Introduction

Psychological therapies for people with severe mental health problems (also referred to as severe mental illness) are a key part of the new integrated offer for adults and older adults, as set out in the NHS long term plan (LTP) and the Community mental health framework for adults and older adults. Severe mental health problems include psychosis, bipolar disorder, complex emotional needs/’personality disorder’ and eating disorders. These diagnoses often occur alongside mood difficulties including depression, anxiety and post-traumatic stress disorder (PTSD).

This guidance is for NHS-commissioned mental health provider organisations, integrated care boards (ICBs), regional NHS England offices and chief psychological professions officers in mental health trusts. It aims to support mental health providers to deliver the LTP objective to increase access to psychological therapies for people with severe mental health problems, as part of a wider transformation of adult and older adult community mental health services.

The NHS England psychological therapies for severe mental health problems (PT-SMHP) programme has 3 main objectives:

1. To increase access to evidence-based psychological therapies, as recommended by the National Institute for Clinical Excellence (NICE), in order to improve outcomes for people with a diagnosis of psychosis, complex emotional needs/‘personality disorder’, bipolar disorder or eating disorder.
2. To ensure timely access to NICE-recommended psychological therapies for adults and older adults with severe mental health problems, to give them the best chance to get better and to stay well.
3. To provide better quality care and improved outcomes through the delivery of NICE-recommended psychological therapies for people with severe mental health problems.

This guidance is aimed specifically at supporting the expansion of psychological therapies for people with severe mental health problems by upskilling and expanding the specialist psychological professions workforce. However, it is recognised that within community mental services there are many other professionals who deliver support and interventions as part of a multi-disciplinary team. NHS England is also committed to upskilling and training the wider workforce, including mental health nurses and allied health professions to enable psychologically informed environments and to deliver evidence-based psychological interventions.

Services in and out of scope of this guidance

Psychological therapies should be more widely available across a range of services and populations. However, this implementation guidance is restricted in scope as follows.

In scope:

• ICB-commissioned community mental health services for adults and older adults (ages 18+) and early intervention in psychosis services (for people aged 14+)
• crisis services may be in scope for expanding structured clinical management (SCM) approaches but given the nature of Crisis Resolution Home Treatment (CRHT) teams’ work with service users, we would not expect that it would be appropriate for CRHT teams to deliver psychological therapies
• the target service user population is adults and older adults with a diagnosis of psychosis, complex emotional needs/ ‘personality disorder’, eating disorder, or bipolar disorder, including those with co-existing secondary needs or diagnoses (for example, substance use, neurodevelopmental conditions, depression, and anxiety disorders)

Out of scope:

• community perinatal mental health services, NHS talking therapies for anxiety and depression (formerly IAPT), forensic services, health and justice services, learning disability services, and children and young people’s mental health services (other than those that provide care for young adults aged 18-25) are out of scope for this programme of work and for this implementation guidance, likewise inpatient services
• mental health practitioners in primary care settings as they provide brief evidence-based psychological interventions, for patients ineligible for NHS Talking Therapies for anxiety and depression
• therapies or interventions not listed in this guidance are out of scope. of this guidance Other therapeutic or psychoeducational interventions may be offered as part of the community mental health offer; however, it is important that individuals have access to full, evidence-based (NICE-recommended) therapies that could benefit them

Key principles for delivering psychological therapies

People with severe mental health problems can present a wide range of health problems beyond their diagnosis of psychosis, bipolar disorder, eating disorder, or complex emotional needs/‘personality disorder’, including depression and anxiety disorders, such as post-traumatic stress disorder (PTSD).

The PT-SMHP programme aims to expand psychological therapy capacity in a way that allows these health problems to be treated in line with the overall LTP objective to deliver holistic and person-centred care. It will be particularly important that the expanded workforce of psychological therapists in community mental health are enabled to serve the needs of those with a range of difficulties where these are not within scope of NHS talking therapies for anxiety and depression (formerly IAPT) services.

