The UK health system faces a paradox of progress in mental health: while growing attention to common conditions such as anxiety and depression has driven welcome gains, it has also exposed a persistent failure to meet the needs of those with severe and enduring mental illness (SMI).
With one in five adults living with a mental health problem in England, there is increasing recognition of the challenges posed by mental ill-health — particularly in relation to growing levels of economic inactivity among young people — and an increased emphasis on early intervention and prevention to address them. This progress matters. But it has not been universal, notably when you consider the unmet needs of those with SMIs.
SMI, including conditions such as schizophrenia and bipolar disorder, remains one of the most complex and costly areas of healthcare. While access to support for common conditions has expanded through services such as NHS Talking Therapies and early intervention initiatives, progress for SMI has been more limited. People living with SMI experience poorer physical health, reduced life expectancy and repeated cycles of relapse and hospitalisation, demonstrating the persistent and widening health inequalities faced by this population.
I am not suggesting care for common mental health conditions is perfect. But those with the most severe and enduring conditions face the greatest disadvantage, and that needs to change. At the same time, if we are serious about treating mental health on par with physical health, we must change how we view and care for people with SMI.
Across much of healthcare, innovation is transforming what is possible. In areas like cancer and cardiovascular disease, advances in diagnostics and treatment have reshaped pathways and significantly improved outcomes. By contrast, there have been few significant step-changes in SMI treatment in recent decades.
This is not an argument against progress in other conditions but a challenge to all of us that if we would not (rightly) tolerate such limited progress in cancer treatment, why is it OK in SMI?
The challenge in SMI is complex and hard to overcome. However, I see real opportunity to improve outcomes through three key areas, particularly around the current medicines pathway.
First, the clinical trial challenge: Mental health patient populations are heterogeneous, treatment responses vary, and clinical trials must navigate ethical constraints – including the use of placebo over extended periods. Outcomes are often measured using clinical scales that may not fully align with what matters most to patients, like side-effect management. Decades of limited innovation in mental health have left the NHS, like other systems, without the trained specialist capability needed to deliver standardised assessments and consistent data crucial for commercially attractive trials.
Second, rethinking how we define value in mental health care: In England, the National Institute for Health and Care Excellence (NICE) provides a robust and internationally respected framework for assessing new medical interventions. However, mental health raises specific challenges for how value is defined and measured within that system. Outcomes that matter most in SMI – such as independence, stability, societal participation and caregiver impact – are not always fully captured by conventional appraisal measures. The lack of innovation in this space also means new interventions are often assessed against longstanding and relatively low-cost standards of care. This creates a cycle where it is harder to demonstrate benefits of novel innovations in an area where progress has been lacking for some time.
Finally, fragmentation and lack of service funding: Care pathways for people with SMI are often fragmented, spanning primary care, specialist services, and community support. Access to core services, including early intervention and crisis care, varies significantly across the country. Add to that workforce pressures, infrastructure constraints and current commissioning arrangements such as the widespread use of block contracts and we are in a situation where the system is not always configured to adopt new innovations, which means people miss out.
We have a great responsibility and opportunity to achieve national mental health ambitions, as outlined in the government’s 10 Year Health Plan. The NHS shift towards more integrated, community-based care, alongside the development of the Modern Service Framework for mental health, provides us with a moment to make a real difference to people with SMI. A moment to create an environment where SMI is prioritised. We must not miss it.
NS-GB-2600043
May 2026
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