Introduction
A news item about government proposals to provide work coaches for patients in National Health Service (NHS) psychiatric (mental healthcare) wards reached national headlines in October 2024. To people closely involved with these wards, the plan was absurd, as almost all inpatients are too unwell to collaborate actively in planning their post-discharge employment. Although the government later denied the plan, the episode suggested a lack of understanding regarding patients’ illnesses and needs.
Mental disorders, especially if severe and/or chronic, have numerous ramifications. At various times in the course of a psychotic illness such as bipolar disorder or schizophrenia, patients may lack motivation and mental clarity to optimise their own physical health and social wellbeing. A holistic, multi-disciplinary, individually tailored approach to care is required to help patients achieve outcomes compatible with the World Health Organisation (WHO) definition of mental health: ‘a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.’ It is not perfection, but the best attainable for each person.
In this paper, the term ‘mental healthcare’ encompasses biological, psychological and social dimensions. That type of holistic therapeutic approach, beyond prescribing medications to manage clinical symptoms, is not new. It aligns with ‘moral therapy’ 200 years ago; with psychobiology and the (re)introduction of meaningful therapeutic activities into UK public mental hospitals in the early twentieth century; and with the biopsychosocial model of the 1970s. Since 2000, similar broad, person-centred approaches have featured repeatedly in mental healthcare policy discourse. However, implementation has been grudging, at least in part because a multi-faceted, comprehensive approach requires increased short-term financial investment, despite the potential for better outcomes and longer-term savings. That grudgingness is also not new: in 1920, Thomas Myers MP in a House of Commons’ debate, criticised some Members’ approach as ‘save the rates and the taxes, even if the people perish’.
Public perceptions of mental disorders: influences on policy
Public perceptions of mental disorders and wellbeing, prejudices and ‘fashion’ have affected policies. Societal expectations, such as about self-reliance, self-management and personal independence were among factors which contributed to decisions since the 1960s to close dedicated mental health inpatient and community facilities from which patients benefitted. As historian and former inpatient Barbara Taylor wrote in The Last Asylum (2014, p.264)
The mental health system I entered in the 1980s was deeply flawed, but at least it recognized needs – for ongoing care, for asylum, for someone to rely upon when self-reliance is no option – that the present system pretends do not exist, offering in their stead individualist pieties and self-help prescriptions that are a mockery of people’s sufferings.
Arguably, today, for mentally unwell people who are homeless, or unemployed, on welfare benefits and living in relative isolation, former mental hospital long-stay wards may have offered more stability and support than their successor, so called ‘community care’. Although new provisions have aspired to ideals, the realities have fallen short. Historian Pat Thane, in Divided Kingdom (2018, p.385-6), noted assumptions rather than evidence influencing policies for other long-term welfare needs where stigma and stereotypes were entwined, resulting in costly and inefficient outcomes. Stigma is also associated with shifting language to skirt round discomforting labels. In NHS, public, political and ‘patient’ (or ‘client’ or ‘service-user’) discourse on mental ‘disorders’ (or ‘problems’, ‘conditions’, ‘difficulties’, ‘disturbances’, ‘illnesses’ etc.), shifting and imprecise terms, plus misunderstandings linked to stigma and stereotyping, create an unpalatable recipe for effective policy making.
Human rights: policy, prevention, resources and parity
According to WHO, the highest attainable standard of health is a human right. To achieve it requires population-wide prevention and early identification of disorders, and an array of services for people suffering from them. For mental health, the degree to which this is fulfilled is contentious. Regarding services for severely mentally ill people, an independent review of the Mental Health Act 1983, commissioned by Prime Minister Theresa May in 2017 and chaired by psychiatrist Simon Wessely, proposed a human rights approach to treatment. This aimed to increase patients’ choice and reduce compulsion, with therapeutic benefit being the primary objective. Eight years on, in 2025, a bill is inching its way through parliament. Such long delays are hardly acceptable on human rights matters.
