The state of health care and adult social care in England 2024/25

Access to mental health care

A high demand for services and long waits for mental health care are well-known. These are longstanding challenges that have been exacerbated in recent years by the impact of the COVID-19 pandemic, austerity, the cost-of-living crisis and challenges with housing.

Over the last 5 years, we have consistently reported our concerns that when people cannot get the care they need when they need it, their mental health can deteriorate and they may then end up requiring urgent and emergency care.

Last year, our rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) highlighted particular concerns about the systemic issues within community mental health care. This year, we started a comprehensive programme of inspections of community mental health services for working-age adults, crisis services, and health-based places of safety (HBPoS). This programme aims to give us a better understanding of where the quality of care, patient and public safety, and staff experience in community mental health services is not up to standard.

To help shape our inspections, we held sessions with people who had experienced adult community mental health services and people that work in NHS trusts providing these services. In this section, we use the findings of this research to explore the challenges for people needing adult community mental health care, and the implications for the mental health care system more widely.

Increasing demand and more complex needs

Data from NHS England shows that the number of people needing mental health care continued to grow in 2024/25, with an average of 453,930 new referrals to secondary mental health services every month. This is an increase of 15% from 2022/23, when there was an average of 394,781 new referrals to secondary mental health services each month (figure 7).

Figure 7: Average number of new referrals each month to secondary mental health services

Source: NHS England’s Mental Health Services Monthly Statistics

Data from NHS England shows that between 2023/24 and 2024/25, the number of contacts with community mental health services increased by 8%, rising from a monthly average of 2.5 million to 2.7 million (this is defined as having a care contact resulting from a referral, such as a face-to-face appointment, phone call, or home visit). The increase in the number of contacts varied by age group, with the number of contacts with mental health services for children aged 6 to 10 growing by 16% in the same period.

During the same period, NHS England’s Mental Health Act statistics show that the number of new community treatment orders (CTOs) continued to rise, increasing by 17% from 2023/24 to 2024/25. Data from NHS England shows that since April 2023, there has been a steady increase in the number of people with serious mental illness who have accessed community mental health services at least twice in the previous year, rising 11% from 576,081 on average per month in 2023/24 to 640,619 on average per month in 2024/25.

Results from the 2024 Community mental health survey, published in April 2025, show that in this context, people are still waiting too long for mental health care and are unable to access the care they need when they need it. The survey found that:

• a third of respondents (33%) reported waiting 3 months or more between their assessment and first appointment for treatment
• 14% reported waiting more than 6 months
• two-fifths (40%) of respondents felt that the waiting time was too long.

These findings are supported by feedback from our focus groups with Experts by Experience, held as part of our focused review of community mental health services for working age adults, crisis services and HBPoS. People described how services would tell them that they were being put forward for specialist support, such as psychotherapy, only to then be stuck on waiting lists for prolonged periods. In some cases, people were discharged to community mental health services and then waited a long time before being told that they were going on a waiting list.

It's been, I think probably 3 1/2, or 4 years since I've been inpatient, and I still haven't received any psychological support. Only in December did they say, OK, we'll put you forward for psychotherapy.

Sometimes, the gap between the initial assessment and being put on a waiting list lasted for years, meaning people were waiting for specialist support for extended periods following the initial assessment. Some people linked the long wait for care with a lack of investment in staff and resources (see also ‘Impact of workforce pressures on people’).

People were also concerned about how thresholds for accessing different services varied across the country, which may lead to people falling between the gaps in care pathways. For example, a person may be considered too high risk for NHS Talking Therapies, but not high risk enough for community mental health services. People told us about their frustrations when they, or those they cared for, had not met the risk threshold for a service:

I haven't received in my 15 years of being in mental health support a structured psychotherapeutic intervention because I've kept kind of yo-yoing between thresholds and different areas, and different areas won't accept certain levels of risk and others will.

