Welcome to the ZSA Facts for Action series

This page provides key information to explain what community mental health services are and will help build your understanding of the role this service has in suicide prevention.

Contents:

  1. What are community mental health services?
  2. Who do community mental health services support?
  3. Why are these services important in the context of suicide prevention?
  4. Impact of Covid-19
  5. National guidelines for practice
  6. Recommendations for action
  7. Understand the bigger picture - more insights from the ZSA Suicide Prevention Resource Map
  8. References

What are community mental health services?

Community mental health services (CMHSs) play a crucial role in delivering mental health care for adults and older adults with severe mental health needs as close to home as possible.[1] They are made up of multi-disciplinary teams typically including psychiatrists, community psychiatric nurses, social workers, clinical psychologists and allied health professionals such as occupational therapists, support workers and administrative staff.[2] They will work alongside people with serious mental illnesses (SMI), such as schizophrenia, psychosis and bipolar disorder, to develop and carry out care plans of treatment, helping that person recover and be able to manage independently.

Community mental health services are wide ranging and include:

  • Assertive outreach services
  • Community mental health teams – functional and organic
  • Criminal justice and liaison services
  • Crisis resolution home treatment services
  • Early intervention in psychosis services
  • Forensic mental health services
  • Personality disorder services
  • Psychological therapy and psychotherapy services
  • Single point of access
  • Specialist eating disorder services
  • Specialist perinatal services
  • Other specialist community based mental health services e.g. homeless outreach

In line with the life course approach to mental health, treatment for people with SMI has moved away from a solely medical to a biopsychosocial model, which acknowledges the array of factors that contribute to severe and complex mental health illnesses.  These key change approaches are also reflected in the national guidelines for best practice as recommended by NICE, promoting a combination of medication and evidence-based psychological interventions.

A recovery orientated approach is taken to rehabilitate people with SMIs.  CMHSs that work with people with an SMI focus on building upon a person’s strengths, increasing their confidence and encouraging hope.  This can be done by working towards particular goals, building good relationships with staff, looking for work, developing daily living skills, doing meaningful leisure activities and sharing experiences with others experiencing similar challenges. Key principles of this approach include individualised, person-centred and collaborative care.  This means that the person with SMI should receive tailored care and be involved in the decision making process (NICE, 2020).[3]   

The services involved in a person’s care will depend on the level of care needed. Those with more complex needs and present a risk to themselves and/or others may require inpatient care, and then transition to a CMHS when needs can be met whilst living in the community. These different services will be explored further in our Facts for Action series.

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Who do community mental health services support?

NHS Digital publishes an annual bulletin which reports on the use of mental health services based on the Mental Health Services Data Set submissions by providers. The data reported below refers to people aged 18+ referred to and accessing community based mental health services (unless otherwise stated).

The latest publication from NHS Digital (2021) shows that in the year 2020/21[4] shows:

  • There were over 2.8 million people in contact with NHS funded secondary mental health, learning disabilities and autism services in 2020/21.
  • 4.6% of those in contact with services were admitted during the year with rates at clinical commissioning group (CCG); this is significantly higher than for children and young people which saw 0.4% admitted 
  • There are more females (54%) than males (46%) in contact with services
  • 16% of those in contact with services were aged 18 to 24, with 56% aged 25 to 64, and 28% aged 65+
  • 65% of service users are of a white ethnic group. It should be noted that the data completeness for ethnicity is poor with only 77% of those in contact with services having a valid ethnicity reported, so we have also looked at ethnicity proportions based on the number of users with valid ethnicity recorded. Please note that the NHS Digital data looks at everyone in contact with NHS funded secondary mental health, learning disabilities and autism services so will include people aged under 18 and also those who have received inpatient care during the year
  • The percentage of those from ethnic minority backgrousnds in contact with services (where valid ethnicity is recorded) is 12%. Please note that the NHS Digital data looks at everyone in contact with NHS funded secondary mental health, learning disabilities and autism services so will include people aged under 18 and also those who have received inpatient care during the year.
  • People living in more deprived areas are more likely to enter NHS funded secondary mental health services than those from less deprived areas. This is illustrated by 60% of people entering treatment living in areas with higher than average deprivation (based on the Indices of multiple deprivation)
  • Care clusters are a framework for planning and organising adult mental health services and the care and support that can be provided for individuals. In mental health there are 21 clusters that cover a range of diagnosis and needs (non-psychotic, psychotic and organic).[6] Analysis of the data for 2019/20 shows that 44% of people in contact with services were allocated to a non-psychotic cluster, 32% to a psychotic cluster and 22% to an organic cluster and for 2% the cluster group was unknown.

