve quality are compounded by poor processes for identifying and responding to issues, and a lack of outcome measures to identify good practice.

• There are an increasing number of adults and older people in hospital, fewer beds, and increases in length of stay, all of which place pressure on inpatient care. Nationally, there has been limited progress on reducing the number of people admitted inappropriately to hospitals outside their local area.

• The mental health workforce has expanded overall, with increases in the number of nurses and psychiatrists. However, expansion has been insufficient to meet demand, and the number of vacancies among NHS mental health providers is higher than for other sectors of the NHS.

• Spending on mental health services has increased and is in line with current policy commitments. However, funding is not keeping pace with demand. Targeted national funding has meant that some areas of care have benefited, while others remain underinvested. Lack of capital investment is a major challenge to improving safety and quality of care.

• There are stark and longstanding inequalities in who is likely to develop a mental illness, as well as in access to care and experiences of care. People with mental health problems are also more likely to experience wider health and social inequalities.

• There is a great deal of data on mental illness and mental health services. However, issues with coverage and quality of data limit its value for being able to plan services and understand what is going on. This directly impacts on the quality and safety of care, and efforts to improve care.

Context 

Less than 50 years ago, most people who received care or treatment for mental illness in England did so in an institutional care setting known as an asylum. In 1974, 100,000 people were housed in mental health institutions, and although people attended outpatient clinics to receive medication, there were few community services. Today, advances in the understanding of mental illness, alongside the development of pharmacological and psychological treatments, mean that most people who access mental health care do so within a community setting.  

Successive policies have led to the development of a range of services: to deliver specific types of treatment (such as NHS Talking Therapies for people with anxiety and depression); to provide evidence-based treatment for people with particular illnesses (such as early intervention in psychosis); and to provide intervention at critical points of need (such as support for people experiencing a mental health crisis in the community). NHS providers and commissioners have also contributed to the current services landscape through locally led decision-making about the types of services that are provided, for whom, and how those services are organised and work together.  

A commitment to achieving parity of esteem between mental and physical health care was enshrined in the Health and Social Care Act 2012. This was followed by the establishment of the Mental Health Taskforce by NHS England in 2015 and led to the Five Year Forward View for Mental Health in 2016. This national strategy focused on improving access to a number of specific community-based services. The subsequent NHS Long Term Plan and associated Mental Health Implementation Plan continued the policy focus on increasing access, targeting support to a number of key pathways. Most notably, though, it sought to enhance support for people with severe mental illness across primary and secondary care and within communities, encompassing and extending the role of the voluntary, community and social enterprise (VCSE) sector.  

The result is that more people than ever are now able to access support for mental health problems. As of November 2023, 1.86 million people (including those referred and those seen) were in contact with NHS-funded secondary mental health services. There were also 162,250 referrals to NHS Talking Therapies. This is partly due to increased investment and a larger overall workforce. However, this investment and expansion in workforce has not covered the full range of services available and has not been at sufficient scale to reflect population need, which means that provision in many areas of care remains far from comprehensive. For example, current plans only go as far as providing support for mental health within schools and colleges to at least 50% of pupils in schools and learners in further education. Although other forms of support may be available, there remains a considerable gap in access. At the same time, issues with quality of care (such as lack of therapeutic care in inpatient settings) have become more prominent, while workforce capacity, as well as the availability of meaningful data, continues to limit progress in improving services. For many people who seek or provide care, the notion of parity is as relevant now as it was when it was first legislated in 2012.  

Understanding mental health care 

In 2019, mental health conditions accounted for 7% of all ill health (as measured by disability-adjusted life years) and were the second leading cause of years lived with disability in the UK. Mental health is as broad in its scope of conditions as physical health. Support for mental health spans preventive activities that enhance and protect mental wellbeing, as well as the diagnosis and treatment of mental disorders and neurodevelopmental conditions. It also includes ongoing support for people living with mental illness, and their families or carers.  

Mental health services are structured into three tiers. Primary care services are provided at a population level. They include mental health support in general practice, NHS Talking Therapies and Mental Health Support Teams (MHSTs) in schools and colleges, as well as enhanced support and treatment for people with severe mental illness who no longer require active intervention by specialist mental health services. Each service provides a range of support, as well as being a route for referral into more specialist services.  

Secondary care services provide assessment and treatment for people experiencing mental illness. They comprise a series of community-based services, including teams that provide treatment and support for people in the community, and specialist teams that provide treatment and support for people with specific mental health conditions, people who require rehabilitation support for mental illness, people with complex and ongoing needs, and people experiencing a mental health crisis. Specialist liaison services are also provided for people with mental illness in acute hospitals, including people attending accident and emergency (A&E) departments, and those who have been admitted for the treatment of physical health problems. Secondary care services also provide care for those who need admission to hospital for mental health needs. This includes acute inpatient and psychiatric intensive care, and rehabilitation support.  

Finally, tertiary services provide specialist care that has traditionally been provided at a regional or national level. This includes inpatient care for people in need of mental health treatment who have been convicted of a criminal offence, children and young people, people with an eating disorder, and people experiencing perinatal mental illness.  

This support is provided by a range of organisations and settings. Most treatment services are commissioned and provided by the NHS, although services are also commissioned from the independent sector – notably specialist inpatient care, and VCSE organisations. Local authorities have statutory duties for commissioning support for people with drug and alcohol problems, and the provision of social care support for people with mental health problems. The latter largely comprises mental health social workers, including approved mental health practitioners, who play a key role in applying the Mental Health Act, and providing aftercare in the community under Section 117 of the Mental Health Act. Both local authority and NHS commissioners are responsible for commissioning a wide range of mental health support from VCSE providers.  

Areas covered by Mental health 360 

Mental health 360 is not exhaustive in its content. It aims to provide an understanding of key issues alongside specific areas of practice, including adult inpatient care, and children and young people’s mental health services. The content of Mental health 360 is partly led by the availability of data. In addition, The King’s Fund conducted a review of inspection reports published by the Care Quality Commission (CQC) in 2022 for services provided by NHS mental health trusts that were rated as requiring improvement or inadequate. Data was extracted from reports and analysed to identify common themes that contributed to issues around quality of care. This report draws on that analysis and includes illustrative quotes from CQC reports.   

For these purposes, Mental health 360 focuses on the services involved in providing assessment and treatment for people with mental illness, rather than those that may provide wider support (such as activities that contribute to the wellbeing and quality of life of people experiencing mental health problems, and their carers). This report focuses on services for people with mental illness, rather than neurodevelopmental conditions such as learning disabilities, as those are areas with unique considerations and issues. The exception is where those are illustrative of a wider issue.  

Mental health 360 does not provide detailed insights into services provided by the independent sector or VCSE organisations. This may change in future years as efforts to capture the provision of mental health support in other settings are reflected within national datasets.