NHS England has set out its vision for effective, good quality care in community mental health services. In this vision:

• care is personalised to people’s individual needs, and mental health professionals work in partnership with people receiving services to provide choices about their care and treatment, and to reach shared decisions
• active steps are taken to support equitable access across protected characteristics, including for groups that typically have not accessed psychological therapies at the expected rate (for example, older adults, including those with mild cognitive impairment, autistic people and people with learning disabilities). These active steps include the inclusion of specific adaptations within education curricula, ensuring that services are accessible and that treatment is adapted to meet population group needs, supported by specialist consultation and supervision where required
• people are offered evidence-based therapy as recommended by NICE
• people receive timely access to the assessments, interventions, and treatments that they need, so that their time in community services delivers therapeutic benefit. Care should be delivered in a therapeutic environment and in a way that is trauma-informed, working with people to identify and understand any traumatic experiences they have had, how this trauma may have impacted upon them and how they can be supported in a way that minimises re-traumatisation
• care is joined up across the health and care system. Community services work cohesively with other partners across the health system including, primary care, other secondary care services, and the voluntary, community social enterprise (VCSE) sector
• services actively identify and address inequalities within their community pathways, alongside people representing affected groups and communities. This includes ensuring that people are not prevented from accessing or receiving good quality community mental health care because of a disability, diagnostic label or another protected characteristic. Services also ensure culturally appropriate care is being offered to diverse racial, ethnic and cultural communities
• services grow and develop the psychological professions workforce in line with national Psychological Professions Workforce Plan, so that services can offer a full range of multidisciplinary interventions and treatment. Staff wellbeing, training and development is supported, so that community services are a great place to work, and staff are enabled to offer compassionate, high-quality care
• there is continuous improvement of community pathways. Services strive to improve by making the best use of data, regularly developing, testing, and refining change ideas using quality improvement methodology, and ensuring that service improvements are always co-produced with people with experience of services, including their family and carers

Workforce competencies required to deliver psychological therapies

All psychological therapies should be offered according to the principles and protocols set out by NICE.

Therapists must be competent to deliver the therapies as set out in nationally agreed competence frameworks for their delivery:

• psychosis and bipolar disorder: psychological interventions with people with psychosis and bipolar disorder (Psychology and Language Sciences, University College London)
• complex emotional needs/‘personality disorder’: psychological interventions with people with personality disorder (Psychology and Language Sciences, University College London)
• Eating disorder: psychological interventions for people with eating disorders: a competence framework (Psychology and Language Sciences, University College London)

Psychological therapies should be delivered by staff with a recognised qualification and registration/accreditation in the psychological therapy (where this is available), be in posts that specify the required accreditations and qualifications, typically at Agenda for Change (AfC) Band 7 and above (and never below Band 6), or in psychiatry posts having completed core psychotherapy training.

Ongoing specific clinical supervision will be required for each intervention, in line with professional standards. This should always be delivered by a clinician both competent in supervision and experienced and competent in the direct delivery of the intervention. This improves treatment adherence and clinical effectiveness.

Teams are working hard to deliver care for people in community mental health services, but there are still far too many people who cannot access evidence based psychological therapies as part of a treatment package that supports their recovery.

National training offer for psychological therapies

In 2023/24, NHS England commissioned psychological therapy and associated training for suitably qualified and competent staff who are either already in post or recruited into new training posts.

National training offer summary (table 1)

*Not considered a full psychological therapy

Some upskilling trainings are brief, and a high level of existing generic psychological therapy competence is required to enter these trainings. Other training is suitable for a range of staff, including peer support workers.

For the latest information on available training courses please see the Health Education England website.

Mental health and wellbeing practitioners

Mental health and wellbeing practitioners (MHWPs) are not trained to deliver psychological therapy, however they can provide capacity in teams to enable staff with appropriate competencies to deliver psychological therapies or alternatively to allow more experienced staff the time to train in psychological therapies.

MHWPs are a B5 role that deliver brief, wellbeing-focused, psychologically informed interventions (but not therapy) and support collaborative care planning within a multidisciplinary team. These roles have been developed as part of a package of initiatives to increase access to psychological therapies for those with severe mental health problems, providing capacity in teams to allow more experienced team members time to train as therapists. Also, they form a key role for community teams more broadly, creating a new pipeline of staff with core skills aligned with transformed models.

In 2022/23, NHS England’s Workforce, Training and Education (WT&E) programme, offered up to 560 funded MHWP posts (funding training and salary support) across England, and a similar number of places have been offered in 2023/24. You can find out more about the MHWP role on the FutureNHS collaboration platform (this platform requires a log in).

