Mapping the Gap

Our mapping of gaps in services builds on discussions that took place with local service leads in the South West in the middle of 2025. The aim of these discussions was to find out which people could be described as ‘falling into the gap’ between primary and secondary care services. We have summarised the results of these discussions by service area. This mapping exercise is designed to help raise the profile of services that already exist, so that further links between services can be made, encouraging more opportunities for learning and support.

The mapping exercise was focussed on the following areas:

Identifying the group(s) of people that services incorporate into their gap services
What services are these people offered currently
Whether there were any emerging gaps and any potential developments
What data is being collected by services
To what extent the overall mental health system seems to be balanced in meeting the needs of the local people
Any potential areas of interest in research or evaluation that local systems may have

It is not an exhaustive list of services, but rather a summary of those identified in the discussions, and as a result there are bound to be important services that we have missed out. It is likely that as time goes on, new services will emerge, and changes will be made to existing services.

Please contact Alex.Stirzaker@Plymouth.ac.uk if you know of additional services that could be added to the map.

Image source: NHS England

Bath and North East Somerset, Swindon and Wiltshire (BSW) ICB Area

What is viewed as the gap?

People with complex emotional needs and people with neurodiversity.

What is currently offered in the Gap?

There is a well-established offer for those with Complex Emotional Needs (CEN) in all 3 localities in BSW. This provides an evidence-based model linked the Dialectical Behaviour Therapy (DBT) pathway.
80% of people referred to the primary care service are either diagnosed with or have a queried diagnosis of neurodiversity. All staff are trained in working with people with ASD or ADHD. Individualised approaches which take into account neurodiversity have been developed with secondary care services.
There are links to Primary care liaison services from the CEN service and CAPs offer brief interventions in 3 of the 4 PCLS teams.
Second step and Elaborate VCSE services work alongside the primary care liaison services. Peer support and support groups are offered.
Nelson Trust and Turning Point offer support to drug and alcohol users, but this is limited.
Some work with families and carers exists, but it is limited to connections for carers in Wiltshire for people with psychosis.
There is a developing service for people with Complex PTSD which offers assessments and brief interventions in a group setting. 1:1 interventions are being developed.
The Sexual assault and referral service (SARS) is outsourced and not joined up with the services, which makes joined up provision challenging.

Further emerging gaps

At Risk Mental State (ARMS) work is absent in early intervention services.
No assertive engagement exists for people with multiple complex needs, i.e. people in and out of prison or those with housing difficulties, who tend to disengage from services.

Data collection

Outcome measures are routinely collected, but not routinely analysed.
Assessment deep dives are routinely conducted with reflective practice being operationalised in referral meetings, to inform service development.
Qualitative feedback is collected in CEN services.

System Balance

In-patient services are expensive and ineffective. There is a gap in stepping up and down in services which makes flow through the system difficult, affecting the throughput in services.
Limited preventative work is on offer and social services provision is limited. More generically community provision is poor and VCSE provision is poorly resourced.

Potential research interests

Looking at health economics to interrogate costs of emergency provision against current delivery of newer interventions, to enable efficiency to be clearly articulated.
Analysis of data collected on outcomes.

Bristol, North Somerset and South Gloucester (BNSSG) ICB Area

What is viewed as the gap?

In the BNSSG ICB Area there are an estimated 12,000 people with personality difficulties.

What is currently offered in the gap?

The Complex Emotional Needs (CEN) service was established 10 years ago from out of area placement funding in North Somerset and sits within Secondary care. It consists of a team of senior practitioners with Clinical Associate Psychologists and Health Care Practitioners, along with 4 peer support workers. The service offers co-produced interventions. A Structured Clinical Management in-house training programme exists and is given to secondary care staff in recovery teams. Complex case support is offered to teams.
Mentalisation Based Therapy and Dialectical Behaviour Therapy services are available, but not consistently across the whole of the ICB. This means that in some areas there is a lighter touch to interventions with problem solving groups. It is not unusual for people have been given multiple diagnoses including trauma and these people are considered, however, treatment for Post Traumatic Stress Disorder sits within psychology services. Consultation is offered to primary care services and police and other external agencies as appropriate.
In primary care there is a co-produced offer for people with mild to moderate emerging Personality Difficulties under Sequoia and Rethink. Interventions offered are a DBT informed 14 week group, a peer-led 12 week support group, and a psycho-education group for 6-8 weeks focussing on complex emotional needs.