People told us that this could be a particular challenge after being discharged from crisis or inpatient services, as their risk threshold was sometimes considered to be too low to access community mental health support or interventions, despite voicing their struggles and need for this support. This meant a risk of deteriorating to the point of needing to be admitted as an inpatient, or of not receiving adequate support to enable them to feel better or well.

The same challenges we see in access to care for working-age adults also remain a concern for children and young people. The latest annual report from the Children’s Commissioner highlights huge inequalities when it comes to accessing support, with some young people waiting up to 17 times longer than others depending on where they live. The report also shows 50,000 more children with active referrals were still waiting for treatment to begin at the end of March 2024 compared with the previous year (320,000 in 2023/24 up from 270,300 in 2022/23). Concerns around these long waits are discussed in more detail in our section on children and young people.

Through our engagement events with providers, held as part of our focused review of community mental health services for working age adults, we heard how alongside rising demand and lengthy waits, people’s needs are becoming increasingly complex. As we have reported previously, when people are not able to access the care they need when they need it, it can lead to their conditions worsening and/or reaching crisis point. In some cases, outside influences, such as difficulties finding housing and employment, are exacerbating this. At the same time, more care is being provided in the community and access to hospital care is becoming more challenging because of higher thresholds, delayed discharges and fewer beds, with NHS England’s data showing that bed occupancy continues to be above the 85% target As a result, more people with higher levels of risk are being managed in the community.

The challenges facing crisis services

Waiting a long time for care can lead to a deterioration in people’s mental health. Results from the 2024 Community mental health survey showed that the longer people wait, the more people reported that their mental health got worse. Among people who waited less than 2 weeks for help, 24% said their mental health got worse, compared with 71% of people who waited more than 6 months (figure 8). Overall, while an improvement on the 2023 survey findings, more than two-fifths (42%) of respondents said they felt their mental health got worse while waiting.

Figure 8: While waiting, between your assessment with the NHS mental health team and your first appointment for treatment, did you experience any changes in your mental health?

Source: 2024 Community mental health survey

As we have reported previously, not getting the care they need when they need it can lead people to end up in crisis. In the last 2 years, the number of urgent and very urgent referrals to crisis services has continued to rise. Data from NHS England's Mental health services data set (MHSDS) shows 77% more very urgent referrals in 2024/25 compared with 2023/24 (rising to 60,935 from 34,455). There are known quality concerns with this data, with a small number of trusts contributing a large percentage of these very urgent referrals. Improvements to data quality and reporting will be required to give us a confident picture of the pressure on crisis care services.

Feedback from our inspection teams suggests the reasons for this increase are complex and varied. Issues such as the ongoing impact of the pandemic, long waiting times, lower bed capacity and people with more complex needs being cared for by community teams are all having an impact.

To support people in crisisto get compassionate care that meets their needs, in July 2023 the government published the Right Care, Right Person (RCRP) framework. This set out a national commitment from the Home Office, Department of Health and Social Care, the National Police Chiefs’ Council, Association of Police and Crime Commissioners, and NHS England to work to end the inappropriate and avoidable involvement of police in responding to incidents involving people with mental health needs. Local areas were tasked with agreeing a joint multi-agency plan for implementing and monitoring the RCRP approach.

The national framework sets out when it is appropriate for police to respond to a mental health-related incident, including:

• to investigate a crime that has occurred or is occurring; or
• to protect people, when there is a real and immediate risk to the life of a person, or of a person being subject to or at risk of serious harm.

When this threshold is not met, partners in local areas will agree the best health-based approach to support those in crisis. The aim is to ensure people in crisis are responded to by the right person, with the right skills, training, and experience to best meet their needs. However, as previously highlighted by NHS Confederation, this reduction in support from police adds to the already rising demand and pressure on mental health services, increasing the risk of people falling through the gaps.

Standards for crisis teams are that they should see very urgent referrals within 4 hours and urgent referrals within 24 hours. Over 2024/25, the total number of people who were seen within 4 hours increased. However, data from NHS England shows that as the number of very urgent referrals continues to increase, the number of people who are actually seen within 4 hours is not increasing at the same rate.

