Patients and GPs are all too familiar with the difficulty of accessing timely and effective NHS support for complex mental health needs. Patients being ‘bounced’ between services who state that an individual is either too complex, not complex enough, or somehow otherwise fails to meet service specifications is a daily reality. This editorial outlines the treatment gap and proposes solutions, based on our collective professional (psychologist, psychiatrist, psychological wellbeing practitioner, GP, charity worker) and lived experience of mental health.
Characterising the gap
Gaps in mental health provision result from how services are currently commissioned. In 2008, access to evidence-based psychological therapies for common mental health problems (mild to moderate depression and anxiety) was transformed in primary care through ambitious national commissioning of the Improving Access to Psychological Therapies (IAPT) services, now known as NHS Talking Therapies (NHS-TT).1 In secondary care, Community Mental Health Teams (CMHTs) are commissioned to provide support for people with severe and enduring mental illness ([SMI]: psychosis, bipolar disorder, and the most severe ‘personality’ and eating disorders) presenting with high risk to self or others.
Commissioning models in mental health provision leave a significant ‘missing middle’ who have needs between NHS-TT and CMHTs: those who remain unwell after receiving NHS-TT input; those eligible for CMHT input but not accepted due to lack of resource; those out of remit for both NHS-TT and CMHT input; and those discharged from CMHTs as no longer deemed high risk but with ongoing needs. As well as more complex common mental health problems and less severe SMI, the ‘missing middle’ also includes patients with grief, anger, self-harm, co-occurring substance abuse, complex PTSD, and conditions linked to neurodiversity.
The ‘missing middle’ can greatly benefit from tailored and timely psychological, social, and medical support in primary care, but they are not able to access it. This service gap puts people at risk; restricts opportunity to reach their full potential in life; places significant burden on friends, families, employers, and broader support networks; and contributes to intergenerational transmission of distress. Failure to address these needs is financially costly, resulting from lost productivity (including employment), costs incurred by informal carers, increased use of other NHS resources less suited to their needs (for example, GP appointments or accident and emergency services), and greater use of highly specialist (including inpatient) mental health services if mental health deteriorates further.2
GPs can be left ‘holding the baby’, facing the moral hazard of coordinating care that does not align to best practice nor ‘missing middle’ patient need. They have limited referral or treatment options (other than psychotropic medication), are uncertain if CMHT referrals will be accepted (given eligibility criteria fluctuate based on service capacity), and can be left managing patients on complex polypharmacy after secondary care discharge without specialist backup.
Estimating the need for services
To enable robust workforce planning and to reduce postcode lotteries of care, it is necessary to understand the number of people requiring services. Approximately 6.5 million working age adults experience common mental health problems each year in England,3 with NHS-TT aiming to reach 25% of this population. Assuming NHS-TT meets 50% recovery targets, 812 500 individuals each year have potential ongoing support needs. Worryingly, CMHTs have rarely been commissioned on prevalence and incidence, but similar data are available. Combining Global Burden of Disease Study 20194 estimates of schizophrenia, bipolar disorder, and anorexia nervosa prevalence with Royal College of Psychiatry figures on personality disorder prevalence,5 we estimate approximately 1.3 million adults in England with SMI could benefit from CMHT input. However, according to the NHS Benchmarking Network,6 only 562 361 were on CMHT caseloads in 2023. The remainder (771 099) have potentially unmet support needs. Assuming 25% of the 2.2 million individuals with less severe personality disorders5 require input each year, a further 550 000 individuals have unmet need. This means a reasonable estimate of the ‘missing middle’ is 2 133 599 people in England. Similar basic modelling could be utilised at Integrated Care Board level to plan local service delivery.
