Reflections on Peter Fonagy’s Review and the future of mental health services.
How do we make sure people get the support they need, rather than just the support that fits a diagnosis? Peter Fonagy’s recent review raises important questions about how services approach mental health and respond to people’s needs.
In this blog, our Deputy CEO, Jalil Kane, reflects on what this means for CHT and why it matters to get to know the person behind the diagnosis.
Reading Peter Fonagy’s review into mental health conditions, ADHD and autism has brought me back to a recent discussion with colleagues about whether we work ‘only’ with people who have a diagnosis. I think this is both true and not true at the same time, and the distinction matters.
The picture that emerges from Fonagy’s review is of more people experiencing mental health difficulties, especially young people, and many struggling to get help. Demand for ADHD and autism assessments has grown sharply, although the review is careful about what this tells us about how common those conditions are. It describes long waits, fragmented services and the difficulties people face when a diagnosis is followed by little support. Its call for a “needs-led plus diagnosis” approach feels important: help should respond to what someone is struggling with, alongside timely assessment and diagnosis. For me, this brings us back to some familiar questions in our own work about how we understand distress, the place diagnosis has within that understanding, and how people secure the support they need.
At CHT, our approach is psychodynamic and formulation-based and set well within the Therapeutic Community tradition.
We aim to understand someone’s distress through the interaction between their life experiences, relationships, biology, and the wider social context that they live in. Historically, this has always been our starting point, subject to people being able to secure funding, and this last bit is the catch. Diagnosis often helps determine how that funding is applied and how resources are assigned, while our clinical work involves developing a fuller understanding of the person.
I was particularly moved by Fonagy’s foreword.
He describes being a young person in considerable distress, outside of a familiar social context and isolated from relationships until a person, a neighbour, noticed, leading him towards therapy. He remembers his therapist taking an interest in a car he was excited about. It was a small moment, but it helped him begin to trust her. She could see what mattered to him and that there was someone there with a future.
That feels quite close to the work of getting to know someone. It takes time to understand what they have been through, what matters to them, and what they might hope for, even when hope is difficult to find.
The review carries this attention to the person into its argument about services. It emphasises formulation and clinical understanding before classification, while recognising the value of diagnosis.
A diagnosis can offer recognition, help explain experiences and guide treatment. It can also become the route through which someone gains access to practical support.
The difficulty comes when we ask it to carry too much meaning. Two people with the same diagnosis may have very different needs.
Their circumstances may change considerably while their diagnosis remains the same. The proposed “needs-led plus diagnosis” approach acknowledges this, keeping timely diagnosis alongside support that responds to how someone is managing now.
For me, this raises a question about how we design services. If we begin with the service categories we already have, there is a danger that we understand someone’s needs mainly through what those services are funded or permitted to offer. We can become very good at describing where a person fits or does not fit, while struggling to provide the help they actually need.
A needs-led approach ought to change that order. We would begin by trying to understand the person’s difficulties and circumstances, together with them, and then organise an appropriate response. That might involve therapy, practical support, adjustments, housing, specialist assessment, or several of these working together.
The review gives some substance to this. It describes care whose type and intensity can change as needs change, expertise coordinated across services, and support offered while assessment continues. These proposals have practical implications: people should be able to receive help without repeatedly having to leave one service, explain themselves again, and try to qualify for another.
Regulation has an important role in protecting people, maintaining standards and making services accountable. But the shape of care should be informed by people’s needs and the evidence about what helps. Regulatory categories and commissioning arrangements need to support that work, not define it, as is so often the case currently. When those categories become the starting point for service design, we risk asking people to adapt to the service before the service has properly understood them.
This is also where I worry about ‘needs-led’ becoming another buzzword.
It is an appealing phrase, and one most of us can get behind. But calling a service ‘needs-led’ does not tell us very much about what happens when someone asks for help. Much of this is already there in the Care Act’s emphasis on needs, wellbeing and the outcomes that matter to the person. For me, the question is how we put those principles into practice consistently across services, so that understanding someone’s needs leads to help, rather than another assessment they have to get through.
The review itself warns that needs assessment could become another gateway or a new means of rationing support. We should take that seriously. If the language changes but people still face the same thresholds, repeated assessments and gaps in care, then we have changed the description more than the experience.
There is something else to hold onto here: our understanding of need develops.
Someone may struggle to explain what is happening, or may need time to feel safe enough to speak about it. We may initially misunderstand them. A formulation needs room to develop and change, and an assessment of need should remain open to the person’s changing circumstances and their own account of what matters.
Making this possible requires resources and time. Flexible care depends on enough staff, specialist expertise, supervision and stable funding. It cannot rest entirely on practitioners trying harder within arrangements that give them little room to respond.
The report’s attention to housing, belonging and participation matters for the same reason. Having somewhere settled to live, someone to turn to, or something meaningful to take part in can make life more manageable. Progress will look different for different people, and we need to stay interested in what it means to them.
For CHT, I hope this review gives us an opportunity to bring our experience of therapeutic communities into a wider conversation about how services can respond to people’s lives.
We have something to contribute, and plenty to learn, especially from the people who live in our communities. I would like us to keep making room for their stories, choices and hopes, and to work with others to make that room possible.
Perhaps that is where the hope lies: in more people feeling that someone has noticed, is willing to understand, and will stay alongside them while a future begins to feel possible.