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Service transformation: Lessons from mental health

Mental health services have undergone radical transformation in the past 30 years. A community-based care model has largely replaced the acute and long-term care provided in large institutions.

Similar change – from hospital to community-based alternatives – is a long-standing policy objective for physical health care in the United Kingdom. How far the two can be compared has been remarkably under-explored. This paper seeks to correct this by examining the transformation of mental health services in England and the relevance to current policy. Drawing on workshops with those involved in the changes and a review of published literature, the paper explores the context and factors that enabled change to happen in mental health. It includes 10 lessons for service transformation based on these experiences.

Key findings

  • Transformation of mental health services was not an easy, consistent or linear process. The research and workshops pointed to a combination of factors playing a key role in overcoming resistance and driving transformation.

  • There was no single driver of change. Key drivers included an increasing optimism about the ability to treat, rather than contain, people with acute and chronic mental health conditions, coupled with a belief that long-term institutional care had detrimental effects.

  • Social movements and practitioners became increasingly vocal in criticising the care in institutions, exerting pressure for change.

  • There were innovations in service delivery (eg, needs-based care models, user-led and recovery-orientated community services) underpinned by the principle of case management.

  • Specific financial models enabled change (eg, double-running costs, ‘dowry’ systems, joint finance initiatives), as did changes in management culture – from a team approach at community level to wider organisational influence among chief executives.


  • Moving the location of care without redesigning is not enough – existing services and institutionalised approaches should not simply be replicated in new settings.

  • High-quality, stable leadership is needed to manage change, handle unexpected demands and results, and ensure vertical integration of expertise, both within the organisation and among voluntary and independent providers.

  • Greater understanding is needed of professional resistance to change; of GPs’ potential in community-based solutions; of the benefits of co-ordination with other organisations.

  • Choice of particular care models should be driven by local need, and supported by national mechanisms/policies.

  • Care pathways should not become overly complex. Services should be developed for each stage of the pathway.