Blueprint for closing the gap
Below we outline a model of care to better meet the needs of the ‘missing middle’, aligned to the principles of the community mental health transformation framework (see Box 1 for a summary).7 These proposals would require significant national investment, however they are potentially offset by reducing use of broader health and social care services, and ultimately may be cost-saving. A prudent first step could be local pilots in diverse parts of the country (akin to the initial IAPT pilot), establishing clear continuation criteria to meet before scaling up.
| NHS Talking Therapies clinicians to be routinely trained to tailor care for patients with features of complexity. GPs and practice nurses to have better access to mental health training to adapt their practice. |
| National commissioning of gap psychological therapies services for clients with more complex mental health presentations, underpinned by evidence-based principles and delivering NICE recommended psychological therapies. These services must be configured to enable novel treatment innovation and evaluation. |
| Integrated provision of psychologically informed support from the voluntary, community, and enterprise sector (VCSE), including recovery workers signposting to social prescribing opportunities to support community reintegration. |
| Provision of liaison psychiatry to facilitate diagnostic assessment, medication review, and risk management, thereby supporting gap and primary care services to contain complex referrals. |
| Services need to be validating, stable, create a sense of safety and predictability, and allow the person agency in their care. |
Box 1. Proposed model of care
First, while it is important that NHS-TT retains its core brief supporting patients with mild to moderate anxiety and depression, patients with features of complexity who are eligible for NHS-TT support (for example, subthreshold personality disorders8) would likely benefit from enhanced treatment outcomes if NHS-TT clinicians were routinely trained to tailor care for these patients. GPs and practice nurses should also have better access to mental health training to adapt their practice.9
Second, national commissioning of gap psychological therapies services for clients with more complex mental health presentations, underpinned by evidence-based principles and delivering NICE recommended psychological therapies, is recommended. Given a less well-developed evidence base for complex mental health presentations (relative to the initial implementation of IAPT), these services must be configured to enable novel treatment innovation and evaluation.
Third, integrated provision of psychologically informed support from the voluntary, community and enterprise sector (VCSE) is needed (for example, social prescribing from recovery workers facilitating community reintegration).
Fourth, provision of liaison psychiatry to facilitate diagnostic assessment, medication review, and risk management is necessary to safely contain complexity and risk, allowing gap services to be open to complex referrals.
There are some good examples of gap provision, although there is insufficient funding at present to scale them up to meet population need in any locality and there is significant variation in the implementation of such services nationally. For example, the Inclusion Thurrock gap service in Essex offers a range of evidence-based psychological therapies.10 The AccEPT clinic in Exeter (https://www.exeter.ac.uk/research/mooddisorders/acceptclinic/) innovates and evaluates novel gap psychological therapies. The Devon Mental Health Alliance (https://www.mentalhealthdevon.co.uk/) illustrates coordinated commissioning of VCSE support.
As important as what is delivered is the way in which it is delivered. Complex mental health is frequently linked to deprivation, minority group status and early trauma, where people were invalidated (their emotional needs not understood or accepted), their environment was chaotic, and they felt unsafe and/or powerless. Patients, and the professionals supporting them, benefit from a containing system that acts as an antidote to these experiences. Services need to be validating, stable, create a sense of safety and predictability and allow the person agency in their care.
Optimal implementation of these recommendations requires partnership working between services, including multiagency team meetings, coordinated access to electronic records, and transparent service specifications that remain consistent irrespective of fluctuating demands. Reflecting the chronic, fluctuating course of many complex presentations, patients will likely benefit from accessing different services at different times. To ensure continuity of care, there needs to be system memory of the patient to provide a joined-up patient journey.
Such provision would represent stepwise improvement in ‘missing middle’ care and reduce broader system burden (including GPs). We implore future politicians and NHS commissioners to acknowledge the scale of the mental health treatment gap and take action to implement the required national level of ambitious, transformative investment to solve it.
Notes
Funding
Laura Warbrick, Barney Dunn and Amy Burnham’s time on this project was supported by the depression stream of the Mental Health Mission (funded by
the Office of Life Science and delivered through the National Institute for Health and Care Research [NIHR] Mental Health Translational Research Collaboration [MH-TRC]; https://www.gov.uk/government/publications/life-sciences-vision-missions/mental-health-mission). The views expressed here are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Provenance
Commissioned; not externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2024
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