As at March 2025, data from NHS England shows 17% of new very urgent referrals were seen in 4 hours, down from 33% in April 2023 (figure 9). This is supported by the results of the 2024 Community mental health survey, which found that of the respondents who contacted an out-of-hours crisis team, over a quarter (27%) did not get the help they needed. Mental health service providers that participated in our engagement events described the increased pressure on crisis teams and inpatient beds as ‘overwhelming’ and ‘scary’.

Figure 9: New very urgent referrals to crisis teams, including people seen face-to-face and within 4-hour time standard for reporting month (all referrals/all age groups)

Source: NHS England’s Mental Health Services Monthly Statistics

As we highlighted in last year’s State of Care report, when people reach crisis point but can’t get help from specialist crisis services, they may attend an emergency department to seek help. However, once at hospital people are then facing long waits for assessment, treatment and discharge.

In July 2025, the government announced as part of the 10-year Health Plan for England that it would be investing up to £120 million to develop more dedicated mental health emergency departments, to ensure patients get fast, same day access to specialist support in an appropriate setting.

Inconsistencies in care

Providers of community mental health services told us how inconsistencies in commissioning meant there was huge variation across the country, leading to disparities in pathways, access to services, and the provision of services. This variation can be a result of factors such as differences in:

• geographical areas
• the populations served
• funding and commissioning
• understanding of people’s needs.

Without an agreed model for how services should be structured or delivered, we have also heard that there is huge variation in the types of services trusts offer and how these are delivered.

We heard how this could lead to variation in care, where the quality of care a person receives, as well as the ability to access services, depends on where in the country they live. One person in our focus groups with Experts by Experience told us this could lead to a sense of being stuck in their local area, as this is where their support network is, and they wouldn’t know about the quality of care available if they moved to a different area:

[You feel] pinned down in one town or city because that's where your support network is, therefore if well enough to work or have a relationship with someone somewhere else, you cannot move.

Providers told us they would like to see commissioning of services meet the level of need in the community as, although provision could be similar across both urban and rural areas, the levels of need were very unbalanced.

Providers in our engagement events as well as people in our focus groups felt that standardised approaches to commissioning would help to combat geographic healthcare inequalities. As one CQC Expert by Experience told us:

We need to address the postcode lottery. There needs to be standardisation so that every area has good quality care. It is not fair that people are not entitled to quality care because of the area they live in. Equity of quality of care, for marginalised groups, for those who are disabled, for all intersections of the community.

Mental health workforce

Despite a growth in the workforce over the last few years, systemic issues with recruitment, retention and skills gaps continue to have an impact on patient experience and safety.

Resourcing and capacity challenges

In both last year’s State of Care report and our 2023/24 Mental Health Act Annual Report, we highlighted how the size of the mental health workforce has not kept up with the rising demand for mental health care (see Increasing demand and more complex needs). Despite an increase in the number of staff over the last few years, the NHS Vacancy Statistics shows that 9% of roles in mental health trusts in the NHS were unfilled in March 2025.

Evidence from our adult community mental health inspection programme has shone a light on some of the challenges facing the mental health workforce, and the impact of these on staff, providers and people who use adult community mental health services.

We know that some staff face additional challenges. We look at the Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standards (WDES) as part of our assessment of workforce equality, diversity and inclusion, under the well-led key question. We discuss the findings from the 2024 NHS WRES and WDES data in our section on Workforce challenges.

Through our engagement events, providers told us how gaps in the workforce are exacerbating pressures on services and staff, and that they are not always able to cope with increasing levels of demand. In some cases, we heard how the NHS mental health transformation programme had contributed to these workforce challenges, creating vacancies and recruitment issues as well as concerns around staff training.

Recruitment and retention issues are also leading to significant challenges around staff experience, skills and competencies. Providers and our inspectors have shared concerns around the pace that some staff are being promoted and of the loss of experienced staff in teams. Providers, along with Experts by Experience, raised concerns about the impact of skill mix, experience, and staff turnover on the quality of care.

