How do we achieve a `balanced system`in community mental health services? A  realist evaluation

Introduction: For years people have been rejected from mental health services as not ill enough for specialist services or too risky, complex for psychological services.  The Community Mental Health Framework(CMHF) in England aims to fill this `gap` in services.  Our evaluation of CMHF services witnessed teams being overwhelmed by demand therefore we started to ask `what would make a balanced system and how could this be achieved`?



Method: Realist informed evaluations were conducted across 4 integrated care systems in England.  Researchers in residence observed real time delivery in community mental health services across multiple teams interviewing practitioners and managers (n=60+). Analysis, interpretation and dialogue with services and wider stakeholders generated a whole system model including indicators of system balance and imbalance.



Results:Analysis across 4 systems indicate problems with over complex pathways, fear of holding risk and uncertainty of  how to support those with less severe problems to self care. We found examples of flexible, efficient processes alongside engagement with social/community assets.  Our whole system model includes a set of causal links which need to be understood by system leaders to make decisions.  We propose placing the service user journey or support at the centre whilst considering the impact of system change on staff to be essential.  These can be aggregated to a set of measurable outcomes including whether those most in need are seen; waiting times and flow data; staff wellbeing and retention.



Conclusion: A systems approach to community mental health service delivery where community assets sit alongside traditional interventions, are important for generating positive outcomes and addressing inequalities. New measures of system functioning are needed alongside data on experience to support decision makers.