Monitoring outcomes

Nationally, there are several programmes in place that focus on increasing data quality and reporting. The national community mental health outcomes programme aims to improve the quality of care and outcomes for people with severe mental health problems. Having high quality data available within the Mental health services data set (MHSDS) helps to inform service planning and development, commissioning, and patient outcomes. An expert Community Mental Health Outcomes Task and Finish group that included clinical advisors, service managers, and people with lived experience of severe mental health problems carefully considered the merits of different outcomes tools against several criteria. These critieria included: meaningfulness to service users; service user and clinician burden; and suitability for use with different cohorts. The group recommended 3 patient reported outcomes measures (PROMs) for use in community mental health services. These are:

• goals based outcomes (GBOs)
• Recovering Quality of Life (ReQoL-10)
• DIALOG

Services should be working towards routine use of these 3 measures (with GBO and ReQoL-10 used at every clinical session for psychological therapy, whenever possible and appropriate). The frequency of PROMs use can be varied depending on an individual’s needs, including in relation to any protected characteristics. This will serve to support care planning and ongoing monitoring to determine whether shared treatment goals are being achieved, and to achieve pre- and post-treatment outcome data for as close as possible to 100% of cases. We know that without this approach to data completeness services overestimate the effectiveness of treatments.

Collectively these recommended tools can help to understand and measure service users’ needs, personal goals, and level of recovery. These PROMs have been well-researched and validated. They measure what service users consider to be meaningful outcomes, while being brief and practical to use in routine clinical settings.

The national ambition is that outcome measures are used routinely within clinical sessions, and that the results are openly discussed between clinicians and service users to guide care planning, improve person-centred care and ensure that the care delivered is both appropriate and effective. This approach would ensure that outcome measures are embedded and used in a meaningful way within local services, with an overall aim of improving the quality of care and service user outcomes. Ultimately, the transparent reporting of outcomes at service level enables a learning culture in which quality improvements are made to improve services and their effectiveness, ensuring they focus on what matters most to the people who use them.

Establishing the 4-week waiting time standard

Alongside the transformation of services as described in the Community mental health framework, the NHS has committed to developing a new waiting time metric for non-urgent adult and older adult care as part of the Clinically-led review of standards (CRS).

Measurement of waiting times will apply to all service users seen within community mental health services and recorded within the Mental Health Services Dataset (MHSDS). The “clock start” for the waiting time metric refers to the recording of a referral in MHSDS. This is mandatory to open a patient episode. Starting therapy contributes to one element of the “clock stop”. The clock stops when someone has received an assessment; completed a baseline outcome measure; and either completed a co-produced personalised care plan or started an intervention (including a psychological intervention or therapy).

NHS England have issued guidance on data reporting and expect data quality to significantly improve, further increasing our understanding of performance across systems. This insight will allow us to identify the appropriate thresholds for a future standard and how to best support systems to improve waiting times for services. Meanwhile, NHS England will continue to work with government on how to implement waiting time standards as quickly and effectively as possible.

Development of a new access metric for PT-SMHP

We are developing our understanding of the impact of the programme and how access is being improved. Currently, data from MHSDS suggests that only 0.9% of the community caseload are receiving access to a psychological therapy. This needs to increase.

The access to psychological therapies measure counts the number of people who have accessed community mental health services within the last 12 months (the denominator) and who have had more than 2 sessions of an in-scope therapy (the numerator).

This metric excludes early intervention in psychosis services, where access to psychological therapy is monitored via an annual national audit. This metric will be used nationally to track the increase and access to psychological therapies for people with severe mental health problems. The data is available on our dashboard.

Advancing mental health inequalities

It is important to consider inequalities and protected characteristics when aiming to provide an equitable service to people from diverse backgrounds. Over the medium term, we are keen to ensure the evidence base is built to identify effective therapeutic models and interventions that can better support cohorts that services have struggled to reach or who have had poorer experience and outcomes, including those from ethnic minority communities and those with experience of trauma. We are also exploring opportunities to develop access metrics to monitor progress and support improvements in access, focusing on groups that are experiencing the most inequalities.

The Patient and carer race equality framework (PCREF), is one of the key recommendations from the Independent review of the mental health act (MHA), to improve experiences of care for diverse racial, ethnic and cultural communities across all mental health services. The PCREF is a core part of NHS England’s Advancing mental health equalities strategy calling upon on all mental health services to take concrete steps to fight stigma and inequalities across the sector.

The PCREF has been co-produced by experts with experience of mental health, along with the help of PCREF pilot trusts and early adopter trusts who have partnered with ethnic-led voluntary sector organisations over the past 3 years to identify what a ‘culturally competent’ trust is. All systems will be expected to have implemented the PCREF by 2024/25.

