What is the Community Mental Health Framework?
The Community Mental Health Framework
In 2019 the National Health Service in England (NHSE) published the Community Mental Health Framework (CMHF) for Adults and Older Adults, which described place-based, whole population health approaches for the delivery of community mental health services. Alongside the CMHF, NHSE proposed significant investment into mental health services, of £2.3 billion per year by 23/24.
The CMHF has changed the expectations for how mental health services are to be delivered in the community. This includes:
Removing gaps in care and services for people with significant challenges to their mental health and wellbeing.
Different providers working together – linking up primary care, voluntary sector provision, secondary mental health services and social care (local authority).
Making changes to the Care Programme Approach (CPA).
Making changes to commissioning.
Reduction in the number of assessments.
Recognition that patients are active participants in a system.
Recognition that personalised care is crucial and co-production underpins the framework’s approach to design and planning of provisions, as well as delivery of care.
A focus on addressing inequalities and meeting the needs of communities currently poorly served by local mental health provision.
There are few details as to how to implement this framework, with freedom for providers and commissioners to try out different local models and approaches. This is why evaluations learning from local innovation are important and why we have decided to share findings via a Knowledge Exchange. There is much we can learn from each other.
The CMHF links to a range of other initiatives and programmes. It aligns with the NHS Plan and fits with many of the aspirations described in the 2023 WHO report on mental health, human rights and legislation, which proposes a paradigm shift away from a biomedical model towards a human rights model, a shift that requires a transformation of service provision towards holistic community-based, person-centered and recovery-orientated options.
On this page ...
Mary Ryan comments on the importance of communities and VCSEs.
John Gibson reflects on the Community Mental Health Framework from a lived experience perspective.
Key aims of the Community Mental Health Transformation
The CMHF is underpinned by the following six aims:
Promote mental and physical health and prevent ill health.
Treat mental health problems effectively through evidence-based psychological and / or pharmacological approaches that maximise benefits and minimise the likelihood of inflicting harm, and use a collaborative approach that: builds on strengths and supports choice; and is underpinned by a single care plan accessible to all involved in the person’s care.
Improve quality of life, including supporting individuals to contribute to and participate in their communities as fully as possible, connect with meaningful activities, and create or fulfil hopes and aspirations in line with their wishes.
Maximise continuity of care and ensure no “cliff edge” of lost care and support by moving away from a system based on referrals, arbitrary thresholds, unsupported transitions, and discharge to little or no support. Instead, move towards a flexible system that proactively responds to ongoing care needs.
Work collaboratively across statutory and non-statutory commissioners and providers within a local health and care system to address health inequalities and social determinants of mental ill health.
Build a model of care based on inclusivity, particularly for people with coexisting needs, with the highest levels of complexity and who experience marginalisation.
Mary Ryan comments on the importance of the person themselves to continuity in their care.
An attempt at radical change
The CMHF attempts to radically change the culture of mental health service delivery. It aims for a whole system approach to mental health care that is no longer fragmented or disjointed, and which no longer excludes people from services or allows them to fall into the gap between primary and secondary care. Services should become easier to access, and, with an emphasis on earlier intervention, arbitrary thresholds should diminish. Systems working together across the community to include health, social care and voluntary, community and social enterprises (VCSEs) would then break down barriers, help with the co-ordination of care and promote close working within local communities. In turn this would lead to easier access, reduce the need for repeat assessments and would eliminate exclusion based upon an individual’s diagnosis, complexity or, perversely, the lack of severity of their presenting problem.
Beccy Wardle discusses the importance of engaging with local communities to understand how needs can be met.
This illustration from NHS England highlights the lack of provision, focus and investment both locally and nationally within community mental health services for adults (people aged 18 and over) with severe mental health needs.
The CMHF describes an integrated approach to the delivery of mental health services. This is informed by working collaboratively with key local organisations and people with lived experience. Coproduction is a central principle within the CMHF. Working towards bespoke local services that fit the needs of the community has become a key aspiration for its delivery. By strengthening relationships with local groups it aims to promote inclusion and address inequalities. This in turn will create greater choice and respond to local need more effectively.