The NHS Digital annual report and reference tables also include data on specialist perinatal mental health community services. The data below was sourced from Tables 10.1 and 10.2:

  • There were 31,550 people in contact with perinatal community services in 2020/21 with the majority of service users aged between 20 and 39 years old (90%). The full breakdown of users by age groups is provided in Table 1
  • 66% of service users are of a white ethnic group. It should be noted that ethnicity was only recorded for 93% of those entering treatment, so we have also looked at ethnicity proportions based on the number of users with valid ethnicity recorded
  • The percentage of people entering perinatal mental health community services from ethnic minority backgrounds is 13% (where valid ethnicity is recorded). This is 8% lower than the percentage of the general population in these groups for people aged 18+ (21%) (based on ONS data). This suggests that people from ethnic minority backgrounds are slightly less likely to access perinatal mental health services.
  • People living in more deprived areas are more likely to be in contact with specialist perinatal mental health community services than those from less deprived areas. This is illustrated by 60% of people entering treatment living in areas with higher than average deprivation (based on the Indices of multiple deprivation).

Age

Number (Percentage)

Up to and including 19

1,235 (4%)

20 to 24

5,095 (16%)

25 to 29

7,984 (25%)

30 to 34

9,140 (29%)

35 to 39

6,199 (20%)

40 to 44

1,670 (5%)

45+

153 (0.8%)

Table 1 – Age breakdown of users of perinatal mental health community services

The NHS Mental Health Dashboard for quarter two 2021/2022[7] includes some indicators relating to specialist community perinatal mental health services linked to the Long Term Plan ambitions:

  • The rolling 12 months figure for the number of women with at least one attended contact with a specialist community perinatal mental health service is a target of 66,000 women by 2023/24. 

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ZSA Suicide Prevention Resource Map insights - how access has changed over time

Our ZSA Suicide Prevention Resource map developed with the NHS Benchmarking Network includes a number of metrics which provide a picture of the overall situation for CMHS across England and shows wide variation in the number of people referred to and accessing these services and the amount of clinical contacts received by individuals.

The data for CMHSs included in the map is mainly drawn from the NHS Benchmarking Network mental health project* and covers the following services: generic community mental health teams (CMHTs), assertive outreach, assessment and brief intervention, community rehabilitation, forensic, eating disorders, perinatal, older people, memory services and other adult CMHT. Early intervention in psychosis and crisis resolution home treatment services are looked at separately in this series.

The data below relates to 2020/21 and comes from the NHS Benchmarking Network’s Mental Health project unless stated otherwise:

  • The number of referrals received per 100,000 registered population varies between 925 and 9,740 with a median average of 3,115 up from 3,008 in 2019/20
  • The number of referrals received per 100,000 weighted population varies between 540 and 7,656 with a median average of 2,723 up from 2,568 in 2019/20
  • The number of people on the caseload per 100,000 registered population varies between 632 and 2,886 with a median average of 1,353 up slightly from 1,302 in 2019/20
  • The number of people on the caseload per 100,000 weighted population varies between 656 and 2,262 with a median average of 1,173 up sligtly from 1,131 in 2019/20
  • The number of clinical contacts per 100,000 registered population varies between 1,660 and 56,457 with a median average of 26,764 up from 22,601 in 2019/20
  • The number of clinical contacts per 100,000 weighted population varies between 1,461 and 44,151 with a median average of 22,612 up from 19,375 in 2019/20
  • The average number of clinical contacts per person on the community mental health service caseload was 19 in 2019/20 (approximately 1.6 per month)
  • The number of clinical contacts delivered to patients in clusters 10 to 17** per 100,000 registered population varies between 537 and 17,203 with a median average of 6,755 up from 5,835 in 2019/20
  • The number of clinical contacts delivered to patients in clusters 10 to 17** per 100,000 weighted population varies between 511 and 12,500 with a median average of 5,736 up from 4,789 in 2019/20

* All data from NHS Benchmarking Network projects is subject to change dependent upon permissions being receiving from provider organisations to have their data included in the map.  The information reported reflects the data available as at 31/08/22.