Local implementation: governance, additional training, support staff

Local strategies and governance 

It is important that staff delivering the therapies in scope are qualified in the specific therapy either through undertaking the national curriculum-based training identified below or having previously undertaken relevant training and clinical supervision and accumulated experience to an equivalent level. New staff should only be training in PT-SMHP therapy programmes that follow the approved national curriculum.

Mental health providers and integrated care boards (ICBs) should develop a specific local strategy for implementing increased access to NICE-recommended psychological therapies for psychosis, complex emotional needs/ ‘personality disorder’, eating disorders and bipolar disorder. This should include:

• recruiting additional psychological professionals with the required specific psychological therapy competences and accreditation into teams
• enabling psychological professionals with the required specific psychological therapy competences and accreditation to supervise trainees / to train as supervisors
• recruiting new staff into more generic roles, and roles which provide team capacity to release suitably qualified, existing staff to train as psychological therapists
• recruiting suitably qualified staff into training posts where they can train ‘on-the-job’ as psychological therapists
• engaging with service users to develop co-produced treatment pathways which are suited to the needs of the population they serve

This local strategy should feed into continuous ICB LTP 5-year (strategic and workforce) planning as set out in the NHS Mental Health Implementation Plan 2019/20 – 2023/24. It is important that local decisions around how to implement community mental health transformation are prioritised with due regard given to increase access to effective PT-SMHP.

The chief psychological professions officer (CPPO), the most senior psychological professional in provider organisations, should lead on the expansion programme of PT-SMHP and the governance behind expanding the psychological therapy workforce in line with this implementation guidance. The CPPO should report on progress with the expansion directly to the trust or provider organisation’s board, where there should be a named board-level sponsor. For additional support with planning workforce development and accessing national training programmes, please contact your local CPPO or NHS England regional lead for mental health workforce training and education.

Local strategies should prioritise the implementation of PT-SMHP and interventions by staff with the full competence to do so safely and effectively. They should aim to provide access to evidence-based psychological therapies for all 4 diagnostic groups (psychosis, complex emotional needs/‘personality disorder’, bipolar disorder and eating disorders) in all localities, seeking to meet local need and minimise geographical inequities. A phased approach may be necessary, or one in which teams with greatest existing expertise provide professional and clinical guidance and supervision to those with less provision.

It is also critical that information on the delivery of these interventions is accurately recorded and reported to help improve services and patient care. Systematized nomenclature of medicine (SNOMED) guidance for NHS commissioned mental health services (in both acute and community settings, including voluntary, community and social enterprises (VCSE) services) has been developed to support improved local recording and reporting of interventions and submission of relevant therapeutic activity through the MHSDS. New SNOMED guidance is to be published in line with the waiting time standard.

Locally commissioned training

Local commissioning should only focus on training for the therapies listed in Table 1 that meet the national curricula requirement, to ensure that the offer satisfies training accreditation and individual registration requirements which are expected to be introduced over the next 2 years and which may be required to practice. 

The psychological therapies and interventions that are within scope for local investment are specified in the relevant UCL competence frameworks and set out below. However, where available services are encouraged to take advantage of nationally commissioned training.

NICE recommended therapies (table 2)

 *NHS England funded training available/in development 

Additional relevant interventions that are not psychological therapies but that are within scope for local investment (and where available services are encouraged to take advantage of nationally commissioned training) include: 

Other interventions (table 3)

*NHS England funded training available/in development 

Supporting staff to access national training 

When considering staff development to enable delivery of these interventions, services are encouraged to prioritise accessing the nationally funded and quality assured training programmes. However, the current national training offer is not intended to lead to local disinvestment from delivery of any other psychological therapies and interventions, including those listed above, if they are evidence-based and local priorities.  

To identify existing staff to put forward for upskilling training or new staff to recruit into training posts, team leaders should work with their CPPO to identify staff: 

• who can have the required amount of protected time built into their job plan to undertake: a) the training; b) the required casework; and c) the associated specialist supervision to become proficient in the specified approach
• who are highly motivated to undertake what can be demanding programmes of study
• with the required entry qualifications and competencies for the upskilling training
• with the required entry qualifications and competencies to undertake supervision training to build the pool of staff who can support other staff during training
• with the required job roles and identified capacity, and at the required grade to implement either the individual therapy/family intervention, or in some cases wider team components of treatment
• with access to the required specialist supervision during and beyond the training period
• with access to service users presenting with difficulties the therapy training is targeting

Staff should only be put forward for training if they will have protected time to spend a minimum of 2 days per week delivering the interventions they are being trained to deliver. Any less would be a poor return on significant public investment in training and is likely to lead to rapid skills decay post-training. 