These pressures are having a negative impact on staff wellbeing. Providers told us staff were burnt out, overworked and experiencing low morale. They described how teams feel they are ‘on their knees’, constantly fighting fires and seeing little longer-term impact, which is in turn contributing to burnout and issues with staff retention.

This is supported by data from the 2024 NHS Staff survey which shows that for mental health and learning disability trusts, and mental health, learning disability and community trusts:

• less than half (49%) of people felt able to meet all the conflicting demands on their time
• over a third (34%) of people reported always or often finding their work “emotionally exhausting”
• a quarter (26%) of people reported they were always or often feeling “burnt out because of their work”.

In addition, as highlighted in our section on Workforce challenges, the overall sickness absence rate for England increased in 2025.

Impact of workforce pressures on people

We reiterate our concern that high demand for community mental health services without the capacity to meet it affects people’s ability to get the help they need when they need it. In our focus groups with Experts by Experience, some people linked the lack of staff and resources with long waits for care (see also Increasing demand and more complex needs). People also described how it could lead to a lack of continuity in care:

For me, it’s the continuity of support that’s challenging, having to repeat their story and rebuild the relationship. This keeps happening in a short space of time. I’ve had 4 care co-ordinators over the space of a year, which is ridiculous.

Some providers that took part in our engagement events also described the impact of under-resourcing, and how this was making caseloads unmanageable. They highlighted how this meant risk assessments and care plans might not be completed, with staff having to choose between managing caseload numbers and delivering an effective quality of care for patients. We heard that this was compounded by a lack of national standards and guidelines around managing caseloads.

Through our inspections we have found a more mixed picture of how services are managing caseloads in the face of rising demand. In some services, there are high caseload numbers but no waiting lists, while others have lower caseload numbers but a large number of people waiting to be allocated care co-ordinator. Inspectors raised concerns that this could lead to ‘hidden waiting lists’, where a person has been referred to the service, but is not receiving support because they do not have a named care co-ordinator.

A few people in our focus groups with Experts by Experience also suggested that long wait times and waiting lists were a direct result of a lack of investment in community mental health services, particularly the lack of specialist staff and resources. This sentiment was supported by feedback from providers in our engagement events, who told us that greater investment and better placing of staff is needed to attract and retain staff with the right skills. They also highlighted the need for system-wide standards for managing caseloads.

Quality and safety of care

The increasing pressure on community mental health services is affecting the ability of providers to manage risk effectively, meet the needs of patients adequately, and provide person-centred care.

In this section, we provide an insight into some of the key challenges around the quality and safety of mental health care.

Lack of involvement and person-centred care

Guidance from the National Institute for Health and Care Excellence (NICE) states that care and treatment should take into account people’s individual needs and preferences. People should also have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.

In last year’s State of Care, we highlighted how people are struggling to get person-centred care that meets their needs. This year, our focus group with Experts by Experience showed that this is still an issue. People told us they need greater involvement, autonomy and choice in how their care is planned and delivered. They described how decisions about their care are sometimes made without involving them, and that they do not always feel listened to, or that staff do not always understand their needs. People particularly wanted greater involvement in decisions around their medicines (see section on Medicines optimisation).

The results of the 2024 Community mental health survey support these experiences, as over a third of respondents (38%) said they did not have a care plan. Of those who did have a care plan, 70% were involved in agreeing their care plan to ‘a large’ or ‘very large extent’. When asked if they were given a choice about how their care and treatment would be delivered 36% of respondents said they were not, and over 1 in 4 (28%) said they did not feel in control of their care.

Some people in our focus group with Experts by Experience talked about not being involved in meetings with multidisciplinary care staff. One person told us they were not able to see the notes from the multidisciplinary team meeting, despite decisions about their care being made in these meetings. People who had been involved in multidisciplinary team meetings still described feeling like they were not being involved in their own care. They described this as annoying, that it made them feel out of the loop, and that the lack of involvement was “a shame”.