Sequoia is accessed by professional referral. Once triaged and accepted, Sequoia reaches out to the person and asks them to book an appointment. If the person does not book an appointment, they are discharged, and they keep the ability to re-access Sequoia via self-referral for three months.

Welcome sessions are offered, in which information on Complex Emotional Needs/Personality Disorder (CEN/PD) and Sequoia’s offer is shared. If the person wants to access a service, they have a 1-1session. If a person does not attend, they are contacted and their referral is left open for a period of time during which they are welcome to make contact. Volunteers provide support with welcome sessions and, in the future, volunteers are planned to be the main participants in delivering these sessions After receiving the intervention from Sequoia, consolidation periods of 3-6 months are suggested before the person can return to services.

Peer connection groups offer longer term support. People with drug and alcohol difficulties are are considered for support, and employment support can be offered too.
Local Primary Care liaison services support the work of Sequoia by holding people during transitions into the service, to promote a seamless transfer into Sequoia should this be necessary .
Safe Havens, run by Second Step, offers face to face and telephone support which can be accessed quickly via self-referral. They have a base in both Bristol and North Somerset where people are seen in the evenings. This offer is open to others outside the Gap too.

Further emerging gaps

People transitioning from child and adolescent mental health services (CAMHS) could benefit from assertive engagement and a flexible approach to enable more effective and timely interventions.
Early intervention services offering at risk mental state (ARMS) work is missing from services. Potential developments could include a peer support offer for this particular age group (18-25 year olds).
There is limited provision for frequent attenders at the 136 suite and support at this site would be useful.
Secondary care Mentalization Based Therapy is missing in North Somerset.
Knowledge and Understanding Framework (KUF) awareness training previously offered to third sector partners is now absent and there is a need for further training on interventions to support the developing workforce.
Although Sequioa intitally planned to offer self-referral, this is not being initiated due to a lack of resources.
There is a large gap in delivery concerning work with families and carers.

Data Collection

Routine outcome measures are collected, but not analysed regularly.

System Balance

Information systems inhibit the work in the gap. Access to information across all part of the system is challenging. The CAMHS directorate is separate from the adult provision, so working together is harder.
Exclusion criteria in Talking Therapies and rigid operating policies mean that some people who might benefit from this resource are excluded.
Limited preventative work is taking place in the system and GPs do not appear to be accessing services early on.

Potential research interest

BNSSG is keen to consider how to change language and the impact this has on delivery to promote changes to the way teams deliver their offer. Changing working cultures away from care co-ordination towards key workers and safety plans is to be considered.
To analyse the collected outcome data and link it to health economics would be a useful exercise, alongside evaluation of the effectiveness of the SCM programme and peer led interventions.

Cornwall and Isles of Scilly ICB Area

What is viewed as the gap?

People with complex emotional difficulties, people will with neurodiversity, i.e. ADHD, and people with an eating difficulty not severe enough for specialist eating disorder services.

What is currently offered in the gap?

Mental Health access and brief intervention teams are staffed with mental health and wellbeing practitioners (MHWPs), offering CBT informed brief interventions at the front door.
A talking therapies service is expanding its offer (staying close to remit in line with NHSE guidelines).
Step up and step-down model between primary and secondary care provision is operationalised with trusted transfer between CMHTs to MHWPs.
Emotional coping skills groups, and 1:1/group trauma informed stabilisation work is delivered by Clinical Associate Psychologists (CAPs) alongside RMNs (in some PCNs) supervised by DBT therapists.
VCSE services sit in the single point of access service and offer support for 6 sessions at front door.
Peer support workers, employed under a subcontract arrangement to the VCSE.

Further emerging gaps

Transition group from CAMHs to adult services is needed
There is a group of people in the gap who end up in inpatient or crisis facilities where staff are not always trained to meet their needs, therefore more experienced providers are needed.
There is a need to develop links to emergency departments to work with people with physical health needs alongside mental health (i.e eating difficulties).
Social care is absent, so housing is a significant problem, i.e. moving people out of inpatient services.
Offering support to families and carers is challenging in Cornwall due to stigma and working within a small community.

