Take action to support better outcomes for people with severe mental illness
There are half a million adults in England living with a severe mental illness (SMI). This figure is likely to be underestimate of actual figures as these numbers are based only on those registered with a GP[i]. People living with a severe mental illness face great inequalities in healthcare with a life expectancy 15-20 years lower than the general population[ii]. Up to 90% of those who complete suicide could have a diagnosable mental illness[iii] though not all have been in contact with mental health services there is clearly much more to be done to ensure greater access for those in need to timely, evidence-based support.
The 2018 National Confidential Inquiry reports that 28% of all suicides were in people who had contact with mental health services in the 12 months prior to death.
Research[iv] shows that the risk of suicide is higher during the period immediately following discharge from in-patient psychiatric care than at any other time in a service user's life. Epidemiological studies suggest that factors related to service organisation and delivery (e.g. social support and continuity of care) are important in the aetiology of suicide following hospital discharge and therefor particular focus should be paid to properly supporting people when they leave inpatient settings.
People from minority ethnic backgrounds experience further disadvantage. For example, black people are more likely to be detained under the Mental Health Act and have lower rates of recovery.
Black people with SMI are more likely than other groups to come into contact with secondary care services through non-health agencies, in particular, the police. Adverse experiences of hospital mental health services among minority ethnic groups continue to be a cause of concern. These issues can lead to a mistrust of services and delays in seeking care. It is vital to work with local black communities, service users, carers and staff to ensure appropriate prevention, access and support services. Black Thrive, as referenced in the example below, was created following the Lambeth Black Health and Wellbeing Commission which co-produced mental health prevention, access to appropriate services and patient experience improvements in this way.
Top tips from Dr Geraldine Strathdee, CBE, co-founder of the Zero Suicide Alliance
- Early intervention and support for people experiencing mental health symptoms is imperative. When a person is developing mental ill health, they should be able to access information, advice and peer support including from digital services. This is vital throughout the life-course and at pivotal moments in life which can raise risks and in various specialties: perinatal, children and young people, parents, workers and employers and for older people. Support around prevention and early intervention of physical illnesses tends to be more advanced at this than with mental illness. This information should be co-produced with communities to ensure it is appropriate for your population. If your JSNA identifies a large Black Caribbean population with disproportionate levels of SMI, for example, make sure you work with that community to create the right communication and support.
- When people first ask for help from the NHS, they should be able to access an assessment by trained people in primary care, in emergency departments and 24/7community crisis services and from long term condition outpatient clinics and community services.
- Once initially diagnosed with potential mental ill health the patient should be referred to the evidence based early intervention services for example Early Intervention Psychosis, Freed ( first episode eating disorders ), perinatal service, alcohol, drugs, depression and seen within Long Term Plan standard times.
- The treatments they access should be in line with the best evidence for effectiveness that deliver to people the social and mental and physical health clinical outcomes and enable them to have high quality lives and where possible, paid quality employment, decent housing and relationships.
- All NHS patient journeys/plans should be co-produced with the patient themselves, with the focus on supporting them to achieve the outcomes they want to help them lead fulfilled lives.
- Staff should be trained and supported to see every contact with patients as an opportunity to show kindness and compassion, instil hope and optimism for positive outcomes and help support education and relapse prevention.
- Pathways into, through and out of services should be mapped with local partners and communities so that at every stage, the most effective intervention is developed. For example, at South London and the Maudsley NHS Trust, where I am a Governor, we have a rehabilitation service partnership with the voluntary sector to provide high quality step-down rehab accommodation and with others to provide employment training and jobs. First Step Trust, has a number of garages and restaurant, where they train and employ people with SMI producing amazing support and results with patients at high risk of relapse and readmission.
Action for Local Authorities and the NHS
1. Deepen integration of local authority and health services to provide holistic support
Too often people with SMI are moved around the health, social care, emergency housing and criminal justice systems without a joined-up approach to address the conditions that have led to, or exacerbated, mental health distress.
People with SMI often have housing, financial, social, substance misuse and other challenges as well as clinical needs and without supporting individuals to address these challenges successful treatment and recovery is much less likely.
Alliance contracts, like the Lambeth Living Well Network Alliance set out in the case study below, bring together social care, housing and mental health service users, commissioners and providers to pool expertise and budgets to support all of an individual with SMI’s needs rather than each bit of the system trying to manage symptoms in isolation.
Another example of a holistic approach is the Big Lottery funded Fulfilling Lives programme, supporting people who are experiencing multiple disadvantage including serious mental illness in 12 areas across England to test new ways of ensuring individuals receive joined up and person centred services which work for them.
After a year on the programme people have improved self-reliance and independence and are engaging better with services. Progress is made with emotional and mental health, managing accommodation and building relationships. There is a reduction in the number of people who are homeless and the number who are rough sleeping. People are also less likely to use crisis services, such as A&E, and to be involved in the criminal justice system. A fulfilled life is more than just addressing basic needs such as accommodation. Over time, Fulfilling Lives beneficiaries are also increasing participation in positive social, cultural and wellbeing activities. And more people are beginning to give something back through volunteering.
The Collaborative is a group of commissioners and providers of mental health, housing and social care services, people who have lived experience of mental health issues and carers. Their goal is to improve the mental health and wellbeing of people in Lambeth by working together.
The Collaborative was established in June 2010, bringing together a ‘good enough’ group of key stakeholders and aiming to open up a conversation about mental health involving everyone across the system in Lambeth, from those commissioning and providing support to those accessing support, to bring about change. One of the fundamental principles was that each person’s perspective and contribution was as valuable as the next and this has been vital in promoting vibrant discussion and forging new ideas and approaches.
Since it was established, the Collaborative has been committed to co-production as the framework for how it works together.
It was also the driving force behind two of Lambeth’s major system-wide transformations: the Living Well Network and the Integrated Personalised Support Alliance (IPSA). The IPSA created an alliance contract to support the 200 most frequent users of acute mental health services with more joined up social, clinical and housing support. In doing so it reduced acute admissions in this cohort by up to 60%. This led to the establishment of the Living Well Network Alliance (the Alliance), which has brought almost all of the funding for Lambeth’s adult mental health services under a single contract, with a shared set of outcomes. The Alliance seeks to support better outcomes for residents with SMI by addressing their needs holistically. Service users can get housing support from Alliance provider Thames Reach, social care from Lambeth Council, clinical support from South London and the Maudsley NHS Trust as well as training and social support at the Mosaic Clubhouse which also houses a non-clinical Evening Sanctuary for those in crisis seven-nights a week. This effort is supported by the Black Thrive partnership which works to ensure that support is appropriate for Lambeth’s Black African and Caribbean residents who are disproportionately over-represented among people in acute mental health settings.