** Clusters 10 to 17 are used for people experiencing symptoms associated with psychosis. People experiencing psychosis are at higher risk of attempting or completing suicide and it is therefore important that these individuals have good access to services.

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Why are these services important?

As we discuss in our Facts for Action for Severe Mental Illness, people with an SMI are at high risk of self-harm and dying by suicide (McManus et al., 2016).[8]

28% of suicides in the UK between 2007 and 2017 were completed by people in contact with mental health services.

In 2017, 1,517 people under mental health care died by suicide. 206 of these deaths were within three months after hospital discharge (14% of all patient suicides), with the highest risk in the first one to two weeks after discharge.[9] This highlights the need for effective discharge planning and community follow up after an inpatient admission to ensure that existing and new needs are met during the transition of care between mental health services.

However, suicide by patients under a Community Treatment Order (CTO), whereby patients received treatment in the community and have to follow certain conditions, only account for 1% of suicides (Hunt et al., 2021).[10]

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Impact of COVID-19

It has been forecast that up to ten million people, the equivalent of nearly 20% of the total population, will need new or addition support for their mental health needs as a result of the COVID-19 pandemic (Centre of Mental Health, 2020).[11]

In response to the pandemic, a number of bodies have undertaken work to predict the potential increase in demand for mental health services.

One example of this is the work undertaken by The Strategy Unit[12] which predicts that there may be 1.8 million new presentations, recurrences or exacerbations of mental ill health across England in the next three years as a direct or indirect result of the pandemic, with the next 18 months being particularly challenging for services. 

Table 2 presents work done by The Strategy Unit which suggests that there could be a 33% increase in overall demand for mental health services in the next three years (to 2022/23) and their modelling app[13] estimates for community mental health services.

Service

Additional Referrals

Cumulative surge in demand

Assertive outreach

291

1.9% (0.8% 2020/21, 0.7% 2021/22 and 0.4% 2022/23)

Community mental health team – functional

123,805

19.1% (7.7% 2020/21, 7.2% 2021/22 and 4.2% 2022/23)

Community mental health team – organic

971

0.7% (0.3% 2020/21, 0.3% 2021/22 and 0.1% 2022/23)

Criminal justice liaison and diversion Service

4,619

4.3% (1.7% 2020/21, 1.6% 2021/22 and 0.9% 2022/23)

Forensic mental health service

4,037

15.4% (6.1% 2020/21, 5.9% 2021/22 and 3.4% 2022/23)

General psychiatry service

50,353

22.6% (9.2% 2020/21, 8.5% 2021/22 and 5% 2022/23)

Personality disorder service

11,989

63.1% (25.9% 2020/21, 23.6% 2021/22 and 13.7% 2022/23)

Psychological therapy service (non-NHS talking therapies)

132,909

201% (81.2% 2020/21, 75.8% 2021/22 and 44% 2022/23)

Psychotherapy service

8,186

47.7% (20.2% 2020/21, 17.4% 2021/22 and 10.1% 2022/23)

Single point of access

113,874

21% (8.5% 2020/21, 7.9% 2021/22 and 4.6% 2022/23)

Specialist perinatal mental health community service

7,433

13% (5.3% 2020/21, 4.9% 2021/22 and 2.8% 2022/23)

Table 2 – Strategy Unit estimates of future demand on community mental health services

Local systems can use the app to model the potential surge in demand for their area and impact on specific services and use this to support planning.

