Bridging “The Gap” in Mental Health Care
For the past three years my as role community mental health development lead has sat squarely in what the mental-health world calls “the gap.” In truth, most of my working life has occupied this space, but the last three years have been more official.
You probably recognise the gap instinctively. It describes people who are judged too “unwell,” “complex,” or “risky” for primary-care services (GPs and Improving Access to Psychological Therapies—Talkworks in Devon), yet not “unwell,” “complex,” or “at-risk” enough to qualify for secondary-care services such as community mental-health teams, specialist psychological therapies, or home-treatment teams.
In theory there should be no space between those two layers of NHS support. In practice the canyon is widening. Primary-care thresholds, set nationally, stay largely static—apart from the silent squeeze of shrinking budgets. Meanwhile the secondary-care cliff edge is retreating fast: staff shortages, soaring demand, chronic under-investment in prevention, and dwindling resources are forcing services to raise the bar of access simply to stay afloat.
Why does this gap bother us so much? Because we cling—nobly, but unrealistically—to the belief that the NHS should meet all the health needs of everyone. Many people’s biopsychosocial needs require different solutions altogether, yet the system still focuses its funding on statutory responses while still feeling morally responsible for those that fall outside of their remit. The truth is, it bothers us because we know that many people who should be getting support, aren’t.
How many people are stranded?
Current prevalence tools estimate that Exeter has about 21,000 residents with a diagnosable mental-health condition that should be covered by statutory services. Roughly 20 % self-manage successfully; around 35 % currently engage with primary or secondary care. That leaves nearly half—some 10,000 people—unsupported.
Let that sink in. To serve them all through today’s NHS model we would need to more than double current mental-health funding for Exeter. Money might as well grow on trees.
Flip the numbers another way: if voluntary, community, and social-enterprise (VCSE) organisations are already supporting even three-quarters of those 10,000 people, they provide mental-health care on a par with statutory services. Local plans and national strategies—such as the NHS Ten-Year Plan—should reflect that reality.
Seven ways to shrink the gap
Here are some of the current ideas being implemented that resonate with me the most, and I think are essential for starting to turn this metaphorical tanker around:
Invest in “relational infrastructure.” Independent connectors who cultivate cross-system relationships are worth their weight in gold. Their networks strengthen teams, unlock resources, and help ideas gain traction. Devon Mental Health Alliance (https://www.mentalhealthdevon.co.uk/what-we-do/community-development) has positively invested in this through their community mental health development lead roles, and the new "Integrator Coach" roles within the NHS Integrated Neighbourhood Team plan creates space to potentially build on this locally.
Co-locate primary, secondary, and VCSE teams. Sharing space breeds trust, speeds referrals, and enables joint working on a person’s whole biopsychosocial picture—saving money and staff in the long run. CoLab's One Mental Health Team (https://www.colabexeter.org.uk/omht) does this brilliantly for individuals who are vulnerably housed and/or rough sleeping.
Make trauma recovery the core goal. Most mental-health struggles stem from trauma—whether chronic stress, insecure attachment, or violence. Treating only symptoms kicks the can down the road until needs become more complex. Trauma-informed pathways must be available at every stage of care. We are running a free online workshop for a Trauma-Informed Community Assessment Tool we have created to support this process, feel free to sign up if you are interested (https://www.eventbrite.co.uk/e/a-tica-tool-workshop-tickets-1419660355339?aff=ebdsoporgprofile&_gl=1*1kqdfp0*_up*MQ..*_ga*NDEyMjEzNzM2LjE3NTU1MDM1NzM.*_ga_TQVES5V6SH*czE3NTU1MDM1NzIkbzEkZzAkdDE3NTU1MDM1NzIkajYwJGwwJGgw).
Re-imagine the first appointment. Single-Session Therapy mirrors GP practice: one appointment at a time, focusing on the issue causing most distress that day. Many people feel seen, heard, and helped immediately—no twelve-month waits. Normal Magic (https://www.normalmagic.co.uk/) are really successfully leading the way with this in Devon.
Learn from High-Intensity-Use (HIU) models. HIU workers support frequent A&E attenders, address wider life needs, and achieve dramatic reductions in hospital use—saving millions. The same whole-person, compassionate approach should guide all support-worker roles. CoLab's HIU team is fairly new, but is already making a considerable difference in people's lives, as are HIU workers based in primary care settings through the Nexus Primary Care Network in Exeter. British Red Cross (https://www.redcross.org.uk/about-us/what-we-do/we-speak-up-for-change/exploring-the-high-intensity-use-of-accident-and-emergency-services) are working hard to see this model replicated around the country.
Offer personal health budgets. Equipping HIU or primary-care workers with flexible budgets lets clients fund whatever improves their wellbeing—counselling, gym membership, cooking classes, you name it. Empowered choice keeps people out of crisis.
Rebuild social infrastructure. COVID snapped an already fraying safety net. We need to restore community spaces, empower neighbours to look out for one another, and weave interdependence back into society. Investing in community builders is a strong start. Wellbeing Exeter have a team of community builders that are doing great work across the city - but we need more of them.
A call to action
Decades of under-investment in prevention—and a system not designed around trauma—have left us a monumental task. Thousands struggle in the gap, and the NHS alone cannot pivot quickly enough. It’s time for all of us—statutory, VCSE, and community alike—to innovate a new way forward. The road is hard, but if we walk it together we’ll one day arrive somewhere better than we can yet imagine.
Matt Merriam, Community Mental Health Development Lead (DMHA)