Regarding prevention, on a population level, social inequalities, including poverty, unemployment, unhealthy environments, childhood deprivation and social marginalisation (of homeless people, asylum seekers etc) impair mental and physical health. Nevertheless, despite being remediable, these social factors are often neglected. Comparable social factors are associated with suicide. Although the suicide rate for England and Wales declined (c.1980-2005), it has increased again alongside growing inequality. In 2023, the Office for National Statistics’ reported ‘the highest [suicide] rate seen since 1999’. However, NHS England’s 2023 suicide prevention policy paper, was less alarming: ‘while overall the current suicide rate is not significantly higher than in 2012, the rate is not falling’. Even if both these statements are numerically correct, the language and emphasis differ, leaning towards the NHS reassuring itself and the public that its contribution to mental healthcare is satisfactory.
A related notion is that of ‘secondary prevention’, aiming to minimise disability caused by a disease process across its entire duration. For people with severe chronic mental disorders, this has a long history of falling short. Over the last century, for example, their life expectancy has, on average, been consistently 15–20 years less than that of the general population, largely due to preventable physical disorders. In 2024, NHS England published guidance to help improve the physical health of people living with severe mental illness. Of its 23 pages, the words ‘should’ and ‘may’ occurred a total of 140 times, and the more forceful terms ‘must’ and ‘duty’, 6 times. ‘Duty’ only appeared regarding legal obligations, not as ‘duty of care’ or ethical duty to patients. In the context of austerity, if language suggests that directives are optional, they are unlikely to carry necessary weight for widespread, effective implementation.
The government has appeared indifferent towards evidence-based prevention strategies concerning mental health. Competing priorities create challenges, particularly in the context of limited resources. However, the Health and Social Care Act 2012 enshrined the principle of ‘parity of esteem’, funding mental and physical health services equitably. Twelve years on, Lord Darzi’s independent investigation of the NHS in England found that although mental ill-health accounted for over 20% of disease burden, it received under 10% of NHS spending. In December 2024, mental health charities petitioned the government for better funding. However, neither the legal obligation to parity, nor the charity plea, appear to have been heard: in January 2025, the government announced its plan to reduce NHS waiting list times—for physical, but not mental, disorders.[LCK1]
Service organisation: policy drive for ‘integration’
NHS policy has encouraged integrated care in various guises, at least since the 1960s. Integration has the potential to streamline communication and information sharing to facilitate a holistic, coordinated approach to care to benefit patients, especially those with complex needs, and to improve efficiency and value from health delivery systems. Regarding mental disorders, the Care Programme Approach (CPA, 1990; revised and renamed Community Mental Health Framework, 2019) was one manifestation of integration. CPA stressed close working between health and social services. It involved patients and carers in decision-making and provided a structure for flexible care according to individual needs. Its objectives were humane but its usage variable, and obtaining sufficient resources, a recurring struggle.
Placing patients’ needs at the centre of policy is crucial, but the needs of frontline staff, key players in service delivery, come a close second, a factor which has often been overlooked. It happened, for example, when provider authorities interpreted Everybody’s Business: Integrated Mental Health Services for Older Adults (Department of Health, 2005) as necessitating the integration of services for older people with those for younger, in the interests of equality. This ignored realities that patients’ mental, physical and social needs change with age, and that staff require specialist knowledge and skills matched to those needs. It also failed to recognise that some frontline staff chose to work with either older or younger adults. In some teams, job satisfaction, morale and quality of care were impaired, and recruitment and retention destabilised. Such occurrences are the straw which breaks the camel’s back, amid an endless flow of new policies and guidelines, and rapid and continuous organisational change which precipitates ‘change fatigue’—overwhelming feelings of stress, exhaustion and burnout which prevent staff from putting their full energy into patient care. Many staff are fearful of speaking up about problems they encounter, despite constructive policies encouraging them to do so.
In 2022, the Health and Care Act replaced locality based clinical commissioning groups with integrated care systems (ICSs), partnerships of organisations to plan and pay for health and care services in their area. An excellent idea, but has it succeeded? Two years later, I asked an NHS consultant ‘liaison’ psychiatrist whose work straddles community, emergency and in-patient settings. Drawing on his own experiences, and those of members of the Royal College of Psychiatrists’ Faculty of Liaison Psychiatry, he described services in silos and fragmentation as endemic, including with the electronic patient record systems. His team, for example, had no access to patients’ social services or primary care records and had to contend with separate mental healthcare and general hospital computer systems which did not ‘talk’ to each other. The degree of service integration varies across the country, but poor communication and fragmented care, plus stringent compliance to data protection regulations, have impeded ‘duty of care’ sharing within and between agencies, contributing to suicides and other tragedies.