The Centre for Mental Health, in collaboration with NHS Trusts and NHS England, has also worked on developing a modelling toolkit for forecasting additional demand for mental health services resulting from the pandemic.[14] This takes the results of various studies and enables the user to input the information they have about their local population into the model to generate an estimate of the amount of additional demand for mental health services in that area.   

Not only has the COVID-19 pandemic has increased the number of people predicted to need mental health support (Centre for Mental Health, 2020)[11] it has also significantly impacted access to services, with 24% of adults, and 2% of young people reporting not being able to access mental health support (Mind, 2020).[15]

In response to the COVID-19 pandemic, the NHS Benchmarking Network has developed a monthly mental health and learning disability COVID-19 dashboard which supports provider organisations to check the impact that COVID-19 has had on core service provision and the impact and extent of the switch to virtual and digital service provision. The data for adult and older adult community mental health services shows that:

  • Prior to the pandemic approximately 25% of clinical contacts were non face to face and increased during the early stages of the pandemic to 68% (face to face work reducing to 32%) 
  • The proportion of work undertaken non face to face has decreased over recent months but is unlikely to return to pre-pandemic levels as providers and systems consider how to embed different delivery approaches in their recovery plans
  • Approximately 5% of clinical contacts are now undertaken using digital technologies e.g. video consultations and the data suggests that these methods are becoming embedded within services and are likely to remain an important part of service delivery in the future.

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National guidelines for practice

National Collaborating Centre for Mental Health

The National Collaborating Centre for Mental Health have developed guidance for the NHS to support delivery of evidence-based mental health care pathways which promote timely and equal access to effective treatment.  This includes guidance for commissioners and service providers on how the pathways can be implemented and benchmarks achieved.[16] Pathways of particular relevance to this theme in our facts for action series are listed below:

NHS Long Term Plan

The NHS Long Term Plan[17] and NHS Mental Health Implementation Plan 2019/20 to 2023/24[18] set out that the NHS will develop new and integrated models of primary and community mental health care. The new community-based offer will include access to psychological therapies, improved physical health care, employment support, personalised and trauma informed care, medicines management and support for self-harm and coexisting substance use.

By 2023/24, this will enable at least 370,000 adults and older adults per year nationally to have greater choice and control over their care, and to live well in their communities.

The Community Mental Health Framework for Adults and Older Adults[19] describes how these ambitions can be realised and is being used as the basis for the testing of new integrated primary and community mental health care models across 12 early implementer sites in 2019/20 and 2020/21.

Rethink have published two guides to support Integrated Care Systems to transform community services based on lessons from pilot sites and other work across England

The NHS Mental Health Implementation Plan [18] describes the following specific ambitions in relation to community based mental health services:

Perinatal mental health

By 2023/24:

  • At least 66,000 women with moderate to severe perinatal mental health difficulties will have access to specialist community care from pre-conception to 24 months after birth with increased availability of evidence-based psychological therapies. Their partners will be able to access an assessment for their mental health and signposting to support as required;
  • Maternity Outreach Clinics will be available across the country, combining maternity, reproductive health and psychological therapy for women experiencing mental health difficulties directly arising from, or related to, the maternity experience.

Adult Severe Mental Illness (SMI) community care

By 2023/24:

  • All STPs/ICSs will have received funding to develop and begin delivering new models of integrated primary and community care for adults and older adults with severe mental illnesses, incorporating care for people with eating disorders, mental health rehabilitation needs and complex mental health difficulties associated with a diagnosis of a ‘personality disorder’, among other groups. These new models of care will span both core community provision and also dedicated services, where the evidence supports them, and they will be built around Primary Care Networks. By the end of 2023/24 every STP/ICS will have at least one new model in place, with care provided to at least 370,000 adults and older adults per year nationally, giving them greater choice and control over their care, and supporting them to live well in their communities.
  • A total of 390,000 people with SMI will receive a physical health check.
  • A total of 55,000 people a year will have access to Individual Placement and Support services.

Older people’s mental health

The implementation of the Long Term Plan provides a unique opportunity to ensure consistent access to ‘functional’ mental health support for older adults and address the mental health needs of older adults wherever they may arise or present. Older people’s mental health is embedded as a ‘silver thread’ across all of the adult mental health ambitions, including NHS Talking Therapies (formally IAPT*), community-based services for people with SMI and crisis and liaison mental health care.