People also described how their family or carers were not consulted or included in conversations about care planning when they wanted them to be. Again, the results from the 2024 Community mental health survey also found that over 1 in 5 respondents (21%) would like their family or friends to be more involved. People in our focus groups mainly talked about friends and family not being informed about care plans, and not being told what warning signs and side effects from medicines they should be looking for. This left their family or carers feeling unsupported and uninvolved.

A lack of involvement could lead to problems when staff do not understand people’s experiences, history and needs. For example, a couple of people in our focus groups told us their experiences of being in a mental health crisis but staff advising them to “get a cup of tea” or to “have a bath”. They believed that staff had not looked at their clinical notes and/or had not tried to understand their needs. These kinds of situations could leave people feeling more stressed than before they had contacted community mental health services. In some instances, people said that not feeling listened to could make them want to disengage from services.

This echoes the findings from our Special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust. Published in March 2024, our review found repeated concerns about a lack of person-centred care, including people not feeling involved in creating their care plans or with changes to their medicine, feeling dismissed, and not listened to.

However, where people in our focus group had positive experiences of involvement, they said staff had taken the time to better understand their needs and the approaches that would suit them. They described how this supported them in continuing their treatment.

Important role of care co-ordinators

Both providers and people who use services emphasised the key role of care co-ordinators in providing person-centred care. As well as being a named contact, care co-ordinators give people greater continuity of care, with oversight of their care throughout the pathway.

We heard about some positive experiences during our focus groups with Experts by Experience, with one participant telling us they had the same care co-ordinator for several years. This meant they were able to build up a rapport with them, and the co-ordinator knew and understood their needs. Other participants with additional needs described their care co-ordinators as being “vital” and “worth their weight in gold”.

However, we heard how the high volume of work for care co-ordinators could compromise the quality of care they provided. We also heard examples where people had had many different care co-ordinators, locum psychiatrists, social workers, and support workers. This often meant the new worker did not know the person and they had to repeat their experiences, which could be distressing. Participants mentioned that a lack of continuity in their care also meant that, at times, they did not know who they would be seeing; for some people this led to increased anxiety and uncertainty.

Without adequate support from mental health professionals in the community, people from our focus groups described having to rely on their support networks, usually friends and families, to provide care. We heard about the impact this could have on the life of a friend or family member, including a deterioration in their physical health and a breakdown in family relations.

Challenges affecting the safety of services

Several providers at our engagement events raised concerns around ageing estates that are increasingly not fit for purpose and do not meet the needs or safety of patients and staff. These concerns have been highlighted by our inspection teams, where the condition of some of the buildings used by community mental health services was not always supporting the delivery of safe and effective care.

People need to feel safe in therapeutic environments that are appropriate for the service they are receiving, and we have found during inspections that not all premises are suitable for the purpose for which they were being used. As well as the poor physical condition of some premises, concerns have been found regarding unreliable technology and the impact this has on staff being able to provide effective care.

Wider system pressures on community mental health services – particularly the challenges around resourcing and capacity (see section on mental health workforce) – are also affecting their ability to deliver safe and effective care that improves patient outcomes.

We previously highlighted evidence from our regulatory activity that showed how problems with staffing and skill mix are a key concern. Along with wider system pressures, this is affecting providers’ ability to effectively manage risk over supporting people’s longer-term recovery.

Providers at our engagement events had concerns about their ability to appropriately manage and understand the impact of patient risks, particularly when staff are under pressure and don’t have capacity to do so. Some described having to manage these risks as ‘firefighting’. Inspectors told us during our focus groups that they are seeing issues around providers not properly recording or effectively managing risks.

We heard how this ongoing pressure meant there was no opportunity to pause and reflect on how to balance and manage potential harms and learn from deaths. Providers noted higher levels of aggression and violence in community services and raised concerns that current system challenges meant that what happened in Nottingham was not an isolated incident and could happen again elsewhere.

Participants in our focus groups with Experts by Experience told us about the impact these challenges were having on people. They described how pressures on services could lead to people being discharged from services before they were ready, increasing the risk of relapse or re-admission.