Crossing organisational boundaries can also create territorial disputes of responsibility, with ethical, financial and practical components. In an emergency, if the public perceives an individual to be at risk, they are likely to call the police. However, since mental illness is not a crime, it is argued that the police should not be the first responders. Rather, dedicated mental health staff should have that role. In 2023, the ‘Right Care, Right Person’ National Partnership Agreement planned that the police would work with ICSs to develop this strategy. Current policy is that if the police attend a mental health crisis and there is no immediate risk to life—a difficult judgement to make—they can withdraw. They have no obligation to refer on, prompting the question of whether that is an ethically justifiable patient-focussed end point to their involvement. The distressed person may or may not be able or willing to seek out other options, such as the Samaritans, Mind, NHS 111 (now with a mental health option), emergency departments or NHS mental health crisis lines. Sadly, the BBC (2023) reported that NHS crisis lines were failing to answer calls in a timely and appropriate manner. Crisis lines undoubtedly help some people, however, as with other aspects of established services, there is insufficient evaluation of their effectiveness, and in this case also lack of consensus about the best methodology for that task, the outcome of which could inform policy.
Guidelines and pathways: benefits and harms
The National Institute for Health and Care Excellence (NICE) has published clinical guidelines since 2002. In contrast to policy innovation, NICE guidelines are derived from clinical research, preferably randomised controlled intervention studies and systematic reviews. Guidelines are not intended to override clinical decision-making concerning individual patients, but deviating from them requires justification. NICE recommendations seek to ‘drive innovation into the hands of health and care practitioners’, but their status reinforces a rule-based culture, which may divert staff from responding to individual patients’ needs outside the prescribed framework. This problem is also reflected in clinical (or care) pathways which intend to improve standards and ‘maximize the outcomes for specific groups of patients‘, rather than individuals. The Liverpool Care Pathway caused controversy in this regard. It aimed to improve end of life care in general hospitals, but rather than being a flexible guide, it became the definitive method. An independent inquiry (2013) into its use had the title More Care, Less Pathway. More recently, Gwen Adshead, psychiatrist and BBC Reith Lecturer 2024, stated that the NHS now has a ‘“widget making” model of mental health care….Patients are put on “pathways of care”, which end with discharge when the course is finished, not when the patient is better.’
The rhetoric and reality of policy design
New policies are presented as original, upbeat, reassuring and straightforward, yet they are complex in many ways. They rarely mention successful or failed earlier policies, or recommendations from inquiries into inadequate care. Their excessive positivity may only tell half the story, usually the half which shows the NHS and the government in a good light. By way of example, the report from the inquiry into failures of care at Winterbourne View Hospital for people with learning disability (2012) was called Transforming Care. In response, NHS England established the Transforming Care Programme. In 2025, its website does not mention its origins but showcases some success stories. In contrast to the official positivity, the Challenging Behaviour Foundation’s webpage Transforming Care – history and future outlines progress since the original inquiry, including missed targets and more failures of care. As with the suicide data, the NHS may present its achievements more optimistically than independent agencies.
In contrast to scientifically derived research evidence required to introduce new clinical treatments or procedures, service developments and new mental health law may be founded on theories or opinion. An amendment (2007) to the Mental Health Act 1983, for example, introduced ‘Community treatment orders’ (CTOs). CTOs aimed to reduce hospital readmission of psychotic patients by supporting them in the community, but were controversial because of the degree to which they curtailed personal liberty. Only after their introduction did a research study demonstrate that they failed in their objective. Another scheme, Improving Access to Psychological Therapies (IAPT; The Depression Report, 2006), was spearheaded by economist Richard Layard. Although linked to evidence-based NICE recommendations, the Report argued [LCK2] [CH3] primarily from an economic perspective. IAPT was introduced as a cost-effective way to return people to employment and reduce reliance on incapacity benefits. It assumed a narrow, single directional relationship of mental disorders, such as depression and anxiety causing inability to work, with little acknowledgement that psycho-social factors, including the workplace, might have contributed. IAPT did not ‘cure’ the ‘problem’. By using employment as an outcome measure, IAPT also automatically excluded people above state pension age, regardless of whether they might benefit. Alleviating older people’s symptoms, however, could also have economic benefits, such as by facilitating their involvement with their community, or by increasing independence and reducing social care costs. Almost 20 years on, renamed NHS Talking Therapies, it is now more inclusive.