Improving Access to Psychological Therapy (IAPT) services are being renamed in 2023 as NHS Talking Therapies, for anxiety and depression. For more information, visit the NHS England website.

NICE guidance

NICE have published a number of pathways, guidance and quality standards relevant to mental health services.  Links to these have been provided below:

For further guidance on mental health and behavioural conditions, visit the NICE website.

To find out more about NICE guidance, advice, standards and pathways on mental health and wellbeing, visit NICE’s mental health and wellbeing topic page.

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Recommendations for action

Action for NHS commissioners and providers (community mental health services):

  • Review progress against and implement necessary changes to community mental health services in line with agreed pathways, NICE guidance and long-term plan ambitions.

Understand the bigger picture - more insights from the ZSA Suicide Prevention Resource Map

Direct indicators

Referrals

Caseload

Contacts

Contacts for people in clusters 10 to 17

Indirect indicators

All data from NHS Benchmarking Network projects is subject to change dependent upon permissions being receiving from provider organisations to have their data included in the map.  The information reported reflects the data available as at 24/08/22.

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References

[1] NHS England. Community mental health services. Available at: https://www.england.nhs.uk/mental-health/adults/cmhs/

[2] Royal College of Psychiatrists. Mental health services and teams in the community. Available at: https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/mental-health-services-and-teams-in-the-community

[3] NICE (2020). Rehabilitation for adults with complex psychosis.  Available at: https://www.nice.org.uk/guidance/ng181

[4] NHS Digital (2021). Mental Health Bulletin 2020-21 Reference Tables v2. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-bulletin/2020-21-annual-report

[5] Office for National Statistics. DC2101EW – Ethnic Group by sex by age. Available at: https://www.nomisweb.co.uk/census/2011/DC2101EW/view/2092957699?rows=c_ethpuk11&cols=c_age

[6] NHS England and Improvement (2020). 2020/21 National Tariff Payment System Annex E: Technical guidance for mental health clusters. Available at: https://www.england.nhs.uk/wp-content/uploads/2021/02/20-21NT_Annex_E_Mental_health_clustering_tool.pdf

 [7] NHS England and Improvement (2021). NHS Mental Health Dashboard. Available at: https://www.england.nhs.uk/publication/nhs-mental-health-dashboard/

[8] McManus S, Hassiotis A, Jenkins R, Dennis M, Aznar C, Appleby L. (2016). ‘Chapter 12: suicidal thoughts, suicide attempts and self-harm,’ in McManus S, Bebbington P, Jenkins R, Brugha T. (eds) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. Available at:  https://webarchive.nationalarchives.gov.uk/20180328130852tf_/http://content.digital.nhs.uk/catalogue/PUB21748/apms-2014-suicide.pdf/

[9] University of Manchester (2019). The National Confidential Inquiry into Suicide and Safety in Mental Health. Annual Report: England, Northern Ireland, Scotland and Wales. 2019. Available at: https://documents.manchester.ac.uk/display.aspx?DocID=46558

[10] Hunt, I., Webb, R., Turnbull, P. et al. (2021). Suicide rates among patients subject to community treatment orders in England during 2009-2018. BJPsych Open, 7(6), e180. Available at: https://doi.org/10.1192/bjo.2021.1021

[11]Centre for Mental Health (2020). Covid-19 and the nation’s mental health: October 2020. Available at: https://www.centreformentalhealth.org.uk/publications/covid-19-and-nations-mental-health-october-2020

[12] The Strategy Unit (2020). Estimating the impacts of COVID-19 on mental health services in England. Available at: http://www.strategyunitwm.nhs.uk/sites/default/files/2020-11/Modelling%20covid-19%20%20MH%20services%20in%20England_20201109_v2.pdf

[13] The Strategy Unit (2020). Mental Health Surge Modelling app. Available at: https://strategyunit.shinyapps.io/MH_Surge_Modelling/