Potential plans for development

More CBT provision in secondary care training is planned.
SCM being offered in some PCNs.
Primary care mental health practitioners are working in GP surgeries to create a consistent approach to working with people with complex emotional difficulties and they triage referrals to the SCM offer. Developments could extend this offer.
Systemic work is offered in Early Intervention for Psychosis services , but not in CMHTs. A robust Family intervention in psychosis training programme is planned.

Data collection

Outcome measures focussed on Talking Therapies.
CMH services now focused on the collection of Dialog, GBO and REQOL.
Systems cannot yet pull reports to give information on clinical sessions.

System balance

There is a need to target young people in schools and colleges.
Focus on prevention with fishermen, farmers, travellers, BAME community and international nurses.
Overall developing a more normalising approach to mental health in communities.

Potential areas of interest

Evaluation of the role of MHWP to understand their effectiveness and the impact they may be having on the mental health delivery culture.
Understanding what works over and above assessments and awareness raising amongst staff.
Neurodiverse groups.

Dorset ICB Area

What is viewed as the gap?

People with complex emotional needs who cannot access secondary care psychological therapies, or who are not able to access talking therapies, and often present with emotionally unstable personality disorders, and complex PTSD.

What is currently offered in the gap?

The Flourish service is offered in a primary care setting, with secondary care support. Referrals are received from mental health practitioners employed within primary care networks / GP surgeries. Flourish offers a trauma informed pathway supported by well-being coordinators who co-ordinate access to and support engagement to the flourish programme.
Support for PTSD stabilisation is available by attending webinar based courses with the intensive psychological therapy service before one -to-one treatment for complex PTSD is made available by the Flourish service. This offers an average of 26 sessions for people with PTSD or complex PTSD.
Peer support is offered at 3 stages with Flourish, at initial engagement, during treatment and especially at discharge from therapy, and is helpful with the neuro diverse group
Access to well-being is offered by Mind, with support for housing and finance, etc, across Dorset. Other VCSE services commissioned locally by the council are available, but can feel fragmented. Neighbourhood team development adds another layer of support for those with physical and mental health needs.
The Safeguarding Families Together (SFT) programme is commissioned by Dorset council to provide a wrap-around offer for parents who are in danger of losing their children into the care system. It includes mental health support and substance misuse support, with further support being offered for domestic abuse and from the probation service. Group supervision is included to support workers involved with these families. The service has been active for two years and is currently commissioned until March 2026. Findings suggest that engagement is better with these families, with fewer dropouts being apparent. Motivational interviewing focused on engagement and trust development is the main focus of the service, and appears to be helpful.
Recovery colleges have been set up and align with the community mental health trust’s teams to provide useful courses for those in the gap.

Further emerging gaps

GP surgeries without mental health practitioners do not have access to the Flourish offer.
Those with drug and alcohol difficulties are underresourced.
People with neurodiversity and PTSD are not well served.
Interventions that promote change are not always made available to those with stable psychosis, who could benefit from them.
A dissociative identity disorder group in secondary care could be useful.
Potential plans for development include the alignment of the Flourish project to adult psychology, which would help with reporting processes and increase support.
The complex trauma pathway remains in development. Access to Adult Psychology Services is made through the CMHT and could be more streamlined.
A ‘thriving together’ complex multidisciplinary team is in development to support those in services with more complicated needs. The team allows further discussion and support agreed by those present and enables the service user to access the right treatment with the right service at the right time.

Data collected

Data currently collected take the form of it ITQ, PCL 5, dialog, REQOL, and a patient feedback questionnaire.

System Balance

Balance within the system is fragmented with limited focus on prevention strategies, and commissioning remains inconsistent across the county.

Livewell Devon Area

What is viewed as the gap?

People with complex post-traumatic stress disorder (PTSD).
People with complex emotional needs.
People with obsessional compulsive disorder (OCD).
People presenting with disordered eating.

What is currently offered in the gap?