In my case they said ‘Right she’s ready to be discharged we’ll get rid of her’ because they’ve got waiting lists and they want to free up space, but you’re not ready to be discharged, they’ve made that decision, not you.

This feedback reflects the findings from our review of quality of care provided by Nottinghamshire Healthcare NHS Foundation Trust. This found issues including a ‘lack of clarity of thinking’ in the multidisciplinary team in relation to the decision to discharge, and people not being involved or notified of this decision.

Increased pressure across the system may, in part, explain the increase in people with serious mental illness needing to access community services.

Medicines optimisation

Medicines can be used to treat or prevent the symptoms of most mental illnesses as part of a comprehensive treatment plan. Taking a person-centred approach and ensuring people are taking their medicine in a safe and effective way is essential to achieving the best possible outcome. When mental illness is treated poorly, either because of delays in starting medicines, people stopping taking their medicine (non-adherence), under-prescribing or over-prescribing, the consequences for people can be devastating and increase the risk of relapse and being admitted to hospital.

Guidelines from the National Institute for Health and Care Excellence (NICE) are clear about the need for good communication between healthcare professionals and patients, to involve patients in decisions about their medicines, and to support adherence.

We commissioned Ipsos to look at good practice in managing medicines in the community from the perspective of people providing this type of care. Some professionals who took part said an important part of sustaining adherence is making sure people feel empowered in their care. This means patients having the same information as the professionals caring for them and actively involving them in the decision-making process. Having accessible patient information was an important factor in this.

In our focus groups with Experts by Experience, some people had positive experiences of communication and being involved in decisions about their medicine, but others raised concerns about a lack of information and choice about the medicines they were taking. They mentioned not understanding how to take their medicine or not having an opportunity to understand any side effects. The Ipsos research found that professionals reported these challenges were greater for people who don't speak English as a first language, as they face significant barriers in understanding diagnoses and treatment plans, and accessing information about available services.

In the Ipsos research, professionals reported that side effects were the most common concern for people (80%), with nearly three-quarters (74%) of respondents describing it as a key reason for people not adhering to their medicine regimen. Respondents described how people’s frustration with side effects can lead some to disengage from treatment altogether.

We can see this reflected in the findings of the 2024 Community mental health survey. Nearly 1 in 3 respondents (29%) who were taking medicine said that the side effects of their medicine had not been explained to them. Similarly, over 1 in 3 (35%) said they had not received an explanation of what would happen if they stopped taking their medicine.

Some people in our focus groups with Experts by Experience described feeling a lack of involvement in decision making. This included feeling they were given little choice about the medicine they were prescribed. It was a case of ‘this is what you’re being prescribed’, rather than a discussion about available options. Reasons around the lack of choice varied from not being able to access the appropriate staff to change their medicine, to participants feeling they were not being heard when querying the choice of medicines.

In the Ipsos research, participants believed regular medication reviews were essential for maintaining patient engagement. However, people in our focus groups with Experts by Experience raised concerns around the lack of reviews, or the prolonged length of time people spent waiting for a review, with one participant telling us they went 5 years without a medication review. This is supported by the findings of the 2024 Community mental health survey, which found that nearly a quarter of respondents (23%) said their mental health team had not checked how they were getting on with their medicine in the last 12 months.

A lack of reviews led to fewer opportunities to talk to clinicians about their medicine and the possible side effects. Inspectors described how this was a specific problem when patients were prescribed medicines that did not need regular contact and monitoring with their community teams.

Providers also spoke of the need for more effective monitoring of side effects, physical health, and non-adherence where people stop taking medicines. They identified a need for a consistent approach in raising and acting on concerns to support people. The systems and technologies used in community mental health care to support the safe and effective use of medicines are often not designed for the setting. This means providers often need to use workarounds or are unable to use the technology optimally.