IAPT was one of several national mental health policy innovations of the noughties, before the global financial crisis of 2008. One of them, which also illustrates the complexity of new policies, was the ‘recovery model’. It was imported from the USA. Aligning with WHO’s definition of mental health, the recovery model sought to empower individuals with severe mental illness to find their own ways to cope and have a satisfying life despite ongoing symptoms. In more traditional language it would have equated with ‘healing’, a process of becoming ‘whole’ in oneself when the possibility of cure is remote. Principles of consumer rights in public services and patient involvement in decision-making about service development as well as their own care, plus the mental health ‘survivor movement’ (which emerged contemporaneous with other organisations aiming to empower socially marginalised people), stimulated the recovery model. Despite its core message of hope, as with many mental health policies, its effects have been varied. It has inspired ‘recovery colleges’ to support personal recovery through adult education and co-production. However, it has also been used as a rationale to withdraw services, such as day centres and day hospitals, which are more staff intensive, more expensive to run and may be construed as promoting dependency. One-size-does-not-fit-all, and the recovery model may be inappropriate for the most vulnerable and mentally unwell people: according to professor of psychiatry Rob Poole, ‘To pretend otherwise does not serve them well’.
Targets, measurements and money and their place in mental healthcare
Targets have been increasingly finance and process driven since the report (1983) by Roy Griffiths, director of the J Sainsbury grocery chain, which introduced principles of ‘general management’ and market disciplines into the NHS. Psychiatrist and epidemiologist Norman Sartorius referred to ‘commoditification’, the ‘gradual conversion of all interactions and activity into economic terms’. Sartorius explained that the emphasis on cost-effectiveness has often been accompanied by a worsening quality of healthcare, especially for those with chronic conditions. He also pointed out that year-on-year short term savings sound good to policy decision-makers who may ignore ‘dangerous consequences’ longer-term, for patients’ outcomes and for expenditure. As an alternative to process targets, patient- and clinician-rated outcome measures, with established reliability and validity, are available. They reflect what matters most to patients. The Royal College of Psychiatrists endorses their routine use in clinical practice, and a report in 2021 stated that they were ‘beginning to be used more routinely in commissioning processes and for the quality assurance of existing services.’ Their influence on policy decisions, however, is unclear.
Input and process targets may be cited as objective evidence but are biased in that they measure what those with management authority, rather than patients and carers, deem important. They are often used as proxy measures for outcomes. That may be suitable for acute physical illnesses, but not for people with chronic mental disorders whose service use is not synonymous with outcome, whether that be wellbeing, symptom severity, or disability. Process data can provide evidence of completed tasks, thus helping to protect staff and employers from allegations of neglect. However, they do not indicate quality of assessment, intervention or therapeutic relationship. Such ‘job done’, rather than outcome, targets can generate staff complacency about what they do, or demoralisation regarding the quality of care provided. They also mark a level of care which once met, need not be exceeded, therefore inhibiting the pursuit of excellence. Monitoring completed tasks may also create a false sense of security among the leadership that resourcing and provision are sufficient[LCK4] . That is, until things go wrong, as demonstrated with the care of Valdo Calocane who killed three people in Nottingham in 2023 due to his paranoid schizophrenia. Reporting in 2025, the independent inquiry into his care revealed a catalogue of errors and service deficits. The services were under resourced and unable to provide for his needs. There was dissonance between national policies and guidance and actual service delivery. There was inadequate understanding, identification and management of risk, inadequate information sharing, and lack of involvement with the patient and his family around care planning.