[14] Centre for Mental Health (2020). Forecast Modelling Toolkit. Available at: https://www.centreformentalhealth.org.uk/forecast-modelling-toolkit

[15] Mind (2020). The mental health emergency: How has the coronavirus pandemic impacted our mental health? Available at: https://www.mind.org.uk/media-a/5929/the-mental-health-emergency_a4_final.pdf

[16] National Collaborating Centre for Mental Health, Royal College of Psychiatrists. Mental health care pathways. Available at: https://www.rcpsych.ac.uk/improving-care/nccmh/care-pathways

[17] NHS (2019). The NHS Long Term Plan. Available at: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

[18]NHS (2019). NHS Mental Health Implementation Plan 2019/20 – 2023/24. Available at: https://www.longtermplan.nhs.uk/publication/nhs-mental-health-implementation-plan-2019-20-2023-24/

[19] NHS (2019). The community mental health framework for adults and older adults. Available at: https://www.england.nhs.uk/publication/the-community-mental-health-framework-for-adults-and-older-adults/

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Content reviewed and updated 30/08/22

Suicide Prevention Resource Map

Explore our interactive map to gain a more in-depth picture of suicide rates in your community and the different health, social and service provision factors related to people dying by suicide.
Glossary of terms

Case study examples of best and innovative practice

Somerset Open Mental Health: trailblazing re-design of community mental health

Open Mental Health is a multi-agency alliance of local voluntary organisations, NHS and social care services in Somerset. They work in partnership to ensure that residents of Somerset get the mental health support they need, when they need it.

The Lambeth Living Well Network Alliance

The Living Well Network Alliance is an agreement to provide mental health services for working age adults in Lambeth. The Alliance brings social care, housing and mental health service users, commissioners, and providers together, pooling their expertise and budgets to support all the needs of a person with an serious mental illness.

MaST at Mersey Care NHS Foundation Trust

Mersey Care NHS Foundation Trust serves more than 11 million people offering specialist inpatient and community services that support mental health, learning disabilities, addictions, brain injuries and physical health.

MaST is a decision support tool developed by Holmusk in partnership with mental health providers enabling mental health staff to adopt a dynamic approach to prioritisation and resourcing. MaST provides insight into people’s Risk of Crisis and Complexity and identifies those who may benefit from a review of their care to improve quality and safety outcomes.

S12 Solutions: digital tool to support the mental health act

S12 Solutions is a digital tool (phone application and web platform) that was designed to support Mental Health Professionals to undertake Mental Health Act (MHA) assessments.

Birmingham Mental Health Alliance for Excellence, Resilience Innovation & Training (MERIT)

The Mental Health Alliance for Excellence, Resilience, Innovation and Training (MERIT) provider collaborative was established in 2016 as a vanguard site in response to the Five Year Forward View for Mental Health and was initially comprised of Solihull Mental Health NHS Foundation Trust, Black Country Partnership NHS Trust, Coventry and Warwickshire Partnership NHS Trust and Dudley and Walsall Mental Health Partnership NHS Trust. Their focus is on proactive early intervention care rather than reactive crisis management, which is achieved by promoting a recovery culture and providing crisis care and reduction of risk, which is used everyday in acute services.

National Institute of Mental Health - scale-up hubs

The National Institute of Mental Health (NIMH) developed a network of global research Hubs called ‘NIMH Scale-Up Hubs” to increase the reach, accessibility, quality, costs and effectiveness of mental health services.

Outcome measurement system at Oxleas NHS Foundation Trust

The Bromley Home Treatment Team at Oxleas NHS Foundation Trust takes referrals from other services and self-referrals to provide community alternatives to admission to hospitals. The Outcome Measurement System was developed by the Bromley Home Treatment Team in partnership with service users and is a ‘state-of-the-art’ technology system which allows professionals to see real time severity of a patient’s mental health, allows monitoring of changes in severity, and uses this information to aid clinical decision making.

Sandwell and West Birmingham Hospital - alcohol care team

The Sandwell and West Birmingham Trust alcohol care team was introduced as part of their care pathway to support admissions to emergency departments and provide guidance for symptom-triggered withdrawal in patients.