A stabilisation group is offered for those with complex PTSD.
A dialectical behaviour therapy (DBT) pathway responds to the needs of people at risk of self harm/self injury.
A mentalization based therapy (MBT) pathway is available for young people 18 to 25.
Psychoeducation groups are offered in primary care, focusing on the development of emotional skills. These groups link to the DBT personality disorder pathway.

Emerging gaps

A potential gap exists between the psychotherapy team in Livewell, community mental health provision and the new gap provision. Potential plans for development include an adult MBT pathway for those with relational difficulties.

Devon Partnership Trust Area

What is viewed as the gap?

People with complex emotional needs.
People with childhood trauma.
People at risk of self-harm.
Drug and alcohol users.
People with atypical eating disorders.
People with stable severe mental illness (SMI).
People who do not recover after receiving the talking therapies offer.

What is currently offered in the gap?

There is limited access to therapies for this group. The current offer consists of psychotherapy and clinical psychology trainees who offer therapies such as cognitive analytic therapy (CAT) when trainees are available, though availability is inconsistent.
Devon Mental Health Alliance employ recovery workers who offer short term interventions to support the gap group with wrap around care. Peer support is also available with the triangle of care offers of treatment to carers alongside psychoeducation. The mental health alliance includes 6 organisations from the third sector that support this group.

Emerging gaps

People with stable psychosis who could benefit from interventions promoting change are not well served, alongside those with medium levels of complexity,
Discussions have taken place regarding the expansion of talking therapies provision to provide evidence-based therapies such as mentalization based therapy, cognitive analytic therapy, etc, but this is currently on hold.

Data collected

Current outcome measures are regularly collected, but further measures focussing on quality of life would be of interest.

System Balance

The service would like to consider the burden of physical health and how this impacts mental health services to create a joined-up offer for this group of people. A focus on potential prevention strategies such as housing schools and Sure Start provision could develop long-term structural change to move away from the focus on secondary care and out of area placements.
Potential research interests could include looking at what works for the group who have experienced trauma, who have disrupted attachments and are dysregulated.
There is further interest in longer term follow up rather than focusing the collection of outcome measures at the point of finishing therapy.

Gloucestershire ICB Area

What is viewed as the gap?

Those falling between talking therapies and not meeting criteria for secondary care services.
People who don’t have ‘recovery needs’ who appear to be functioning well within their work, home, and relationships, and who are not high users of crisis, A&E etc.
People who use substances, people who experience emotional dysregulation as primary symptoms, people who experience difficulties around anger. Homeless people. People presenting with ADHD & Autism as primary MH label.

What is currently offered in the gap?

The Open Access Therapeutic Support (OATS) service includes a 3 day a week therapeutic community model facilitated by peer support workers (Service User Network model), offering self referral, with the only exclusion criteria being for people with a history of a sexual offence. Currently, this is only available in Gloucester city.
OATS is a joint service with VCSE partners offering support to friends and family with a 12 week course for people supporting someone with complex emotional needs (CEN) and is accessed via VCSE providers. Further carers 1:1 support comes from secondary care. All VCSE work is supported by supervision offered by mental health practitioners. The Citizens Advice Bureau is commissioned separately.
The Anchor project works with people for 9-12 months, offering intensive support and the Cavern offers an A&E listening service. The Nelson Trust offers a managing emotions group for women.
Mental Health intermediate care teams offer assessment, medication support and brief interventions for up to 6 sessions, offering skills-based work, safety planning and signposting in GP surgeries. ARRS workers link to the OATS service.
Guidepost offers a tele-coaching service commissioned specifically aimed at people with CEN. Gloucestershire Talking Therapies offer some High Intensity therapies including a trauma group, but this is carefully screened to ensure clients are well enough supported within the community.
There is a young adults team for 18-25 year olds to provide alternatives to transitions to adult services
Structured Clinical Management in secondary care services is poorly implemented in recovery teams.

Further emerging gaps

Currently Services are focussed mainly on Gloucester, with limited availability across the county. Therefore significant gaps exist.
No tier 4 psychological therapies are available unless the person meets criteria for secondary care as this is embedded in recovery teams.
People with psychosis stay in secondary care as no step down services are available.
Neurodiversity is a big gap, with long waits for assessments and limited access to interventions.
Shifting the culture and the ways in which people deliver services is recognised as a significant gap, which requires attention as the services grow.