The lure of targets for administrative purposes is also demonstrated in the context of memory clinics. Established to assess people for possible dementia, these clinics became widespread from around 2000, arguably to ration prescribing of expensive new acetylcholinesterase inhibitor medications which provided some benefit for people with Alzheimer’s dementia. The dementia diagnosis target box could be ticked following the clinical assessment and giving information to the patient, or whoever accompanied them to the clinic, and ‘signposting’ them as to where to find help in the future.
Dementias are fatal degenerative diseases, but patients are generally discharged back to primary care, and receive limited specialist post-diagnosis monitoring, especially long-term. People with diseases with a similar trajectory of decline but which affect mainly physical function are more likely to receive longer-term expert follow up, e.g. motor neurone disease. How would any of us cope with a dementia diagnosis, adjusting to a fatal illness then being discharged!? Primary care and signposting as the mainstay of treatment throws the ball into the patient’s court. There has been little evaluation of signposting schemes overall, let alone for people with dementia who may have little insight into their limitations, and impaired intellectual, new learning and adaptational abilities. With support sourced through ever-changing digital means, signposting risks failing to achieve humane and dignified outcomes. That failure also has an economic cost: when patients and their families feel isolated and despairing, medically unnecessary expensive general hospital admissions may result.
Sometimes, short-term sticking plaster NHS budgets appear if levels of provision are dire: the NHS is reported to have spent £2billion on private mental health beds in 2024, probably needed due to excessive reduction of within-NHS mental health beds (in: 1990, 59,000 beds; 2000, 34,000 beds; 2010 25,000 beds; 2023, 17,800 beds). Regarding bed shortages, when a person with assessed acute mental healthcare needs requires urgent inpatient care but there are no beds available in their usual local network, an ‘out of area placement’ (OAP) may be arranged. The government promised to eliminate OAPs by 2021, but in March 2024, around 900 patients were out of area, almost 10% of whom were over 300km from their homes. OAPs cost more than local care in short-term financial accounting; and they deter family, friends and the care co-ordinator from visiting, which may jeopardise continuity of care and effective discharge planning. They are associated with anxiety for patients, post-traumatic stress disorder, suicide, and an undermining of patients’ and their families’ trust in the mental health system.
Conclusions
NHS mental health policy over the last quarter of a century has lacked well-researched, patient-focussed evidence tied to human rights. Services have been adequate for many mentally unwell people, but they have failed many others, including those with the most severe mental disorders, whose overall physical, mental and social wellbeing could be improved. Many of the themes discussed in this paper are ongoing. In the context of failures to implement and fund recommendations from previous inquiries, we are yet to see what happens with those from the Valdo Calocane inquiry. Still more inquiries are underway: at the time of writing, an independent statutory inquiry (chair: Baroness Lampard) is investigating the deaths of mental healthcare inpatients in Essex.
Regarding the number of new policies and guidelines, this analysis cannot be comprehensive. Instead, it has highlighted recurrent patterns, and inconsistencies and polarizations of principles, values and actions. Patients have become more empowered, linked to the survivor movement and the recovery model, while frontline staff feel disempowered, including by change fatigue, being task-driven, and fearing speaking-up. Good research evidence is required to authorise new clinical interventions, but theoretical and economic models have underpinned changes in service delivery. Patients’ long-term needs, and the associated financial implications, seem invisible to policy makers. Clinical pathways aim to improve care, but can distract from individual patient needs. Promises have been broken and parity between mental and physical healthcare resourcing has not been reached. Meanwhile, the NHS offers reassurance that all is well, but crises, tragedies and observations from external bodies suggest otherwise.
Policy makers require deeper understanding of the realities of mental illness, patients’ needs and relevant research, and the will to steer mental healthcare out of the current quagmire[LCK5] [CH6] , giving due regard to the parity of esteem principle. Much is known about how to achieve more patient-centred, evidence-based, effective holistic and humane care. Some is written into policies, but it lacks a sense of commitment regarding implementation. In spring 2025 a Royal College of Psychiatrists’ newsletter emphasised psychiatrists’ desire to collaborate with policy development and implementation, to work to translate ideas into action, with the enduring WHO human rights principles underpinning change.