Additional resources

• Framework for developing a PTSMHP strategy
• Guidance to improve joint working between NHS Talking Therapies and Community Mental Health services

Annex A: PT-SMHP workforce planning informed by skill mix ratios to deliver NICE guidance 

Estimating service capacity to deliver psychological therapies  

To provide a meaningful choice of NICE compliant therapy for each target condition, modelling has been conducted to estimate the percentage of overall psychological therapy capacity in community mental health services (and specialist eating disorder services) that systems should assign to each therapy type. These are ranges, which, if implemented, would allow NICE compliance and choice. 

The modelling has been developed by UCL and the PT-SMHP programme team at NHS England and reviewed by the PT-SMHP Expert Advisory Group, leading to several refinements.  

The scope of this modelling covered the provision of NICE compliant psychological therapies for psychosis, bipolar disorder, complex emotional needs/ ‘personality disorder’, and complex depression, anxiety, PTSD, or those without a diagnosis were supported in community mental health – that is, where not eligible for NHS Talking Therapies for anxiety and depression.

Modelling of proportions of different psychological therapy modalities  

The goal should be to provide a meaningful choice of NICE recommended therapy for each condition within scope. Where there are more than 2 modalities of therapy recommended by NICE for a condition, any 2 or more of these therapies should be offered by a service. 

It is assumed that a total of 30% of therapy provision in community mental health will target complex anxiety disorders (10%), depression (10%) or PTSD (10%), where these are not appropriate for NHS Talking Therapies for anxiety and depression. 

The other 70% of the therapy capacity for community mental health is assumed to be spread according to prevalence of the other conditions within scope (psychosis, bipolar disorder, complex emotional needs/’personality disorder’ and eating disorders), recognising that people presenting with these diagnoses will have a wide range of needs and personal goals. 

Proportions of different therapies are based on population prevalence data, noting that an individual may need therapy for multiple presenting problems in their lifetime. This modelling is based on data from the Adult Psychiatric Morbidity Survey (APMS 2014).

Each ICB should provide a meaningful choice of modalities of therapy for each condition in Table 1. “Meaningful choice” is taken to mean at least 2 types of therapy for each condition, with the second modality comprising at least 10% of provision for that problem type. 

Each ICB should provide therapies within the range set out in column A of Table 1 below, while providing a choice of therapies for that condition. 

Nationally, the percentage of the total psychological therapy capacity expected to be allocated to each therapy is shown in column B of Table 1 below; this will vary depending on local population need. 

Table 1: indicative allocation of capacity across psychological therapies and target problems

* Based on proportionate allocation of therapy type meet population need for psychosis, bipolar, complex emotional needs/’personality disorder’ and eating disorders, with 30% nominally allocated to target problems of PTSD, depression and anxiety disorder where these are not eligible for NHS Talking Therapies for Anxiety and Depression (NHS TTad). 

** Based on providing a meaningful choice of NICE compliant therapies for each target problem (including co-morbidities), across community mental health and specialist eating disorder services but will vary based on patient choice. 

*** Family interventions are typically provided by pairs of practitioners, so WTE workforce requirement is doubled to provide the equivalent capacity to individual therapies. 

Growth in psychological therapy capacity required 

To provide an increase in access of the scale required to approach adherence to NICE recommendations there needs to be a significant increase in the capacity to deliver psychological therapies. Nationally, the PT-SMHP programme is committed to growing the psychological workforce to help increase access to community mental health services. To improve access to psychologically informed interventions and increase the supply pipeline of trainee therapists we would also need to grow the mental health and wellbeing practitioner workforce by around 500 staff a year across this period.  

This modelling will continue to be developed to support services to effectively plan and grow their workforce so they can provide meaningful choice to NICE compliant therapies for people with severe mental health problems.  

Proportions of staff expected to have completed each training pathway 

The figures in Table 1 above have been extrapolated to estimate the proportion of staff that would be expected to have completed each training pathway, to deliver the estimated national proportions of therapies listed. These estimates are shown in Table 2 below – they reflect that CBT training for severe mental health problems will also enable therapists to provide NICE guided therapies for the presenting problems of depression, anxiety and PTSD. 

Table 2: national indicative split of community mental health and adult eating disorders psychological therapies staff required to have completed each therapy training pathway 

* including CBT for comorbid anxiety, depression, PTSD and behavioural activation for comorbid depression

** accounting for the need for family intervention practitioners to work in pairs, so workforce capacity requirement doubled compared to individual therapies.

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