Providers also raised concerns about a lack of accountability of prescribing and variation in accessing certain medicines across primary and secondary care. They also highlighted the need for clear guidance around community mental health and medicines, and the value of pharmacy staff in supporting community teams and optimising people’s care and treatment with medicines. However, use of dedicated pharmacy support varies across the country.

In March 2025, the government announced it had agreed funding with Community Pharmacy England worth an extra £617 million over 2 years as part of its plans for rebuilding community pharmacy and to support people to have easier access to care and support locally.

Lack of holistic care

In our focus group of Experts by Experience, several people told us there was too much focus on the medical model, and less of a holistic approach looking at people’s care. Participants reflected about being given medicines, but not being asked about other aspects of their life, such as sleeping, diet, and physical health.

In some cases, although they had multiple conditions, only one condition was treated at a time. This led them to feel that their physical or mental health had been forgotten while being treated for another condition, and that services could only deal with either the physical or the mental conditions as opposed to looking at the whole person.

This was reflected in the results of the 2024 Community mental health survey. Only 1 in 3 (29%) respondents said that their NHS mental health team had definitely supported them with their physical health needs in the last 12 months. A further 39% of respondents stated they did not have support for physical health needs, but they would have liked it.

But holistic care is not just about meeting people’s physical and mental health needs. There are social factors and wider system pressure – notably housing – that prevent people from getting the care they need. Providers in some areas discussed the challenges associated with poor availability of appropriate and supportive accommodation. This can result in people being discharged from secondary care as homeless, which can have an impact on the quality of care services can deliver.

Lack of social and other support was another finding of the 2024 Community mental health survey, with 67% of respondents saying their NHS mental health team had not offered any help or support with finding financial advice or benefits in the last 12 months. Similarly, more than three-quarters (77%) of respondents said they had not received any help or advice with finding support to manage the cost of living.

As part of its Community Mental Health Transformation programme, NHS England has committed to creating a more holistic model of care to meet people’s needs, which brings together services across the system. This is supported by the ambitions of the NHS 10 year plan to move care from hospital into the community.

System-wide challenges

Funding and the changing mental health landscape

Lord Dazi’s Independent investigation of the NHS in England in 2024 highlighted the chronic and long-standing under-investment in mental health services and how this, along with low productivity, has led to a treatment gap for people across the country. In the report, Lord Darzi also describes how long waits have become normalised.

Throughout our engagement events, providers discussed the significant challenges around funding for mental health services. We heard about the impact of a lack of funding in multiple areas including workforce, capacity and integration of services. This includes inpatient services. We will be discussing more around the challenges facing mental health services and the impact on people based on our monitoring activity in our forthcoming 2024/25 Monitoring the Mental Health Act report.

A recent report from the Centre for Mental Health noted the benefits of investing wisely in mental health. It highlighted that the introduction of NHS Talking Therapies in 2008 and the more recent development of community perinatal mental health services have both led to significant improvements in people’s lives, as well as economic and social benefits.

In 2019, the government published the NHS Long Term Plan. This, and the subsequent NHS mental health implementation plan, set out plans for improving mental health services through new and integrated models of primary and community mental health care. While many providers at our engagement events welcomed these ambitions, they told us that implementing this model has created additional challenges for them, and that there was a sense of ‘change fatigue’.

More recently, as part of the 10 Year Health Plan for England, the government has made a number of commitments to improving mental health care including the introduction of Young Futures Hubs to support children and young people’s mental health, funding for mental health units to fix their buildings, and the introduction of 24/7 neighbourhood care models.

In July 2025, NHS England announced the first 6 providers chosen to pilot a 24/7 neighbourhood mental health centre. These centres bring together a range of services under one roof, including crisis services, community mental health services and short-stay beds. People with serious mental illness such as schizophrenia or bipolar will also be able to walk in without an appointment if they need mental health support, as well as advice on employment, housing, or volunteering.

Communication, collaboration and system working

Through our engagement events with providers, many told us that a lack of collaboration between services and across the mental health system was their biggest challenge. We heard how poor collaboration has an impact on people’s experience of care, the co-ordination of their care and transitions between pathways.

