The UK health system faces a paradox of progress in mental health: while increased attention to common conditions such as anxiety and depression has brought welcome benefits, it has also exposed a persistent failure to meet the needs of those with severe and persistent mental illness (SMI).
With one in five adults living with a mental health problem in England, there is growing recognition of the challenges posed by mental illness – particularly in relation to rising levels of economic inactivity among young people – and a growing emphasis on early intervention and prevention to tackle them. This progress matters. But it has not been universal, especially when considering the unmet needs of those with SMI.
SMI, including conditions such as schizophrenia and bipolar disorder, remains one of the most complex and costly areas of health care. 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 readmission and hospitalization, demonstrating the persistent and growing health disparities faced by this population.
I am not suggesting that care for common mental health conditions is perfect. But those with the most severe and persistent conditions face the greatest disadvantage, and that must change. At the same time, if we are serious about treating mental health equally with physical health, we need to change the way we see and care for people with SMI.
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In much of healthcare, innovation is transforming what is possible. In areas such as cancer and cardiovascular disease, advances in diagnosis and treatment have reshaped pathways and significantly improved outcomes. In contrast, there have been several significant step changes in the treatment of SMI 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 okay in SMI?
The challenge in SMI is complex and difficult to overcome. However, I see real opportunities to improve outcomes through three main areas, particularly around the current drug 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 placebos over long periods. Outcomes are often measured using clinical scales that may not fully match what matters most to patients, such as side effect management. Decades of limited innovation in mental health have left the NHS, like other systems, without the capacity of trained specialists needed to provide standardized assessments and consistent data essential 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 evaluating new medical interventions. However, mental health raises specific challenges for how value is defined and measured within that system. The outcomes that matter most in SMI—such as independence, stability, social participation, and caregiver influence—are not always fully captured by conventional assessment measures. The lack of innovation in this space also means that new interventions are often evaluated against long-term and relatively low-cost standards of care. This creates a cycle where it is more difficult to demonstrate the benefits of new innovations in an area where progress has been lacking for some time.
Finally, fragmentation and lack of funding of services: Care pathways for people with SMI are often fragmented, including primary care, specialist services and community support. Access to basic services, including early intervention and crisis care, varies significantly across the country. Add to this workforce pressures, infrastructure constraints and current commission arrangements such as the widespread use of block contracts and we are in a situation where the system is not always set up to adopt new innovations, meaning people lose out.
We have a huge responsibility and opportunity to achieve the national mental health ambitions as outlined in the Government’s 10 Year Health Plan. The shift of the NHS towards more integrated, community-based care, together with the development of the Modern Service Framework for mental health, provides us with a moment to make a real difference for people with SMI. A moment to create an environment where SMI is prioritized. We must not lose it.
NS-GB-2600043
May 2026