An integrated approach to the delivery of mental health services in a community.
This diagram shows what this approach might look like in a community. It includes self-help and an enabling approach to address inequalities. While recognising the wide range of constituents, it also shows there is no set design for this courageous ambition.
People would be able to present at any point in the system – from pharmacies, advisory services or community groups to education, social services, the criminal justice system or primary care – and be guided to the right support without delay (a ‘no wrong door’ approach). Services could meet people in the spaces where they already are and where they feel comfortable, which for some people will include via digital media. This means working more effectively with the community and with VCSE organisations, schools and non-healthcare providers. It might also mean ensuring that both online and face-to-face options are available, so that people can access the support they need without delay and no one misses out because of digital exclusion. A single trusted assessment would unlock a pathway to care that works for the individual with their physical and mental health needs met together. People with mental health problems would be enabled as active participants to make positive changes, rather than remain passive recipients of disjointed, inconsistent and episodic care. A collaborative approach to decision making and care delivery would enable a more joined up approach between those who need services and those who provide them.
2019 saw the beginning of the roll out of the CMHF. It began with the selection of 12 Early Implementer sites, one from each of the 12 regions in England. These 12 sites acted as trailblazers for the implementation of the CMHF and were often ICS areas that had demonstrated evidence of transforming community services. Some had established primary care mental health provision or were already developing neighbourhood services. This meant that these 12 pilot sites were further ahead in their journey to transform existing services and were likely to be able to create further learning, which might be helpful for future implementation.
Implementation incorporating principles of co-production
Over the following years, until 2024, the remaining ICS areas across England were asked by NHS England to put the CMHF into practice, incorporating principles of co-production. The ambition is potentially one of the largest transformations in NHS mental health care, and inevitably the rate at type of transformation varies across England. Delivery has been affected by COVID-19 and workforce challenges which makes large-scale change of this nature very difficult.
Alison Brabban reflects on the challenges the system faces, but also the how the Community Mental Health Framework moves towards addressing those challenges.
Why is it so important that we pay attention to the mental health of the communities in which we live?
We know that many of our community mental health teams have long waiting lists and there are gaps between services. We also know that people find it difficult to access the services they need and to navigate their way around a system that offers support from many different sources, including GPs, health and social care providers, local authorities and the voluntary sector.
Protective and adverse factors in mental health. Source: The British Psychological Society.
This figure helps us to understand social causes of the scale of the challenge facing communities given the potential impact that mental health difficulties will have upon many individuals. Not only do mental health difficulties result in shortened life expectancy, but they have a significant impact on the economy, with this disproportionately affecting some groups. Four times as many black people than white people are sectioned under the Mental Health Act and yet they receive less therapy. More women and girls are affected by most mental health problems and older people less often.
The cost of mental health. Source: the Centre for Mental Health.
Further, the economic and social costs of mental ill health in England reached £300 billion in 2022, dwarfing the spend by NHS on mental health care, according to the NHS Confederation’s Mental Health Network.
In October 2023 the WHO published its report Mental health, human rights and legislation, which emphasised that mental health is a state of physical, mental, emotional, and social wellbeing determined by the interaction of the individual with society. The report gives attention to the intersecting layers of a person’s identity, i.e., race, gender, age, etc., and the impacts that this may have upon their mental health. Emphasis is also placed on the importance of community mental health services as a mechanism to respond to the needs of individuals in the community.
A robust community that responds to the needs of the people living within it will promote better lives for those who are part of it. The Community Mental Health Framework published by NHSE England in 2019 began to attend to some of these issues by trying to promote the development of inclusive and accessible services open to all.
Links to key documents / resources:
Royal College of Psychiatrists
The Community Mental Health Framework for Adults and Older Adults [pdf]
NHSE Mental Health Implementation Plan 2019 [pdf]
The NHS Community Mental Health Transformation - YouTube
WHO Mental health, human rights and legisalation: guidance and practice
Centre for Mental Health: The economic and social costs of mental ill health
More in this section ...