Providers expressed frustration around poor communication and information sharing, including sharing care plans between providers. They told us that sharing care plans was vital for communicating people’s treatment plans, risk assessments, and for reducing the burden on the person themselves, so they do not have to repeat the same information multiple times.

Findings of the 2024 Community mental health survey show that poor communication is a prevalent issue, with 76% of respondents saying that they had to repeat their mental health history to their NHS mental health team. Over a third (36%) of these respondents said it happened often. Participants in our focus group of Experts by Experience described how having to repeat their history was distressing and could send a message that services and staff did not care.

People also told us that poor communication between services could also lead to indecisiveness about who would provide care. This led to them being in limbo about who would provide their care and if they would even get it at all. One participant told us that they were refused care as the service thought they were being cared for by a different service, despite that not being the case.

Good communication was seen as particularly vital when a person is discharged back to primary care. Providers spoke of the need to ensure all discharge notes are available to a person’s primary care doctor (GP) – ideally immediately. Providers told us this was important to reduce both risk and the potential for people’s wellbeing to deteriorate, and possible future hospital admissions or crisis. Poor communication around discharge was an issue we identified in our Special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust.

We heard from providers that information can get lost in translation, and that there were too many handover points. A lack of shared computer systems to store and access information across services added to difficulties in communication and contributed to ‘working in a silo’. Another factor from providers was that there are too many IT systems in place that do not ‘speak to each other’. This resulted in not being able to produce key data metrics to effectively monitor service delivery and identify risk areas, and staff having to use workarounds to input and extract information, such as flagging when people do not attend appointments.

Shared care protocols

Providers and people who use services told us that the relationship between community mental health services and primary care was challenging and needed improvement. This was a particular concern in relation to shared care protocols (see also section on medicines safety).

In the research we commissioned from Ipsos, over a quarter (26%) of respondents said that shared care protocols were one of the main challenges for services when supporting people who are taking psychotropic medicines in the community. Both mental healthcare providers and GP respondents expressed frustration and concerns around shared care protocols. Through our engagement with providers, we heard how some GPs were not always providing shared access to patient information or had withdrawn from shared care protocols. This was said to be adding pressure on community mental health services.

In February 2025, we held a workshop with GPs and hospital pharmacy leads to better understand the challenges for each sector more widely. At the workshop, GPs described how their workload was increasing and how they felt that shared care protocols were often for patients with medically complex conditions, which they did not have the knowledge to manage. They were concerned about patient safety and how shared care protocols increase the burden on already stretched resources. These concerns were reflected by the Ipsos research findings, with GPs expressing a lack of capacity and confidence to effectively manage patients under shared care agreements.

These findings were further supported by participants at our focus groups with Experts by Experience, who similarly told us that GPs are often happy to take on simple medication regimens, but are less likely to take on complicated medicines, making it much harder to get them changed. We heard how, in some instances, community mental health services had advised GPs to not make any changes to a person’s medicines. In others, GPs were said to be pushing back on medicines prescribed by community mental health services.

While shared care protocols are designed to make care more convenient and accessible, these challenges mean that many patients experience delays and inconsistency and find the system confusing. At our focus group with GPs and hospital pharmacy leads, GPs told us that issues with communication and transfer of care between specialists and primary care often left both the patients and GPs struggling to navigate between services. This was supported by findings from the Ipsos research, in which professionals described how patients frequently find themselves caught in the middle of a fragmented and confusing system.

We have shared the concerns identified through our workshop with GPs and hospital pharmacy leads with the Department of Health and Social Care (DHSC) and NHS England. We highlighted how system-wide reform is needed to deliver better patient-centred, safe and consistent shared care systems. This includes developing national leadership, equitable funding, integrated IT systems, stronger regulation, and workforce support.

DHSC is working with NHS England to further understand and explore challenges with shared care prescribing, including how this interacts with private prescribing. As part of this, it launched an open call for evidence on private (non-NHS) prescribing in August 2025.