Potential Developments

How to improve access to EMDR for people with Complex PTSD.

Data collection

There is limited consistency of data collection across teams.
The friends and family test data is collected.
The services have access to Rio, but find it difficult to pull meaningful reports to describe who has received services and what has happened to them.
Some data has been collected regarding the details of crisis calls, but there is limited consistency in reporting.
The OATS service has collected data on service usage on the 12 months before entry into the service and has begun work to compare this with service usage after attending OATS.

System Balance

People with psychosis are held onto in secondary care with limited step down.
No system wide service strategy exists, which makes change tricky as there is a lack of clarity of what services should be provided, i.e. in secondary care.
Strong ICB leadership is required to see the importance of mental health alongside physical health needs, to help raise the importance of mental health provision.
The service has identified a need to track flows through the care system, and to examine risk to see if there are changes to risk profiles if interventions are offered within OATS.

Potential research interests

An evaluation of the 12 week family work.
Exploration of the effectiveness of Interventions developed for people with CEN and ADHD.
The development of focus groups before and after the experience of care to give feedback on service development and delivery.
Identifying how to work more effectively across the system by developing collaborations to promote systemic working.

Somerset ICB Area

What is viewed as the gap?

People with complex trauma.
People with CEN.
People who do not fit into services (i.e. do not fit into secondary care but are too tricky for talking therapies) and are bounced around the system.

What is currently offered in the gap?

What the services offer depends on the needs of the individual. This might include responding to social needs first i.e. housing, debt and working with community partners to identify support i.e support groups for isolated people.
Psychoeducation groups are offered for 8 sessions facilitated by Assistant Psychologists and Clinical Associate Psychologists (CAPs). These groups focus on trauma work and compassionate-focussed work. These are run jointly with VCSE partners. This is the bulk of the work in the gap.
If individuals need more than 16 sessions of Cognitive Analytic Therapy, groups situated in secondary care are offered, but they work with this community population too. This results in seamless movement between the gap and secondary care.
Ad hoc support is available from Mindline.
Good links exist with talking therapies, with joint team decision making taking place in hubs situated in the community, adding to seamless transfers.
Complex Emotional Needs services are designed to respond to people with moderate Mental Health difficulties. Structured Clinical Management is offered, which incorporates a 20-week emotional and relational skills course.
VCSE partners such as Yeovil Mind and Chardwatch offer hubs in the community where a significant amount of the gap work takes place. This co-location means that reciprocal relationships exist, with supervision and rooms being shared.
Most support for families and carers comes from the VCSE, but this is not consistent.
Working relationships are generally good and attention is paid to the principles of attachment which underpin practice. This approach is thought to be very useful in promoting a consistent approach to the work with people attending the services. It offers stability to both staff and service users.

Further emerging gaps

People with psychosis tend to stay in secondary care with recovery wellbeing workers who offer support, but work is not goal directed.
Limited therapy is available in the gap, which is primarily focussed on the Open Mental Health offer of support.
Longer term interventions need to be developed for the CEN population.
There are limited interventions for people with neurodiversity.
There are inconsistencies in delivery across some localities.
Demand on services is outstripping availability.
A gap is emerging for people with anti-social personality disorder.
There is limited support for people with neurological disorders.

Potential plans for development

Gaps are diminishing between services, but further work on the flow into secondary care services needs exploration.
A disordered eating service for those with a restrictive intake is being considered.
The development of a mentalization based therapy volunteers programme to support people coming out of services.
Training is needed across the whole system regarding people with CEN.

Data collection

Data collection is poor and inconsistent.
Case audits have been conducted on 100 people, but it is difficult to find time to examine what the data is demonstrating.
Some areas are already involved in evaluation such as MBT and MBTi with open access.

Research interests

A qualitative methods exploration to understand the experience of staff members in the system with these new ways of working.
An evaluation of MBT services is being conducted and work is being undertaken on dissociative identity disorder.
Analysis of the outcome data collected and linking this to health economics would be helpful.
There is an interest in establishing a community of practice bringing practitioners together to examine the real diversity in delivery across different areas that could give opportunities for learning. A uniformed system of delivery may not be the most helpful way to design services so any learning across the system to explore these differences and their effectiveness would help with development.

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